What are the treatment options for hidradenitis suppurativa?

Treatment of Hidradenitis Suppurativa

Treatment of hidradenitis suppurativa must be stratified by Hurley stage, with topical clindamycin 1% for mild disease, clindamycin-rifampicin combination for moderate disease, and adalimumab for severe or refractory cases, prioritizing early aggressive intervention to prevent irreversible scarring and tunnel formation. 1, 2

Disease Severity Assessment

Before initiating treatment, determine Hurley stage by examining all intertriginous areas (axillae, groin, inframammary, perianal) 1:

• Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 1, 3
• Hurley Stage II: Recurrent nodules with limited sinus tracts and scarring 1, 3
• Hurley Stage III: Extensive disease with multiple interconnected sinus tracts and diffuse scarring 1, 3

Document baseline pain using Visual Analog Scale (VAS) and inflammatory lesion count (abscesses + inflammatory nodules) 1. Screen for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease at initial visit 1.

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

First-line therapy is topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 2, 3

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1
• For acutely inflamed nodules, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) directly into lesions for rapid symptom relief within 1 day 1
• Alternative skin cleansers include benzoyl peroxide and zinc pyrithione 1

If inadequate response after 12 weeks, escalate to oral tetracyclines: doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for 12 weeks 1.

Moderate Disease (Hurley Stage II)

First-line therapy is clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks. 1, 2

This combination achieves response rates of 71-93%, far superior to tetracycline monotherapy (30% abscess reduction) 1. Treatment can be repeated intermittently as needed 1.

Critical pitfall: Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses, as these have minimal effect on deep inflammatory lesions 1.

Add intralesional triamcinolone 10 mg/mL for acutely inflamed nodules and abscesses to provide rapid symptom relief 1.

If no clinical response after 12 weeks, escalate directly to adalimumab 1, 2.

Severe or Refractory Disease (Hurley Stage III or Failed Antibiotics)

First-line biologic therapy is adalimumab with the following FDA-approved dosing regimen 1, 2, 4:

Adults and adolescents ≥60 kg:

• Day 1: 160 mg (single dose or split over two consecutive days)
• Day 15: 80 mg
• Day 29 and subsequent doses: 40 mg weekly OR 80 mg every other week 1, 4

Adolescents 30-60 kg:

• Day 1: 80 mg
• Day 8 and subsequent doses: 40 mg every other week 4

Assess treatment response at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 1. Adalimumab achieves HiSCR response rates of 42-59% at week 12 1.

If adalimumab fails after 16 weeks, second-line biologic options include 1:

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months
• Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients)
• Ustekinumab (alternative IL-12/23 pathway targeting)

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 1, 2.

Surgical options by extent of disease 1:

• Deroofing: For recurrent nodules and limited tunnels
• Radical surgical excision: For extensive disease with sinus tracts and scarring, with wound closure by secondary intention, skin grafts, or flaps

Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy for extensive disease 1.

Essential Adjunctive Measures (All Patients)

Regardless of disease severity, implement the following 1, 2:

• Smoking cessation referral: Tobacco use worsens outcomes and disease progression
• Weight management referral if BMI elevated: Obesity is associated with worse outcomes
• Pain management: NSAIDs for symptomatic relief
• Appropriate wound dressings for draining lesions
• Screen for depression/anxiety and refer for mental health support
• Screen for cardiovascular risk factors: Measure blood pressure, lipids, and HbA1c

Treatment Monitoring and Reassessment

Reassess all patients at 12 weeks using 1:

• Pain VAS score
• Inflammatory lesion count (abscesses + nodules)
• Dermatology Life Quality Index (DLQI)
• HiSCR for patients on biologic therapy

Take treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1.

Therapies with Insufficient Evidence

The following therapies have insufficient evidence and are NOT recommended 1: alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, methotrexate, oral prednisolone, phototherapy, radiotherapy, and ustekinumab (as first-line).

Do NOT use cryotherapy or microwave ablation for treating lesions during the acute phase 1.

Special Populations

Pediatric patients 12 years and older with moderate to severe disease: Adalimumab is FDA-approved with weight-based dosing as outlined above 1, 4.

Pediatric patients 8 years and older requiring systemic antibiotics: Oral doxycycline is recommended 1.