What are the treatment options for hidradenitis suppurativa?

Treatment for Hidradenitis Suppurativa

Treatment selection depends on disease severity using the Hurley staging system: topical clindamycin 1% for mild disease (Hurley Stage I), clindamycin 300 mg plus rifampicin 300-600 mg daily for moderate disease (Hurley Stage II), and adalimumab for severe or refractory disease (Hurley Stage III). 1, 2

Initial Assessment and Staging

Before initiating treatment, determine disease severity using the Hurley staging system 1, 2:

• Hurley Stage I (Mild): Isolated nodules and abscesses without sinus tracts or scarring 2
• Hurley Stage II (Moderate): Recurrent abscesses with sinus tract formation and scarring 2
• Hurley Stage III (Severe): Diffuse involvement with multiple interconnected sinus tracts and extensive scarring 2

Document baseline pain using Visual Analog Scale (VAS) and quality of life using Dermatology Life Quality Index (DLQI) 2. Screen all patients for depression, anxiety, cardiovascular risk factors (blood pressure, lipids, HbA1c), inflammatory bowel disease, and metabolic syndrome 1, 2.

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

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1
• Alternative skin cleansers include zinc pyrithione 1
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) can be injected directly into acutely inflamed nodules for rapid symptom relief within 1 day, showing significant reductions in erythema, edema, suppuration, and pain 1

If topical therapy fails after 12 weeks, escalate to oral tetracyclines: doxycycline 100 mg once or twice daily for 12 weeks or tetracycline 500 mg twice daily for up to 4 months 1, 2.

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 typically lasts 8-12 weeks and can be repeated intermittently 1.

Critical pitfall: Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses or deep inflammatory nodules, as these have minimal effect on deep inflammatory lesions 1, 2.

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

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

First-line biologic therapy is adalimumab with the following dosing schedule 1, 2, 3:

• 160 mg at week 0 (given in one day or split over two consecutive days)
• 80 mg at week 2
• 40 mg weekly starting at week 4

Adalimumab achieves HiSCR response rates (≥50% reduction in inflammatory lesion count with no increase in abscesses or draining fistulas) of 42-59% at week 12 versus 26-28% with placebo 4. The number needed to treat is 4, with a favorable benefit-risk ratio 4.

Important consideration: 40% of initial non-responders at 12 weeks may still achieve response by week 36 with continued treatment, but almost half of week 12 responders lose response by week 36 despite continued weekly dosing 4.

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 of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks)
• Ustekinumab

Adolescent Dosing (12 Years and Older)

For adolescents 12 years and older with moderate to severe hidradenitis suppurativa 1, 3:

• 30 kg to <60 kg: Day 1: 80 mg; Day 8 and subsequent doses: 40 mg every other week
• ≥60 kg: Day 1: 160 mg (split over two days if needed); Day 15: 80 mg; Day 29 and subsequent: 40 mg weekly or 80 mg every other week

Surgical Interventions

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

Surgical options include 1, 2:

• Deroofing for recurrent nodules and tunnels
• Radical surgical excision for extensive disease with sinus tracts and scarring
• Wound closure options: secondary intention healing, skin grafts, or flaps

Refer patients with Hurley Stage III disease or lack of response to medical therapy after 12 weeks to a hidradenitis suppurativa surgical multidisciplinary team 2. Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1.

Essential Adjunctive Measures (All Patients)

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

• Smoking cessation referral: Tobacco use is associated with worse outcomes and predicts poor antibiotic response 1, 2
• Weight management referral: Obesity is strongly associated with disease severity 1, 2
• Pain management with NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for draining lesions 1, 2
• Screen for depression/anxiety and provide mental health referrals as needed 1, 2

Treatment Monitoring and Response Assessment

Reassess all patients at 12 weeks using 1, 2:

• Pain VAS score
• Inflammatory lesion count
• HiSCR (≥50% reduction in inflammatory lesion count with no increase in abscesses or draining fistulas)
• Quality of life measures (DLQI)

If no clinical response after 12 weeks of antibiotics, escalate to the next treatment tier 1, 2. If adalimumab shows no response after 16 weeks, consider alternative biologics 1.

Critical Pitfalls to Avoid

• Do NOT use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules, not inflammatory nodules or abscesses 1
• Do NOT continue ineffective antibiotics beyond 12 weeks without reassessment, as this increases antimicrobial resistance risk 1, 2
• Do NOT use tetracyclines as first-line for severe flares, as they are ineffective for deep inflammatory lesions and sinus tracts 2
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Therapies with Insufficient Evidence

The British Journal of Dermatology states there is insufficient evidence to recommend numerous therapies, including alitretinoin, anakinra, apremilast, azathioprine, ciclosporin, methotrexate, oral prednisolone, phototherapy, and many others 1. Cryotherapy and microwave ablation are not recommended for treating lesions during the acute phase 1.