What are the treatment options for hidradenitis suppurativa?

Treatment Options for Hidradenitis Suppurativa

Treatment of hidradenitis suppurativa follows a severity-based algorithm using the Hurley staging system, with topical clindamycin for mild disease, oral clindamycin plus rifampicin for moderate disease, and adalimumab for severe or refractory cases. 1, 2

Disease Severity Assessment

• Determine Hurley stage by examining all intertriginous areas (axillae, groin, inframammary, perianal) to assess for isolated nodules (Stage I), recurrent nodules with sinus tracts (Stage II), or diffuse involvement with multiple interconnected tracts and scarring (Stage III) 1, 2
• Document baseline inflammatory lesion count (abscesses and nodules), pain using Visual Analog Scale (VAS), and quality of life impact using Dermatology Life Quality Index (DLQI) 1, 2
• Screen for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease at initial assessment 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 topical clindamycin with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1, 2
• Add intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules, which provides rapid symptom relief within 1 day with significant reductions in erythema, edema, suppuration, and pain 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 OR tetracycline 500 mg 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% in systematic reviews, far superior to tetracycline monotherapy (30% abscess reduction) 1
• 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 these lesions 1
• Add intralesional triamcinolone 10 mg/mL for acutely inflamed nodules to provide rapid symptom relief 1
• Consider treatment break after 10-12 weeks to assess need for ongoing therapy and limit antimicrobial resistance 1

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

First-line biologic therapy is adalimumab with dosing of 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2, 4

• Adalimumab is FDA-approved for moderate to severe hidradenitis suppurativa in patients 12 years of age and older 4
• Achieves HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) response rates of 42-59% at week 12 1
• Assess treatment response at 12 weeks using HiSCR and patient-reported outcomes; if no clinical response by 16 weeks, consider alternative treatments 1, 3

Second-Line Biologic Options After Adalimumab Failure

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months thereafter is the preferred second-line biologic 1
• Secukinumab demonstrates response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks and can be used in combination with infliximab for treatment-refractory disease 1
• Ustekinumab is an alternative option targeting different cytokine pathways (IL-12/23) 1

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 1, 2, 5

• Deroofing is recommended for recurrent nodules and tunnels without extensive scarring 1
• Radical surgical excision is recommended for extensive disease (Hurley Stage III) with sinus tracts and scarring, with the width of excision influencing therapeutic outcome 1
• Wound closure options include healing by secondary intention, skin grafts, TDAP flap, or other reconstructive methods 1
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1

Alternative Systemic Therapies

• Acitretin 0.3-0.5 mg/kg/day is an alternative option for patients unresponsive to adalimumab 1
• Dapsone starting at 50 mg daily and titrating up to 200 mg daily can be considered for patients unresponsive to adalimumab 1
• Ertapenem 1g daily for 6 weeks can be considered as rescue therapy or during surgical planning for severe disease requiring IV antibiotics 1

Essential Adjunctive Measures

• Smoking cessation referral is critical as tobacco use is associated with worse outcomes 1, 2, 3
• Weight management referral for patients with elevated BMI, as obesity worsens outcomes 1, 2, 3
• Pain management with NSAIDs for symptomatic relief 1, 3
• Appropriate wound dressings for draining lesions 1
• Screen for cardiovascular risk factors including blood pressure, lipids, and HbA1c 1
• Screen for depression and anxiety given the profound negative impact on quality of life 1, 6

Treatment Monitoring

• Reassess at 12 weeks using pain VAS score, inflammatory lesion count, DLQI, and HiSCR (for patients on biologic therapy) 1, 2
• For patients on oral antibiotics, consider treatment breaks after 10-12 weeks to assess need for ongoing therapy and limit antimicrobial resistance 1
• Discontinue adalimumab if no clinical response by 16 weeks and consider alternative treatments 1, 3

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 doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit 1
• Do NOT use cryotherapy or microwave ablation for treating lesions during the acute phase 1
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk 1

Therapies with Insufficient Evidence

The British Journal of Dermatology states there is insufficient evidence to recommend numerous therapies including alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, hyperbaric oxygen therapy, intravenous antibiotics (except ertapenem), isoniazid, laser and photodynamic therapies, methotrexate, oral prednisolone, oral zinc, phototherapy, photochemotherapy, radiotherapy, spironolactone, and tolmetin sodium 1