What are the treatment options for a patient with hidradenitis suppurativa?

Hidradenitis Suppurativa Treatment

For hidradenitis suppurativa, treatment selection is determined by Hurley stage: topical clindamycin 1% twice daily for 12 weeks for mild disease (Hurley I), clindamycin 300 mg plus rifampicin 300-600 mg orally twice daily for 10-12 weeks for moderate disease (Hurley II), and adalimumab (160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4) for severe or refractory disease (Hurley III or antibiotic failure). 1, 2, 3, 4

Initial Assessment and Disease Staging

• Determine disease severity using the Hurley staging system: Stage I (isolated nodules/abscesses without sinus tracts), Stage II (recurrent abscesses with sinus tract formation and scarring), Stage III (diffuse involvement with multiple interconnected sinus tracts and scarring). 2, 3
• Document baseline pain using Visual Analog Scale (VAS) and inflammatory lesion count (abscesses, nodules, draining fistulas). 2, 3
• Screen all patients for depression/anxiety, cardiovascular risk factors (blood pressure, lipids, HbA1c), inflammatory bowel disease, and metabolic syndrome. 2, 3

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

• First-line: 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. 2
• Adjunct: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules provides rapid symptom relief within 1 day. 1, 2
• Alternative for more widespread mild disease: Doxycycline 100 mg once or twice daily OR tetracycline 500 mg twice daily for 12-16 weeks. 1, 2, 3

Moderate Disease (Hurley Stage II)

• First-line: Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks. 1, 2, 3
• This combination achieves response rates of 71-93%, far superior to tetracycline monotherapy (30% abscess reduction). 1, 2
• Treatment can be repeated intermittently as needed. 1
• Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses or deep inflammatory nodules—these have minimal effect on deep lesions. 2, 3

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

• First-line biologic: Adalimumab with FDA-approved dosing: 4
  • Adults: 160 mg subcutaneous on Day 1 (single dose or split over two consecutive days), 80 mg on Day 15, then 40 mg weekly starting Day 29
  • Adolescents ≥60 kg: Same as adult dosing
  • Adolescents 30-60 kg: 80 mg Day 1, then 40 mg every other week starting Day 8
• Adalimumab achieves HiSCR response rates of 42-59% at week 12 versus 26-28% with placebo. 5
• Second-line biologics if adalimumab fails: 1, 2
  • 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

Surgical Interventions

• Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 1, 2, 3
• Deroofing for recurrent nodules and tunnels in limited areas. 2
• Radical surgical excision for extensive disease with sinus tracts and scarring, with wound closure by secondary intention, skin grafts, or flaps. 1, 2
• Refer patients with Hurley Stage III or lack of response to medical therapy after 12 weeks to a hidradenitis suppurativa surgical multidisciplinary team. 3

Treatment Monitoring and Response Assessment

• Reassess at 12 weeks using: 2, 3
  • 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 next treatment tier. 2, 3
• For adalimumab, if no clinical response by 16 weeks, consider alternative biologics. 1, 2
• Note: 40% of initial adalimumab non-responders may achieve response by week 36 with continued treatment. 5

Essential Adjunctive Measures (All Patients)

• Smoking cessation referral: Tobacco use is associated with worse outcomes and predicts poor antibiotic response. 2, 3
• Weight management referral: Obesity is strongly associated with disease severity. 2, 3
• Pain management: NSAIDs for symptomatic relief. 2, 3
• Wound care: Appropriate dressings for draining lesions. 2, 3

Special Populations

Pregnancy

• Systemic antibiotics: Avoid oral erythromycin due to increased risk of elevated liver enzymes; use rifampin with caution. 1
• Anti-androgens: Metformin is safe for use in pregnancy. 1
• Biologics: Continue adalimumab throughout pregnancy if well-controlled; consult pediatrician about timing of live vaccines in neonates with in-utero biologic exposure. 1

Breastfeeding

• Systemic antibiotics: Use rifampin, amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole; exercise caution with clindamycin (GI side effects in infant); limit doxycycline to 3 weeks maximum. 1
• Biologics: Likely safe during breastfeeding based on pharmacokinetics (large proteins not well-absorbed by infant GI tract). 1

Adolescents (12 years and older)

• Adalimumab is FDA-approved for moderate to severe hidradenitis suppurativa in patients ≥12 years with weight-based dosing. 4

Critical Pitfalls to Avoid

• Do NOT continue ineffective antibiotics beyond 12 weeks without reassessment—this increases antimicrobial resistance risk without benefit. 2, 3
• Do NOT use tetracyclines as first-line for Hurley Stage II with abscesses—they are ineffective for deep inflammatory lesions and sinus tracts. 2, 3
• Do NOT use topical clindamycin alone for Hurley Stage II—it only reduces superficial pustules, not inflammatory nodules or abscesses. 2
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance. 2
• Almost half of adalimumab responders at week 12 may lose response by week 36 despite continued weekly dosing—monitor closely. 5