What is the initial treatment for a patient with Hidradenitis Suppurativa (HS) on the thighs?

Treatment for Hidradenitis Suppurativa on the Thighs

For HS on the thighs, start with clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks, combined with intralesional triamcinolone 10 mg/mL injected directly into any acutely inflamed nodules or abscesses. 1, 2

Initial Assessment Before Treatment

Determine Hurley stage by examining the thighs for:

• Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 2
• Hurley Stage II: Recurrent nodules with limited sinus tracts and some scarring 1, 2
• Hurley Stage III: Extensive sinus tracts, scarring, and diffuse involvement 1, 2

Document baseline inflammatory lesion count (nodules, abscesses, draining fistulas) and pain using Visual Analog Scale (VAS) to track treatment response 2

Screen for comorbidities: depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease 2, 3

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I - Isolated Nodules Only)

First-line: Topical clindamycin 1% solution/gel applied twice daily to all affected thigh areas for 12 weeks 1, 2

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 2
• Add intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for any inflamed nodules—provides rapid symptom relief within 1 day with significant reductions in pain, erythema, and edema 1, 2

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, 2

Moderate Disease (Hurley Stage II - Recurrent Nodules with Abscesses)

First-line: 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, 2
• Add intralesional triamcinolone 10 mg/mL for acutely inflamed nodules 1, 2

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

Reassess at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 2, 3

If inadequate response after 12 weeks: Escalate to adalimumab 1, 2

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

First-line biologic: Adalimumab with the following dosing schedule 1, 2, 4:

• Day 1: 160 mg subcutaneous (single dose or split over two consecutive days)
• Day 15: 80 mg subcutaneous
• Day 29 and ongoing: 40 mg weekly subcutaneous

Critical pitfall: 40 mg every other week is insufficient dosing and not recommended 5

Assess response at 12-16 weeks using HiSCR 2, 3

If adalimumab fails after 16 weeks, second-line biologic options include 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) 1, 2
• Ustekinumab (alternative IL-12/23 pathway targeting) 1, 2

Surgical Considerations

Combine adalimumab with surgery for extensive disease with sinus tracts and scarring—this combination results in greater clinical effectiveness than adalimumab monotherapy 3

Surgical options 1, 2:

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

Non-surgical methods rarely result in lasting cure for advanced disease 2, 5

Mandatory Adjunctive Measures (All Patients)

Smoking cessation referral: Tobacco use is associated with dramatically worse outcomes (odds ratio 36) 3, 6

Weight management referral if BMI elevated: Obesity significantly worsens disease (odds ratio 33) and predicts poor antibiotic response 3, 7

Pain management: NSAIDs for symptomatic relief 1, 2

Appropriate wound dressings for draining lesions 2

Treatment Duration and Monitoring

For clindamycin-rifampicin: Treat for 10-12 weeks, then consider treatment breaks to assess ongoing need and limit antimicrobial resistance 1, 2

For adalimumab: Continue 40 mg weekly indefinitely if achieving HiSCR response 4

Monitor at 12 weeks using objective measures: HiSCR, pain VAS score, inflammatory lesion count, and DLQI quality of life score 2, 3

Critical Pitfalls to Avoid

Do NOT use topical clindamycin alone for Hurley Stage II—it only reduces superficial pustules, not inflammatory nodules or abscesses 2

Do NOT continue doxycycline beyond 4 months without reassessment—prolonged use increases antimicrobial resistance risk without proven additional benefit 2

Do NOT use tetracyclines as first-line for Hurley Stage II with deep inflammatory lesions or abscesses 2

Topical clindamycin may increase Staphylococcus aureus resistance; combine with benzoyl peroxide to reduce this risk 2, 5