What is the initial treatment approach for a patient with hidradenitis suppurativa?

Initial Treatment Approach for Hidradenitis Suppurativa

For newly diagnosed hidradenitis suppurativa, begin with Hurley staging assessment, then initiate topical clindamycin 1% twice daily for Hurley Stage I disease, oral tetracycline (doxycycline 100 mg or lymecycline 408 mg once or twice daily) for 12 weeks for moderate disease, or immediate referral to dermatology for Hurley Stage III disease. 1

Immediate Assessment Steps

Before initiating any treatment, document the following baseline parameters:

• Record Hurley stage (I, II, or III) for the worst affected regions—this determines your entire treatment pathway 1
• Measure pain using Visual Analog Scale (VAS) 1, 2
• Count inflammatory lesions (abscesses, nodules, draining fistulas) and document number of flares in the last month 1, 2
• Assess quality of life using Dermatology Life Quality Index (DLQI) 1, 2
• Screen for comorbidities: depression/anxiety, cardiovascular risk factors (blood pressure, lipids, HbA1c), type 2 diabetes 1, 2

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

First-line therapy:

• 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
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) can be injected into acutely inflamed nodules for rapid symptom relief within 1 day 2

If inadequate response after 12 weeks:

• Escalate to oral tetracycline therapy (see below) 1, 2

Hurley Stage II (Moderate Disease)

First-line therapy:

• Oral tetracycline: doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for 12 weeks 1, 2
• Continue topical clindamycin 1% twice daily 1
• Provide dressings for pus-producing lesions 1

Critical caveat: Doxycycline monotherapy shows only 30% abscess reduction and is NOT recommended as first-line for Hurley Stage II with abscesses or deep inflammatory nodules 2. For patients with active abscesses, proceed directly to second-line therapy.

Second-line therapy (or first-line for Hurley II with abscesses):

• 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 2
• Consider treatment break after completion to assess need for ongoing therapy and limit antimicrobial resistance 1, 2

Hurley Stage III (Severe Disease)

Immediate actions:

• Refer to dermatology secondary care immediately 1
• Consider immediate clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily while awaiting specialist evaluation 1
• Initiate adalimumab if clindamycin-rifampicin fails after 12 weeks or for extensive disease 2, 4

Adalimumab dosing (FDA-approved):

• Adults: 160 mg at Week 0 (single dose or split over two consecutive days), 80 mg at Week 2, then 40 mg weekly starting at Week 4 4
• Adolescents ≥12 years weighing 30-60 kg: 80 mg Day 1, then 40 mg every other week starting Day 8 4
• Adolescents ≥12 years weighing ≥60 kg: Use adult dosing 4

Mandatory Adjunctive Measures (All Stages)

These interventions must be addressed at initial presentation:

• Smoking cessation referral if relevant—tobacco use has an odds ratio of 36 for HS 1, 2
• Weight management referral if BMI elevated—obesity has an odds ratio of 33 for HS 1, 2
• Pain management with NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for draining lesions 1, 2
• Screen for depression/anxiety 1, 2
• Screen for cardiovascular risk factors (measure BP, lipids, HbA1c)—HS patients have nearly doubled risk of cardiovascular-associated death 1

Reassessment at 12 Weeks

Evaluate treatment response using:

• Pain VAS score 1, 2
• Inflammatory lesion count 1, 2
• Number of flares in the last month 1
• Quality of life (DLQI) 1, 2
• HiSCR (Hidradenitis Suppurativa Clinical Response) for patients on biologics: ≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas 2, 4

Treatment Escalation Pathway for Lack of Response

If no response after 12 weeks of first-line therapy:

1. Escalate to clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks 1, 2

If no response after 12 weeks of clindamycin-rifampicin: 2. Consider acitretin 0.3-0.5 mg/kg/day (for males or non-fertile females) OR dapsone 1, 2 3. Initiate adalimumab (dosing as above) 2, 4

If adalimumab fails after 16 weeks: 4. Second-line biologics: infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 2, secukinumab 2, or ustekinumab 2

For extensive disease with sinus tracts and scarring: 5. Refer to HS surgical multidisciplinary team for radical excision with healing by secondary intention, TDAP flap, or other reconstructive methods 1, 2

Critical Pitfalls to Avoid

• Do NOT use doxycycline as first-line for Hurley Stage II with abscesses—it has minimal effect on deep inflammatory lesions 2
• Do NOT continue antibiotics beyond 12-16 weeks without reassessment—this increases antimicrobial resistance risk 1, 2
• Do NOT use topical clindamycin alone for Hurley Stage II—it only reduces superficial pustules, not inflammatory nodules or abscesses 2
• Do NOT delay referral for Hurley Stage III disease—these patients require immediate specialist evaluation 1
• Do NOT overlook comorbidity screening—HS is associated with metabolic syndrome, inflammatory arthritis, inflammatory bowel disease, and doubled cardiovascular mortality risk 1, 5