What are the treatment options for a patient with Hidradenitis Suppurativa (HS)?

Treatment of Hidradenitis Suppurativa

For mild HS (Hurley Stage I), start with topical clindamycin 1% twice daily for 12 weeks; for moderate disease (Hurley Stage II), use clindamycin 300 mg plus rifampicin 300-600 mg orally twice daily for 10-12 weeks; for severe or refractory disease, adalimumab 40 mg weekly is the first-line biologic, with surgical excision reserved for extensive disease with sinus tracts and scarring. 1, 2

Disease Severity Assessment

• Document Hurley stage at baseline for the worst-affected region to guide treatment selection 1, 2:

  • Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 2
  • Hurley Stage II: Recurrent nodules with limited sinus tracts and scarring 2
  • Hurley Stage III: Diffuse involvement with multiple interconnected sinus tracts and scarring 1

• Immediate dermatology referral is mandatory for Hurley Stage III disease 1, 2

• Screen all patients at baseline for depression, anxiety, cardiovascular risk factors (hypertension, diabetes, hyperlipidemia), and inflammatory bowel disease if persistent GI symptoms are present 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
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 2

Acute flares:

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) injected directly into inflamed nodules provides rapid symptom relief within 1 day, with significant reductions in erythema, edema, suppuration, and pain 1, 2

Reassess at 12 weeks using pain VAS score, inflammatory lesion count, and quality of life measures (DLQI) 2

Hurley Stage II (Moderate Disease)

First-line systemic therapy:

• 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) 2

Alternative first-line option (for more widespread mild disease without deep abscesses):

• Doxycycline 100 mg once or twice daily for 12 weeks 1, 2
• Critical pitfall: Do NOT use doxycycline as first-line for Hurley Stage II with abscesses or deep inflammatory nodules, as it has minimal effect on these lesions 2

Reassess at 12 weeks:

• If inadequate response after clindamycin-rifampicin, escalate to adalimumab 2
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Hurley Stage III (Severe Disease) or Failed Conventional Therapy

First-line biologic therapy:

• Adalimumab dosing per FDA label 3:
  • Adults: 160 mg at week 0 (given in one day or split over two consecutive days), 80 mg at week 2, then 40 mg every week starting at week 4 1, 2, 3
  • Adolescents ≥12 years, 60 kg and greater: Same as adult dosing 1, 3
  • Adolescents ≥12 years, 30-60 kg: 80 mg at day 1, then 40 mg every other week starting day 8 1, 3
• HiSCR response rates of 42-59% at week 12 in placebo-controlled trials 2
• Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS—this dosing is ineffective 1

Second-line biologic options (if adalimumab fails after 16 weeks):

• Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks 1, 2
• Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients at 16-52 weeks) 1, 2
• Ustekinumab for patients ≥6 years old 1, 2

Surgical intervention:

• Extensive/radical excision is necessary for lasting cure in advanced disease with sinus tracts and scarring when conventional systemic treatments have failed 1, 2
• Deroofing for recurrent nodules and tunnels in localized disease 2
• Secondary intention healing or TDAP flap closure for axillary wounds 1
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2

Pediatric Considerations (Ages 2-17 Years)

Topical therapy:

• Topical clindamycin 1% twice daily combined with antiseptic washes to decrease bacterial resistance 1, 2, 4

Systemic antibiotics:

• Doxycycline 100 mg once or twice daily for patients ≥8 years old 1, 4
• Clindamycin 300 mg plus rifampicin 300 mg twice daily for 10-12 weeks 1

Biologic therapy:

• Adalimumab is FDA-approved for ages ≥12 years (strong recommendation) and suggested for ages 2-11 years 1, 4, 3
• Weight-based dosing for ages 2-11 years: 10 mg every other week (10-15 kg), 20 mg every other week (15-30 kg), 40 mg every other week (≥30 kg) 1
• Infliximab, secukinumab, and ustekinumab are suggested for patients ≥6 years old 1

Hormonal therapy:

• Spironolactone suggested for adolescent females requiring anti-androgens 1, 4
• Combined oral contraceptives suggested for adolescent females 1, 4
• Metformin especially in cases of insulin resistance 1, 4

Special Populations

Pregnancy

Systemic antibiotics:

• Avoid oral erythromycin due to increased risk of elevated liver enzymes 1
• Rifampin can be used with an approach similar to other HS populations 1

Anti-androgens:

• Metformin is safe for use in pregnancy 1

Biologics:

• Continue biologic therapy throughout pregnancy if well-controlled 1
• Adalimumab is the recommended biologic during pregnancy 1
• Infliximab and secukinumab can be used with an approach similar to other HS populations 1
• 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 1
• Exercise caution with clindamycin (may increase GI side effects in infant) 1
• Limit doxycycline to 3 weeks without repeating courses 1

Biologics:

• Biologics are likely safe during breastfeeding based on pharmacokinetics, as these are large proteins not well-absorbed by the GI tract 1

History of Malignancy

• Doxycycline is safe in patients with history of malignancy 1
• Intralesional steroids can be used for acute, localized flares 1

Mandatory Adjunctive Measures for All Patients

• Smoking cessation referral where relevant (tobacco use worsens outcomes) 1, 2
• Weight management referral where relevant (obesity worsens outcomes) 1, 2
• Pain management with NSAIDs for symptomatic relief 2, 4
• Appropriate wound dressings for draining lesions 1, 2
• Screen for depression/anxiety at baseline and during follow-up 1, 2
• Screen for cardiovascular risk factors (measure BP, lipids, HbA1c) 1, 2

Treatment Response Monitoring

• Reassess at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 2
• Measure pain VAS score, inflammatory lesion count, and DLQI 1, 2
• For adalimumab, if no clinical response after 16 weeks, consider alternative treatments 2

Long-Term Monitoring for Complications

In patients with long-standing moderate-to-severe HS, monitor for:

• Fistulating gastrointestinal disease 1, 2
• Inflammatory arthritis 1, 2
• Genital lymphoedema 1, 2
• Cutaneous squamous cell carcinoma 1, 2
• Anemia 1, 2

Treatments NOT Recommended

• Do NOT use isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 1
• Do NOT use etanercept for moderate-to-severe HS 1
• Do NOT use cryotherapy or microwave ablation 1
• Insufficient evidence to recommend alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, fumaric acid esters, methotrexate, oral prednisolone (except acute flares), phototherapy, or radiotherapy 1