What are the treatment options for a patient with hydradenitis 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 (Stage I), clindamycin 300 mg plus rifampicin 300-600 mg orally twice daily for 10-12 weeks for moderate disease (Stage II), and adalimumab 40 mg weekly as first-line biologic for severe disease (Stage III). 1, 2, 3

Initial Assessment

Before initiating treatment, document the following:

• Hurley staging for the worst-affected anatomical region: Stage I (isolated nodules/abscesses without sinus tracts), Stage II (recurrent nodules with limited sinus tracts and scarring), or Stage III (diffuse involvement with multiple interconnected sinus tracts) 1, 2, 3
• Pain severity using Visual Analog Scale (VAS) 1, 2
• Quality of life impact using Dermatology Life Quality Index (DLQI) 1, 2
• Inflammatory lesion count (nodules, abscesses, draining fistulas) to establish baseline for HiSCR response monitoring 1

Screen for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, inflammatory bowel disease, and inflammatory arthritis 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 antiseptic washes (chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione) daily to reduce Staphylococcus aureus colonization and antimicrobial resistance risk 1, 2

For 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, 3

Reassessment at 12 weeks:

• If inadequate response, escalate to Hurley Stage II treatment regimen 1, 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, 3
• This combination achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy (30% abscess reduction) 1, 3
• Continue topical clindamycin 1% and antiseptic washes as adjunctive therapy 1, 2

Alternative first-line options (if clindamycin-rifampicin contraindicated):

• Doxycycline 100 mg once or twice daily for 12 weeks (acceptable for widespread mild disease or mild Hurley Stage II without deep inflammatory lesions or abscesses) 1
• Tetracycline 500 mg twice daily for up to 4 months 1

Critical pitfall: 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, 3

Reassessment at 12 weeks:

• Measure pain VAS score, inflammatory lesion count, number of flares, and DLQI 1, 2
• If no clinical response after 12 weeks, escalate to adalimumab 1, 3

Hurley Stage III (Severe Disease)

Immediate dermatology referral is mandatory 1, 2, 3

First-line biologic therapy:

• Adalimumab (FDA-approved for moderate-to-severe HS in patients ≥12 years old): 4
  • Adults: 160 mg at Week 0 (single dose or split over two consecutive days), 80 mg at Week 2, then 40 mg weekly starting Week 4 1, 2, 3, 4
  • Adolescents 12-17 years weighing 30-60 kg: 80 mg Day 1, then 40 mg every other week starting Day 8 4
  • Adolescents ≥60 kg: Adult dosing 4
• Achieves HiSCR response rates of 42-59% at week 12 in placebo-controlled trials 1, 3

Response assessment:

• Evaluate at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 1, 2, 3
• If no clinical response by Week 16, consider alternative treatments 1, 3, 4

Second-line biologic options after adalimumab failure:

• Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks (higher doses and more frequent intervals supported for severe refractory cases) 5, 1, 2
• Secukinumab (response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks; can be used in combination with infliximab for treatment-refractory disease) 5, 1
• Ustekinumab (conditional strength, moderate quality evidence) 5, 1

Surgical Interventions

Indications for surgery:

• Extensive disease with sinus tracts and scarring when conventional systemic treatments have failed 1, 2, 3
• Surgery is often necessary for lasting cure in advanced disease 1, 3

Surgical options:

• Deroofing for recurrent nodules and tunnels 1
• Radical surgical excision (wide local excision) for extensive disease with the width of excision influencing therapeutic outcome 1, 2, 3
• Wound closure options: secondary intention healing, TDAP flap, delayed primary closure, skin grafts, or substitutes 1, 2

Combined approach: Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1

Special Populations

Pediatric Patients

Ages 8 years and older requiring systemic antibiotics:

• Doxycycline 100 mg once or twice daily 1
• Clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks 1

Ages 12 years and older with moderate-to-severe disease:

• Adalimumab with weight-based dosing (FDA-approved) 1, 4

Patients with History of Malignancy

Systemic antibiotics:

• Oral clindamycin (safe with monitoring for severe diarrhea and C. difficile colitis) 5
• Oral dapsone (unlikely to be associated with increased risks based on mechanism of action) 5
• IV ertapenem for severe, recalcitrant cases 5

Anti-androgens:

• Metformin (strong recommendation due to evidence of safety and potential survival benefit in certain malignancies) 5
• Spironolactone, oral contraceptives, finasteride (conditional recommendations) 5

Systemic immunomodulators:

• Prednisone for acute, widespread flares 5
• Methotrexate as adjunct to prevent anti-TNF antibody formation 5
• Oral retinoids (exposure does not increase risk of recurrent malignancy) 5

Biologics:

• Consult with oncologist and consider activity of HS, patient age, cancer characteristics (organ, stage, histologic type, prognosis), time since completion of cancer treatment, and individual carcinogenic effects 5
• Anti-TNFs for patients in remission >5 years, especially in non-high-risk malignancies 5
• Secukinumab or ustekinumab for patients with malignancy in last 5 years (conditional, low quality evidence) 5

Breastfeeding Patients

• Amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole 1
• Limit doxycycline to ≤3 weeks without repeating courses 1

Patients with HIV

• Avoid rifampicin due to drug interactions with certain HIV therapies 1
• Use doxycycline for added prophylactic benefit against bacterial STIs 1

Mandatory Adjunctive Measures for All Patients

Regardless of disease severity or treatment regimen:

• Smoking cessation referral (tobacco use has odds ratio of 36 for HS and worsens outcomes) 1, 2, 6
• Weight management referral if BMI elevated (obesity has odds ratio of 33 for HS; substantial weight loss associated with symptom improvement) 1, 2, 6
• Pain management with NSAIDs for symptomatic relief; consider opioids for severe pain 1, 2
• Appropriate wound dressings for draining lesions (select based on drainage amount, anatomical location, and patient preference) 1, 2
• Screen for depression/anxiety 1, 2
• Screen for cardiovascular risk factors (measure blood pressure, lipids, HbA1c) 1, 2

Treatment Breaks and Antimicrobial Stewardship

• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk 1
• Combine topical clindamycin with benzoyl peroxide to reduce Staphylococcus aureus resistance risk 1

Long-Term Monitoring for Complications

Monitor patients with long-standing moderate-to-severe HS for:

• Fistulating gastrointestinal disease 2, 3
• Inflammatory arthritis 2, 3
• Genital lymphoedema 2, 3
• Cutaneous squamous cell carcinoma 2, 3
• Anemia 2, 3

Tuberculosis Screening

• Screen for latent TB prior to initiating biologics using TST and/or IGRA 5
• If latent TB positive, treat with 4-month course of oral rifampin before starting biologics 5
• Annual TB screening if on glucocorticoids >15 mg prednisone equivalent daily for ≥4 weeks 5, 2
• Monitor all patients for active TB during biologic treatment, even if initial latent TB test negative 5, 4