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

Treatment of Hidradenitis Suppurativa

For mild disease (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 disease (Hurley Stage III) or failure of antibiotics, initiate adalimumab with loading doses of 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4. 1, 2, 3

Disease Severity Assessment

• Determine Hurley stage to guide treatment selection: Stage I (isolated nodules without sinus tracts), Stage II (recurrent nodules with limited sinus tracts and scarring), Stage III (extensive disease with multiple interconnected sinus tracts and scarring) 1, 2
• Document baseline inflammatory lesion count (abscesses and nodules), pain using Visual Analog Scale (VAS), and quality of life using Dermatology Life Quality Index (DLQI) 1, 2
• Screen for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease at initial evaluation 1

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

• 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 1
• Add intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules, providing rapid symptom relief within 1 day 1

Hurley Stage II (Moderate Disease)

• First-line: Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks, achieving response rates of 71-93% 1, 2, 3
• Alternative first-line: Doxycycline 100 mg once or twice daily for 12 weeks for widespread mild disease or mild Hurley Stage II without deep inflammatory lesions or abscesses 1
• Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses, as these show only 30% abscess reduction and have minimal effect on deep inflammatory lesions 1
• Reassess at 12 weeks using pain VAS score, inflammatory lesion count, number of flares, and DLQI 1

Hurley Stage III (Severe Disease) or Antibiotic Failure

• First-line biologic: Adalimumab 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4, achieving HiSCR response rates of 42-59% at week 12 1, 2, 3, 4
• Adalimumab is FDA-approved for moderate-to-severe hidradenitis suppurativa in patients 12 years of age and older 4
• Assess treatment response at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 1, 2
• If no clinical response after 16 weeks of adalimumab, escalate to second-line biologics: infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1
• Alternative second-line biologics after adalimumab failure: secukinumab (response rates 64.5-71.4% in adalimumab-failure patients) or ustekinumab 1

Treatment Escalation Pathway

• If no response after 12 weeks of topical clindamycin, escalate to oral tetracyclines (doxycycline 100 mg once or twice daily for 12 weeks) 1
• If no response after 12 weeks of tetracyclines, escalate to clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks 1
• If no response after 12 weeks of clindamycin-rifampicin, escalate directly to adalimumab 1, 2
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

Surgical Interventions

• Radical surgical excision is recommended for extensive disease with sinus tracts and scarring that fails medical management, with non-recurrence rates of 81.25% after wide excision 1, 3
• Deroofing is recommended for recurrent nodules and tunnels in localized disease 1
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy for extensive disease 1
• Wound closure options include healing by secondary intention, skin grafts, TDAP flap, or other reconstructive methods 1

Mandatory Adjunctive Therapies (All Patients)

• Smoking cessation referral is critical, as tobacco use is associated with worse outcomes 1, 2, 3
• Weight management referral for patients with elevated BMI, as obesity worsens outcomes 1, 2, 3
• Pain management with NSAIDs for symptomatic relief 1, 2, 3
• Appropriate wound dressings for draining lesions 1, 2
• Screen for depression/anxiety and provide mental health referrals as needed 1
• Screen for cardiovascular risk factors (measure blood pressure, lipids, HbA1c) 1

Special Populations

Pediatric Patients

• For children 12 years and older with moderate-to-severe disease: adalimumab is FDA-approved with weight-based dosing 1, 4
• For children 8 years and older requiring systemic antibiotics: doxycycline 100 mg once or twice daily, or clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks 1

Pregnancy and Breastfeeding

• For breastfeeding patients: use amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole 1
• Limit doxycycline to ≤3 weeks in breastfeeding patients without repeating courses 1

HIV-Positive Patients

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

Critical Pitfalls to Avoid

• Do NOT use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules, not inflammatory nodules or abscesses 1
• Do NOT continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit 1
• Do NOT use cryotherapy or microwave ablation for treating lesions during the acute phase 1
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk 1

Monitoring and Follow-Up

• Reassess all patients at 12 weeks using pain VAS score, inflammatory lesion count, number of flares, and DLQI 1, 2
• For patients on adalimumab, assess HiSCR at 12 weeks and consider alternative treatments if no clinical response by 16 weeks 1, 2
• Monitor for treatment-related adverse events, particularly infections and malignancies with biologic therapy 4