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

Treatment for 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 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4. 1, 2, 3, 4

Initial Assessment and Staging

• Examine all intertriginous areas (axillae, groin, inframammary, perianal) to determine Hurley stage and total disease burden 2
• Document baseline pain using Visual Analog Scale (VAS) and count inflammatory lesions (nodules, abscesses, draining tunnels) 2, 5
• Screen immediately for comorbidities: depression/anxiety, diabetes, hypertension, hyperlipidemia, inflammatory bowel disease (if GI symptoms present) 1, 2
• Refer to smoking cessation services and weight management if relevant 1, 2

Treatment by Disease Severity

Hurley Stage I (Mild Disease: Isolated Nodules Without Sinus Tracts)

• First-line: Topical clindamycin 1% solution/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, 3
• Adjunctive: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules provides rapid relief within 1 day 1, 2
• Reassess at 12 weeks using pain VAS, lesion count, and DLQI 2, 5
• If inadequate response after 12 weeks, escalate to oral tetracyclines (doxycycline 100 mg once or twice daily for 12 weeks) 1, 2

Hurley Stage II (Moderate Disease: Recurrent Nodules with Limited Sinus Tracts)

• First-line: 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 (30% abscess reduction) 2
• Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses, as these have minimal effect on deep inflammatory lesions 2
• Intralesional triamcinolone 10 mg/mL for acutely inflamed nodules and abscesses 2
• Reassess at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 2, 5
• If no response after 12 weeks, escalate to adalimumab 2, 3

Hurley Stage III (Severe Disease: Extensive Sinus Tracts and Scarring)

• Immediate referral to dermatology 1, 2
• First-line biologic: Adalimumab (FDA-approved for moderate-to-severe HS in patients ≥12 years) 1, 2, 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 2, 3, 4
  • Adolescents 12-17 years, 30-60 kg: 80 mg at day 1, then 40 mg every other week starting day 8 4
  • Adolescents ≥60 kg: Same as adult dosing 4
  • HiSCR response rates: 42-59% at week 12 2
• Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS—this dosing is ineffective 1
• If no response after 16 weeks of adalimumab, consider second-line biologics 2, 5

Second-Line Biologic Options After Adalimumab Failure

• Infliximab: 5 mg/kg at weeks 0,2,6, then every 8 weeks 1, 2
• Secukinumab: Response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 2
• Ustekinumab: Alternative targeting different cytokine pathways 2

Alternative Systemic Therapies (For Patients Unresponsive to Antibiotics)

• Acitretin: 0.3-0.5 mg/kg/day in males and non-fertile females 1, 2
• Dapsone: Starting at 50 mg daily, titrating up to 200 mg daily 1, 2
• Metformin: Consider in patients with concomitant diabetes or PCOS 1

Surgical Interventions

• Deroofing: For recurrent nodules and tunnels in localized disease 2
• Radical surgical excision: For extensive disease with sinus tracts and scarring when conventional systemic treatments have failed 1, 2
  • Width of excision influences therapeutic outcome; non-recurrence rates of 81.25% after wide excision 3
  • Healing by secondary intention or TDAP (thoracodorsal artery perforator) flap closure for axillary wounds 1, 2
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2

Mandatory Adjunctive Measures for All Patients

• Pain management with NSAIDs for symptomatic relief 1, 2, 5
• Appropriate wound dressings for draining lesions 1, 2
• Smoking cessation referral (tobacco use worsens outcomes) 1, 2, 5
• Weight management referral if BMI elevated 1, 2, 5
• Screen for depression/anxiety 1, 2
• Screen for cardiovascular risk factors: measure BP, lipids, HbA1c 1, 2

Critical Pitfalls to Avoid

• Do NOT offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 1
• Do NOT offer etanercept for moderate-to-severe HS—it is ineffective 1
• Do NOT offer cryotherapy during the acute phase due to pain from the procedure 1, 2
• Avoid long-term antibiotic use without treatment breaks to reduce 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

Monitoring and Reassessment

• Reassess at 12 weeks using pain VAS score, inflammatory lesion count, number of flares, and DLQI 2, 5
• For patients on adalimumab, use HiSCR to measure treatment response 2, 5
• Monitor long-standing moderate-to-severe HS for fistulating gastrointestinal disease, inflammatory arthritis, genital lymphoedema, cutaneous squamous cell carcinoma, and anemia 1