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

Hidradenitis Suppurativa Treatment

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; and for severe or refractory disease (Hurley Stage III or failed 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

Initial Assessment

Before initiating treatment, perform the following:

• Determine Hurley stage by examining all intertriginous areas (axillae, groin, inframammary, buttocks) to assess disease burden and guide treatment selection 1, 2
• Document baseline inflammatory lesion count and pain using Visual Analog Scale 1
• Screen for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease (if persistent GI symptoms present) 1, 3
• Refer immediately to dermatology if Hurley Stage III disease is identified 2, 3

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 antiseptic wash (benzoyl peroxide, chlorhexidine 4%, or zinc pyrithione) daily to reduce Staphylococcus aureus resistance risk 1

For acute inflamed nodules:

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) provides rapid symptom relief within 1 day, significantly reducing erythema, edema, suppuration, and pain 1

If inadequate response after 12 weeks:

• Escalate to oral tetracyclines (see below) 1, 3

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

Alternative first-line (for widespread mild disease or mild Hurley Stage II without deep inflammatory lesions):

• Doxycycline 100 mg once or twice daily for 12 weeks 1, 3
• Lymecycline 408 mg once or twice daily for 12 weeks 1, 3
• Tetracycline 500 mg twice daily for up to 4 months 1

Critical caveat: Do NOT use tetracyclines as first-line for Hurley Stage II with abscesses or deep inflammatory nodules, as they have minimal effect on these lesions 1

If inadequate response after 12 weeks:

• If started on tetracyclines, escalate to clindamycin-rifampicin combination 1, 3
• If already on clindamycin-rifampicin or if this fails, escalate to adalimumab 1, 2

Hurley Stage III (Severe Disease) or Failed Conventional Therapy

First-line biologic therapy:

• Adalimumab is the FDA-approved biologic for moderate-to-severe HS in patients ≥12 years old 4

Adult dosing:

• Day 1: 160 mg (given in one day or split over two consecutive days)
• Day 15: 80 mg
• Day 29 and subsequent: 40 mg weekly 1, 2, 4
• Achieves HiSCR response rates of 42-59% at week 12 1, 2

Adolescent dosing (12 years and older):

• 30-60 kg: Day 1: 80 mg; Day 8 and subsequent: 40 mg every other week 4
• ≥60 kg: Same as adult dosing 4

If adalimumab fails after 16 weeks:

• Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks 1, 3
• Secukinumab (conditional recommendation, moderate quality evidence; response rates 64.5-71.4% in adalimumab-failure patients) 1
• Ustekinumab (conditional recommendation, moderate quality evidence) 1

Alternative systemic therapies (if biologics contraindicated or unavailable):

• Acitretin 0.3-0.5 mg/kg/day in males and non-fertile females 1
• Dapsone starting at 50 mg daily, titrating up to 200 mg daily 1
• Ertapenem 1g daily for 6 weeks as rescue therapy or during surgical planning for severe disease requiring IV antibiotics 1

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 2, 3, 5

Surgical options:

• Deroofing for recurrent nodules and tunnels 1
• Radical surgical excision for extensive disease with sinus tracts and scarring when conventional systemic treatments have failed 1, 2, 3
• Wound closure options: secondary intention healing, skin grafts, or flaps 1
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1

Mandatory Adjunctive Measures for All Patients

Regardless of disease severity or treatment chosen:

• Smoking cessation referral (tobacco use worsens outcomes) 1, 2, 3
• Weight management referral if BMI elevated (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 refer as needed 1, 2, 3
• Screen for cardiovascular risk factors (measure BP, lipids, HbA1c) 1, 2

Treatment Response Monitoring

Reassess at 12 weeks using:

• HiSCR (Hidradenitis Suppurativa Clinical Response): ≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas 1, 2
• Pain VAS score 1, 2
• Inflammatory lesion count 1, 2
• Quality of life measures (DLQI) 1, 2

For adalimumab: If no clinical response after 16 weeks, consider alternative treatments 1, 2

After antibiotic courses: Consider treatment breaks to assess need for ongoing therapy and limit antimicrobial resistance 1

Pediatric Considerations

For children ≥8 years 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

For adolescents ≥12 years with moderate-to-severe disease:

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

Critical Pitfalls to Avoid

• Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses or deep inflammatory nodules 1
• Do NOT use topical clindamycin alone for Hurley Stage II (only reduces superficial pustules, not inflammatory nodules or abscesses) 1
• Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS (this dosing is ineffective; weekly dosing is required) 1
• 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
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk 1
• Discontinue adalimumab if patient develops serious infection or sepsis 4

Therapies with Insufficient Evidence

The following therapies have insufficient evidence to recommend: alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, hydrocortisone, hyperbaric oxygen therapy, intravenous antibiotics (except ertapenem), isoniazid, laser and photodynamic therapies, methotrexate, oral prednisolone, oral zinc, phototherapy, photochemotherapy, radiotherapy, spironolactone, staphage lysate, tolmetin sodium 1

Do NOT use cryotherapy or microwave ablation for treating lesions during the acute phase 1

Long-Term Monitoring

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

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