Hidradenitis Suppurativa Treatment
For patients with hidradenitis suppurativa and diabetes, initiate treatment based on Hurley staging: 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), or adalimumab for severe disease (Stage III), while simultaneously screening for cardiovascular risk factors and considering metformin as adjunctive therapy given the diabetes comorbidity. 1, 2
Initial Assessment and Comorbidity Screening
Document Hurley stage for the worst-affected anatomical region at baseline to determine treatment pathway 1, 2. For Hurley Stage III (severe) disease with diffuse involvement, sinus tracts, and scarring, consider immediate referral to dermatology 1.
Screen all patients with HS for metabolic comorbidities, including diabetes, hypertension, hyperlipidemia, and central obesity, as these occur at significantly higher rates in HS patients 1, 2, 3. Measure blood pressure, lipid panel, and HbA1c at baseline 1, 2. Additionally, screen for depression and anxiety, as quality of life is profoundly impacted 1, 2.
For patients with diabetes specifically, consider metformin as it may provide dual benefit for both glycemic control and HS disease activity 1. This is particularly relevant for females with polycystic ovary syndrome 1.
Treatment Algorithm by Disease Severity
Hurley Stage I (Mild Disease)
Offer topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks as first-line therapy 1, 4, 2. This reduces superficial pustules but has no effect on inflammatory nodules or abscesses 1, 4.
Combine topical clindamycin with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk, which increases significantly with clindamycin monotherapy 1, 4, 2.
Consider intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed individual nodules, which provides rapid symptom relief within 1 day with significant reductions in erythema, edema, suppuration, and pain 1, 4, 2.
Hurley Stage II (Moderate Disease)
Offer clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks as first-line therapy for moderate disease 1, 2. This combination achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy which shows only 30% abscess reduction 1, 5.
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 such lesions 1, 5. Tetracyclines are only appropriate for more widespread mild disease or mild Hurley Stage II without deep inflammatory lesions 1, 5.
If tetracyclines are used (doxycycline 100 mg once or twice daily for 12 weeks), consider treatment breaks after 12 weeks to assess need for ongoing therapy and limit antimicrobial resistance 1, 5.
Hurley Stage III (Severe Disease) or Refractory Cases
Offer adalimumab 160 mg subcutaneously at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 for moderate-to-severe HS unresponsive to conventional systemic therapy 1, 5, 2. This is the only FDA-approved biologic for HS in patients ≥12 years old 1, 5.
Adalimumab achieves HiSCR (Hidradenitis Suppurativa Clinical Response: ≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) response rates of 42-59% at week 12 1, 5, 2.
Do NOT use adalimumab 40 mg every other week, as this dosing is ineffective for HS 2.
If adalimumab fails after 16 weeks, consider infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks as second-line biologic therapy 1, 2. Alternative second-line biologics include secukinumab (response rates 64.5-71.4% in adalimumab-failure patients) and ustekinumab 1, 5.
Alternative Systemic Therapies
Consider acitretin 0.3-0.5 mg/kg/day in males and non-fertile females who are unresponsive to antibiotic therapies 1, 2.
Consider dapsone starting at 50 mg daily, titrating up to 200 mg daily for patients unresponsive to antibiotic therapies 1, 5, 2.
Surgical Interventions
Offer radical surgical excision for extensive disease with sinus tracts and scarring when conventional systemic treatments have failed 1, 2. The width of excision influences therapeutic outcome 1, 2.
Consider combining adalimumab with surgery for greater clinical effectiveness than adalimumab monotherapy 5, 2.
Wound closure options include secondary intention healing, TDAP flap, delayed primary closure, or skin grafts 1, 2.
Mandatory Adjunctive Measures for All Patients
Refer to smoking cessation services, as smoking has an odds ratio of 36 for HS and worsens outcomes 1, 5, 2.
Refer to weight management services if BMI is elevated, as obesity has an odds ratio of 33 for HS 1, 5, 2.
Provide pain management with NSAIDs for symptomatic relief; consider opioids for severe pain 1, 2.
Provide appropriate wound dressings for pus-producing lesions, selecting based on drainage amount and anatomical location 1, 2.
Treatment Monitoring and Reassessment
Reassess treatment response at 12 weeks using pain Visual Analog Scale (VAS) score, inflammatory lesion count, number of flares, and Dermatology Life Quality Index (DLQI) 1, 2.
For patients on adalimumab, measure treatment response using HiSCR and patient-reported outcomes 1, 2. If no clinical response by week 16, escalate to alternative treatments 5, 2.
Long-Term Monitoring
In patients with long-standing moderate-to-severe HS, monitor for fistulating gastrointestinal disease, inflammatory arthritis, genital lymphoedema, cutaneous squamous cell carcinoma, and anemia 1, 2.
Critical Pitfalls to Avoid
Do NOT offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 2.
Do NOT offer etanercept for moderate-to-severe HS, as it is ineffective 2.
Do NOT use topical clindamycin alone for Hurley Stage II with abscesses, as it only reduces superficial pustules, not inflammatory nodules or abscesses 5, 4.
Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk 1, 5, 2.