What is the recommended approach for using oral corticosteroids (e.g. prednisone) in a patient with Hidradenitis Suppurativa (HS)?

Oral Corticosteroids in Hidradenitis Suppurativa

Primary Recommendation

Oral corticosteroids (prednisone) should be reserved exclusively for acute, widespread flares of hidradenitis suppurativa and are not appropriate for routine or long-term management. 1

Clinical Role and Indications

Prednisone has a highly limited role in HS management:

• Use prednisone only for acute, widespread flares in patients who require rapid symptom control while awaiting response to definitive therapies 1
• Prednisone is suggested with conditional strength and low-quality evidence specifically for this narrow indication 1
• Do not use oral corticosteroids as maintenance therapy for HS, as the disease requires chronic management and corticosteroids carry unacceptable long-term risks 1

Special Population Considerations

Patients with History of Malignancy

• In patients with prior malignancy requiring systemic immunomodulators for HS, prednisone is suggested for acute, widespread flares (conditional recommendation, low quality) 1
• This represents one of the safer immunosuppressive options in this population for short-term use 1

Pediatric Patients

• In pediatric patients with HS requiring systemic immunomodulators, prednisone is suggested for acute, widespread flares only 1
• The same restrictions apply: short-term use for acute exacerbations, not maintenance therapy 1

Patients Requiring Tuberculosis Screening

• If prednisone dose exceeds 15 mg daily (prednisone equivalent) for at least 4 weeks, annual screening for latent TB is mandatory 1
• This threshold is critical for infection risk stratification 1

Treatment Algorithm Position

Oral corticosteroids occupy a very specific niche in the HS treatment hierarchy:

For Mild Disease (Hurley Stage I):

• First-line: Topical clindamycin 1% twice daily for 12 weeks 2, 3
• Intralesional triamcinolone 10 mg/mL for acute inflamed nodules 2, 3
• No role for oral corticosteroids 1, 2

For Moderate Disease (Hurley Stage II):

• First-line: Clindamycin 300 mg + rifampicin 300-600 mg orally twice daily for 10-12 weeks 2, 3
• Alternative: Doxycycline 100 mg once or twice daily for 12 weeks 2
• Oral prednisone only if acute widespread flare occurs during treatment 1

For Severe Disease (Hurley Stage III):

• First-line biologic: Adalimumab 160 mg week 0,80 mg week 2, then 40 mg weekly 2, 3
• Prednisone may be used as bridge therapy during biologic initiation for severe acute flares 1
• Transition off prednisone as biologic takes effect 4

Critical Evidence Gaps and Limitations

The evidence supporting oral corticosteroids in HS is notably weak:

• No randomized controlled trials exist evaluating oral corticosteroids specifically for HS 1, 2
• The 2019 British Association of Dermatologists guidelines state there is insufficient evidence to recommend oral prednisolone for HS 1
• The 2025 North American guidelines upgraded this to a conditional suggestion for acute flares only, but still with low-quality evidence 1

Why Corticosteroids Are Not Standard HS Therapy

HS is fundamentally different from other inflammatory dermatoses:

• HS requires chronic, long-term management due to its relapsing-remitting nature 5, 4
• Corticosteroids do not address the underlying follicular occlusion and bacterial colonization that drive HS pathophysiology 5, 6
• Recurrence rates are extremely high after corticosteroid discontinuation 5
• Long-term corticosteroid use carries unacceptable risks: infections, hypertension, osteoporosis, weight gain, glucose intolerance 7

Preferred Alternatives to Oral Corticosteroids

For Acute Lesion Control:

• Intralesional triamcinolone 10 mg/mL provides rapid symptom relief within 1 day for individual inflamed nodules 2, 3, 8
• Complete response in 70.37% of lesions, partial response in 25.19% 8
• Significantly reduces erythema, edema, suppuration, and pain 2, 8

For Systemic Control:

• Clindamycin 300 mg + rifampicin 300-600 mg twice daily achieves 71-93% response rates 2, 3
• Adalimumab achieves HiSCR response in 42-59% at week 12 2, 3
• These therapies can be continued long-term without the toxicity profile of corticosteroids 2, 4

Common Pitfalls to Avoid

• Do not prescribe oral corticosteroids as first-line therapy for any stage of HS 1, 2
• Do not use oral corticosteroids for maintenance therapy or repeated courses 1, 5
• Do not use corticosteroids instead of definitive therapy (antibiotics, biologics, surgery) 4
• Do not forget TB screening if prednisone ≥15 mg daily for ≥4 weeks 1
• Do not apply topical corticosteroids to active HS lesions, as this can worsen infection risk 7

Practical Implementation

When oral corticosteroids are deemed necessary for an acute widespread flare:

• Use the lowest effective dose for the shortest duration (typically prednisone 20-40 mg daily for 5-10 days) 6
• Simultaneously initiate or optimize definitive therapy (clindamycin-rifampicin or adalimumab) 4
• Taper rapidly as acute inflammation subsides 6
• Do not repeat courses without addressing why definitive therapy is failing 4