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

Hidradenitis Suppurativa Treatment Approach

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; and for severe disease (Hurley Stage III) or failed antibiotic therapy, initiate adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4. 1, 2, 3

Initial Disease Severity Assessment

Determine Hurley stage to guide treatment selection: 1, 2, 3

• Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 2, 3
• Hurley Stage II: Recurrent nodules with limited sinus tracts and scarring 2, 3
• Hurley Stage III: Diffuse involvement with multiple interconnected sinus tracts and extensive scarring—requires immediate dermatology referral 2, 3

Document baseline metrics: pain using Visual Analog Scale (VAS), inflammatory lesion count, and affected body regions 1, 3

Screen for comorbidities: depression/anxiety, diabetes, hypertension, hyperlipidemia, inflammatory bowel disease, and inflammatory arthritis 1, 2, 4

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

First-line therapy: 1, 2, 3

• 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, 2

For acute inflamed nodules: 1, 2

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) provides rapid symptom relief within 1 day, with significant reductions in erythema, edema, suppuration, and pain 1, 2

Alternative topical option: 1

• Resorcinol 15% cream reduces pain and abscess duration, though irritant dermatitis is a common side effect 1, 5

Hurley Stage II (Moderate Disease)

First-line systemic therapy: 1, 2, 3

• 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, 2

Alternative first-line option for widespread mild disease or mild Hurley Stage II without deep inflammatory lesions: 1

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

Critical pitfall: 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 deep inflammatory lesions 1

Hurley Stage III (Severe Disease) or Failed Antibiotic Therapy

First-line biologic therapy: 1, 2, 3, 6

• Adalimumab dosing (FDA-approved): 1, 2, 3, 6

  • Week 0: 160 mg (given in one day or split over two consecutive days)
  • Week 2: 80 mg
  • Week 4 and beyond: 40 mg weekly

• 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, 2

Critical pitfall: Do NOT use adalimumab 40 mg every other week—this dosing is ineffective and not recommended 1, 3

Second-line biologic options after adalimumab failure: 1

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1
• Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients at 16-52 weeks) 1
• Ustekinumab 1

Treatment Response Assessment

Reassess at 12 weeks using: 1, 2, 3

• HiSCR (≥50% reduction in inflammatory lesions) 1, 2, 3
• Pain VAS score 1, 3
• Inflammatory lesion count 1, 3
• Quality of life using Dermatology Life Quality Index (DLQI) 1, 3

Treatment escalation pathway: 1

• If no response after 12 weeks of topical clindamycin (Hurley Stage I), escalate to oral tetracyclines 1
• If no response after 12 weeks of tetracyclines, escalate to clindamycin 300 mg + rifampicin 300-600 mg twice daily for 10-12 weeks 1
• If no response after 12 weeks of clindamycin-rifampicin, escalate to adalimumab 1, 2
• For adalimumab, if no clinical response after 16 weeks, consider alternative biologics or surgical intervention 1, 2

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

Surgical Interventions

Indications for surgery: 1, 2, 3

• Extensive disease with sinus tracts and scarring when conventional systemic treatments have failed 1, 2, 3
• Surgery is often necessary for lasting cure in advanced disease 1, 2

Surgical options: 1, 2

• Deroofing for recurrent nodules and tunnels 1
• Radical surgical excision for severe disease with extensive sinus tracts and scarring 1, 2
• Wound closure options include secondary intention healing, skin grafts, or flaps 1

Combined approach: Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1, 2

Pediatric Considerations

For adolescents 12 years and older with moderate to severe HS: 1, 6

• Weight 30-60 kg: Day 1: 80 mg; Day 8 and subsequent doses: 40 mg every other week 1, 6
• Weight ≥60 kg: Day 1: 160 mg; Day 15: 80 mg; Day 29 and beyond: 40 mg weekly or 80 mg every other week 1, 6

For children ≥8 years requiring systemic antibiotics: 1

• Doxycycline 100 mg once or twice daily 1
• Clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks 1

Mandatory Adjunctive Measures for All Patients

Lifestyle modifications: 1, 2, 3, 4, 7

• Smoking cessation referral (tobacco use associated with worse outcomes) 1, 2, 3, 4, 7
• Weight loss for patients with obesity 1, 2, 3, 7
• Wearing loose-fitting clothes 7

Symptom management: 1, 2, 7

• Pain management with NSAIDs for symptomatic relief 1, 2, 7
• Appropriate wound dressings for draining lesions 1, 2, 8

Comorbidity screening and management: 1, 2, 4

• Screen for depression/anxiety 1, 2, 4
• Screen for cardiovascular risk factors: measure blood pressure, lipids, HbA1c 1, 2
• Monitor for inflammatory bowel disease, inflammatory arthritis, metabolic syndrome 2, 4

Treatments NOT Recommended

The following lack sufficient evidence or are ineffective: 1, 3

• Isotretinoin (unless concomitant moderate-to-severe acne of face/trunk) 1, 3
• Etanercept (ineffective) 1, 3
• Cryotherapy during acute phase (causes excessive pain) 1, 3
• Microwave ablation 1, 3
• Numerous other therapies including alitretinoin, anakinra, apremilast, azathioprine, ciclosporin, colchicine, methotrexate, phototherapy, radiotherapy 1

Special Population Considerations

Pregnant patients: 3

• Metformin for those requiring anti-androgens 3
• Adalimumab for those requiring biologics 3

Breastfeeding patients: 1

• Amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole 1
• Limit doxycycline to ≤3 weeks without repeating courses 1

HIV patients: 1

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