What is the initial treatment approach for a patient presenting with hidradenitis suppurativa?

Initial Treatment of Hidradenitis Suppurativa

Begin with topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks for mild disease (Hurley Stage I), escalate to oral tetracyclines (doxycycline 100 mg once or twice daily for 12 weeks) for moderate disease (Hurley Stage II), and initiate adalimumab for severe or refractory disease (Hurley Stage III or failed antibiotics). 1, 2

Disease Severity Assessment

• Determine Hurley stage immediately to guide treatment selection: Hurley Stage I (isolated nodules without sinus tracts or scarring), Hurley Stage II (recurrent nodules with limited sinus tracts and scarring), or Hurley Stage III (diffuse involvement with multiple interconnected sinus tracts and scarring) 1, 2
• Document baseline pain using Visual Analog Scale (0-10 scale) and count inflammatory lesions (abscesses and nodules) 1
• Examine all intertriginous areas (axillae, groin, inframammary, perianal) to determine total disease burden, not just the presenting site 1

Mandatory Initial Screening

Before initiating any treatment, screen for:

• Depression and anxiety (extremely common and profoundly impacts quality of life) 1, 2
• Cardiovascular risk factors: measure blood pressure, lipids, and HbA1c 1, 2
• Inflammatory bowel disease (particularly Crohn's disease, which has strong association) 1
• Metabolic syndrome components: diabetes, hypertension, hyperlipidemia 1

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

First-line therapy:

• Topical clindamycin 1% solution or gel twice daily for 12 weeks applied to all affected areas, not just active lesions 1, 2
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk (topical clindamycin alone increases resistance rates) 1
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) for acutely inflamed nodules provides rapid symptom relief within 1 day 1

Critical pitfall: Do not use topical clindamycin alone without antiseptic wash, as this significantly increases antibiotic resistance 1

Hurley Stage II (Moderate Disease)

First-line oral antibiotic therapy:

• Doxycycline 100 mg once or twice daily for 12 weeks OR lymecycline 408 mg once or twice daily for 12 weeks 1
• Continue topical clindamycin 1% twice daily plus antiseptic wash 1

Critical limitation: Tetracyclines show only 30% abscess reduction and have minimal effect on deep inflammatory lesions or abscesses—they work best for widespread mild disease without deep nodules 1

Second-line therapy (if inadequate response after 12 weeks):

• Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks 1, 2
• This combination achieves response rates of 71-93%, far superior to tetracycline monotherapy 1
• This is the preferred regimen for Hurley Stage II with abscesses or inflammatory nodules 1

Do NOT use doxycycline as first-line for Hurley Stage II with abscesses—it has minimal effect on these deep lesions 1

Hurley Stage III (Severe Disease) or Failed Antibiotics

First-line biologic therapy:

• Adalimumab 160 mg subcutaneous at Week 0 (can split over two consecutive days), 80 mg at Week 2, then 40 mg weekly starting at Week 4 1, 2, 3
• HiSCR response rates: 42-59% at Week 12 1
• FDA-approved for moderate-to-severe HS in patients ≥12 years old 3

Critical dosing error to avoid: Do NOT use adalimumab 40 mg every other week—this dosing is insufficient and ineffective for HS 2

Reassess at Week 12 using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 1

If adalimumab fails after 16 weeks:

• Secukinumab (IL-17 inhibitor): response rates 64.5-71.4% in adalimumab-failure patients 1
• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1
• Ustekinumab (IL-12/23 inhibitor) 1

Essential Adjunctive Measures for ALL Patients

Regardless of disease severity, implement immediately:

• Smoking cessation referral (tobacco use significantly worsens outcomes) 1, 2
• Weight management referral if BMI elevated (obesity is a major risk factor) 1, 2
• Pain management with NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for draining lesions 1
• Wear loose-fitting clothing 4

Treatment Reassessment Timeline

• Reassess at 12 weeks using pain VAS score, inflammatory lesion count, number of flares, and Dermatology Life Quality Index (DLQI) 1
• If no response after 12 weeks of first-line therapy, escalate to next treatment tier 1
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1

When to Consider Surgery

• Deroofing for recurrent nodules and tunnels 1
• Radical surgical excision for extensive disease with sinus tracts and scarring when medical therapy fails 1, 2
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1

Critical reality: Non-surgical methods rarely result in lasting cure for advanced disease with sinus tracts and scarring 1

Special Populations

Adolescents ≥12 years old:

• Adalimumab is FDA-approved with weight-based dosing: 30-60 kg receive 80 mg Day 1, then 40 mg every other week starting Day 8; ≥60 kg receive adult dosing 3

Pediatric patients ≥8 years old:

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

Pregnant patients:

• Adalimumab is recommended for those requiring biologics 2
• Metformin is recommended for those requiring anti-androgens 2

Breastfeeding patients:

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