What is the best treatment approach for a patient with hidradenitis suppurativa (acne inversa) in the neck?

Treatment of Hidradenitis Suppurativa in the Neck

For hidradenitis suppurativa affecting the neck, initiate treatment with topical clindamycin 1% twice daily for 12 weeks if disease is mild (Hurley Stage I), or escalate immediately to oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks if moderate disease (Hurley Stage II) with inflammatory nodules or abscesses is present. 1, 2, 3

Disease Severity Assessment

• Determine Hurley stage to guide treatment selection: Stage I (isolated nodules without sinus tracts), Stage II (recurrent nodules with limited sinus tracts), or Stage III (extensive sinus tracts and scarring). 1
• Document baseline inflammatory lesion count, pain using Visual Analog Scale (VAS), and assess quality of life using DLQI to establish severity and track response. 1
• Examine all intertriginous areas (axillae, groin, inframammary) to determine total disease burden, as neck involvement often coexists with disease elsewhere. 1

Treatment Algorithm by Severity

Mild Disease (Hurley Stage I - Isolated Nodules)

• Start with topical clindamycin 1% solution or gel applied twice daily to all affected neck areas for 12 weeks. 1, 2
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk, as topical clindamycin monotherapy significantly increases resistance rates. 2, 3
• Topical clindamycin reduces superficial pustules but has no effect on inflammatory nodules or abscesses—if these are present, systemic therapy is required. 2, 4
• For acutely inflamed nodules, add intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion), which provides rapid symptom relief within 1 day with significant reductions in erythema, edema, suppuration, and pain. 1, 2

Moderate Disease (Hurley Stage II - Recurrent Nodules/Abscesses)

• First-line: Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks. 1, 3, 5
• This combination achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy (30% abscess reduction). 1, 5
• Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses, as these have minimal effect on deep inflammatory lesions. 1, 6
• Alternative first-line option: Doxycycline 100 mg once or twice daily for 12 weeks can be used for widespread mild disease or mild Hurley Stage II without deep inflammatory lesions or abscesses. 1, 6

Severe or Refractory Disease (Hurley Stage III or Failed Antibiotics)

• Escalate to adalimumab: 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1, 7
• Adalimumab is FDA-approved for moderate-to-severe HS in patients ≥12 years old, with HiSCR response rates of 42-59% at week 12. 1, 7
• Do NOT use adalimumab 40 mg every other week, as this dosing is ineffective for HS. 1
• If adalimumab fails after 16 weeks, second-line biologic options include infliximab 5 mg/kg at weeks 0,2,6, then every 2 months, or secukinumab/ustekinumab targeting different cytokine pathways. 1

Treatment Monitoring and Reassessment

• Reassess at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas), pain VAS score, inflammatory lesion count, and DLQI. 1, 3
• If no clinical response after 12 weeks of first-line antibiotics, escalate to clindamycin-rifampicin combination. 1
• If no response after 12 weeks of clindamycin-rifampicin, escalate to adalimumab. 1, 3
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance development. 1

Surgical Considerations for Neck Involvement

• Radical surgical excision should be considered for extensive neck disease with sinus tracts and scarring that fails medical management, with wound closure options including secondary intention healing, skin grafts, or flaps. 1
• Deroofing can be used for recurrent nodules and tunnels in the neck. 1
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy for extensive disease. 1

Mandatory Adjunctive Measures for All Patients

• Smoking cessation referral is critical, as tobacco use is associated with worse outcomes and higher disease severity scores. 1, 3
• Weight management referral if BMI is elevated, as high BMI predicts poor response to antibiotics. 1, 3
• Pain management with NSAIDs for symptomatic relief. 1, 3
• Appropriate wound dressings for draining lesions in the neck. 1, 3
• Screen for depression/anxiety, as HS significantly impacts quality of life. 1
• Screen for cardiovascular risk factors (blood pressure, lipids, HbA1c), as HS patients have increased cardiovascular mortality. 1, 3

Critical Pitfalls to Avoid

• Do NOT use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules, not inflammatory nodules or abscesses. 1, 2
• Do NOT use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses, as it has minimal effect on these lesions. 1, 6
• Do NOT continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit. 1
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 1, 3
• Do NOT offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk. 1