What is the recommended long-term treatment approach for a patient with hidradenitis suppurativa?

Long-Term Treatment of Hidradenitis Suppurativa

For long-term management of hidradenitis suppurativa, treatment must be stratified by Hurley stage: topical clindamycin 1% twice daily for 12 weeks for mild disease (Stage I), clindamycin 300 mg plus rifampicin 600 mg orally twice daily for 10-12 weeks for moderate disease (Stage II), and adalimumab 40 mg weekly as maintenance therapy for severe or refractory disease, with surgical excision reserved for extensive scarring and sinus tracts that fail medical management. 1, 2, 3

Disease Severity Assessment

• Determine Hurley stage at initial evaluation: Stage I (isolated nodules without sinus tracts), Stage II (recurrent nodules with limited sinus tracts and scarring), or Stage III (diffuse involvement with extensive sinus tracts and scarring). 1, 2
• Document baseline inflammatory lesion count, pain using Visual Analog Scale (VAS), and quality of life using Dermatology Life Quality Index (DLQI). 1, 2
• Screen for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease at baseline. 1

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

• First-line: 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
• Alternative for more widespread mild disease: Tetracycline 500 mg twice daily for up to 4 months OR doxycycline 100 mg once or twice daily for 12 weeks. 1, 3
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) can be injected into acutely inflamed nodules for rapid symptom relief within 1 day. 1

Moderate Disease (Hurley Stage II)

• First-line: Clindamycin 300 mg orally twice daily PLUS rifampicin 600 mg orally once or twice daily for 10-12 weeks, achieving response rates of 71-93%. 1, 2, 3
• This combination is vastly superior to tetracycline monotherapy (which shows only 30% abscess reduction). 1
• Treatment can be repeated intermittently for disease flares. 1
• 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

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

• First-line biologic: Adalimumab with FDA-approved dosing of 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 for long-term maintenance. 1, 2, 3, 4
• Adalimumab achieves HiSCR response rates (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) of 42-59% at week 12. 1
• Continue adalimumab 40 mg weekly as long as HS lesions are present and patient maintains response. 5, 1
• Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective. 1

Second-Line Biologic Options After Adalimumab Failure

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months thereafter. 1, 3
• Secukinumab (conditional recommendation, moderate quality evidence) with response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks. 1
• Ustekinumab (conditional recommendation, moderate quality evidence). 1

Surgical Interventions for Long-Term Disease Control

• Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 1, 2, 6, 7
• Deroofing is recommended for recurrent nodules and tunnels. 1, 3
• Radical surgical excision is recommended for extensive disease (Hurley Stage III) with sinus tracts and scarring when conventional systemic treatments have failed, with non-recurrence rates of 81.25% after wide excision. 1, 2, 6
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy. 1
• Early surgical intervention along with medical therapy is favored to promote healing and minimize scars within the therapeutic window of opportunity. 7

Mandatory Adjunctive Therapies for All Patients

• Smoking cessation referral is critical, as tobacco use is associated with worse outcomes. 1, 2, 3
• Weight loss should be encouraged for patients with obesity, as obesity is associated with increased HS severity. 1, 2, 3
• Pain management with NSAIDs for symptomatic relief. 1, 2
• Appropriate wound dressings for draining lesions. 1, 2
• Screen for and treat depression/anxiety. 1, 2
• Screen for cardiovascular risk factors (blood pressure, lipids, HbA1c). 1

Monitoring and Treatment Reassessment

• Reassess treatment response at 12 weeks using pain VAS score, inflammatory lesion count, number of flares, and DLQI. 1, 2
• For patients on adalimumab, assess using HiSCR at 12 weeks. 1, 2
• If no clinical response after 12 weeks of first-line therapy, escalate to next treatment tier. 1, 2
• If adalimumab fails after 16 weeks, consider alternative biologics (infliximab, secukinumab, ustekinumab). 1
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance. 1

Special Population Considerations

Adolescents (12 years and older)

• For moderate-to-severe disease, adalimumab is FDA-approved with weight-based dosing: 30-60 kg receive 80 mg on Day 1, then 40 mg every other week; ≥60 kg receive adult dosing (160 mg Day 1,80 mg Day 15, then 40 mg weekly starting Day 29). 1, 4

Pediatric Patients (8 years and older)

• Doxycycline 100 mg once or twice daily is recommended for those requiring systemic antibiotics. 1

Pregnancy and Breastfeeding

• For breastfeeding patients, use amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole; limit doxycycline to ≤3 weeks without repeating courses. 1

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
• Do NOT continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit. 1
• Do NOT offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk. 1
• Do NOT offer etanercept for moderate-to-severe HS, as it is ineffective. 1
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 1
• Do NOT use oral corticosteroids for routine or long-term management; reserve only for acute widespread flares while awaiting response to definitive therapies. 1

Alternative Systemic Therapies for Refractory Cases

• Acitretin 0.3-0.5 mg/kg/day in males and non-fertile females as an alternative option for patients unresponsive to adalimumab. 1
• Dapsone starting at 50 mg daily, titrating up to 200 mg daily, as an alternative option. 1
• Ertapenem 1g daily for 6 weeks as rescue therapy or during surgical planning for severe disease requiring IV antibiotics. 1