Long-Term Treatment for Hidradenitis Suppurativa
For long-term management of hidradenitis suppurativa, adalimumab 40 mg weekly is the first-line biologic therapy for moderate-to-severe disease (Hurley Stage II-III) that has failed conventional systemic antibiotics, while tetracyclines or clindamycin-rifampin combinations serve as long-term maintenance options for mild-to-moderate disease (Hurley Stage I-II). 1
Disease Severity Assessment and Treatment Algorithm
Determine Hurley stage first, as this dictates the entire treatment pathway 1, 2:
- Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring
- Hurley Stage II: Recurrent nodules with limited sinus tracts and scarring
- Hurley Stage III: Diffuse involvement with multiple interconnected sinus tracts and extensive scarring
Document baseline inflammatory lesion count, pain Visual Analog Scale (VAS) score, and quality of life using DLQI 1, 2.
Long-Term Treatment by Disease Severity
Mild Disease (Hurley Stage I)
Topical clindamycin 1% solution or gel applied twice daily to all affected areas serves as first-line long-term maintenance therapy 1, 3. However, topical clindamycin monotherapy significantly increases Staphylococcus aureus resistance rates, so combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to mitigate this risk 3, 2.
Tetracyclines (doxycycline 100 mg once or twice daily or tetracycline 500 mg twice daily) can be used for 12-week courses as long-term maintenance when appropriate, with treatment breaks to assess ongoing need and limit antimicrobial resistance 1. The evidence supporting tetracyclines is weak (Level IIb), based on a single trial showing only 30% abscess reduction 1, 2.
Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) provides rapid relief for acute inflammatory nodules within 24 hours, but this is adjunctive therapy for flares, not standalone long-term treatment 1, 4.
Moderate Disease (Hurley Stage II)
Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks is the superior first-line choice, achieving response rates of 71-93% 1, 2. This regimen can be repeated intermittently as long-term maintenance therapy in patients with mild-to-moderate disease 1.
Dapsone (starting at 50 mg daily, titrating up to 200 mg daily) may be effective for a minority of patients with Hurley Stage I or II disease as long-term maintenance therapy 1, though evidence is limited 1.
Hormonal agents should be considered in appropriate female patients as long-term therapy, either as monotherapy for mild-to-moderate disease or in combination with other agents 1. Options include:
- Estrogen-containing combined oral contraceptives
- Spironolactone
- Cyproterone acetate
- Metformin (especially with concomitant diabetes or PCOS)
- Finasteride
Avoid progestogen-only contraceptives, as anecdotal data suggest they may worsen HS 1.
Reassess at 12 weeks using pain VAS score, inflammatory lesion count, and DLQI 1, 2. If inadequate response, escalate to adalimumab 1.
Severe or Refractory Disease (Hurley Stage III or Failed Antibiotics)
Adalimumab is the FDA-approved first-line biologic for long-term management of moderate-to-severe HS in patients ≥12 years old 5. Dosing schedule 1, 5:
- Adults and adolescents ≥60 kg: 160 mg at week 0 (single dose or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting at week 4
- Adolescents 30-60 kg: 80 mg at week 0, then 40 mg every other week starting at week 8
Continue adalimumab 40 mg weekly as long as HS lesions are present and the patient maintains response, with HiSCR response rates of 42-59% at week 12 2, 5. Assess response using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) at 12-16 weeks 1, 2.
If adalimumab fails after 16 weeks, second-line biologic options include 1, 2:
- Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months (higher doses and more frequent intervals supported for severe refractory cases)
- Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients at 16-52 weeks)
- Ustekinumab 45-90 mg every 12 weeks
Acitretin 0.3-0.5 mg/kg/day in males and non-fertile females can be considered as an alternative systemic therapy for patients unresponsive to adalimumab 1, 2.
Cyclosporine can be considered in patients with recalcitrant moderate-to-severe HS who have failed or are not candidates for standard therapy 1.
Surgical Integration with Long-Term Medical Management
Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 1, 2. Options include 1, 2:
- Deroofing for recurrent nodules and tunnels
- Radical surgical excision for extensive disease with sinus tracts and scarring (consider when conventional systemic treatments have failed)
- Wound closure options: secondary intention healing, TDAP flap for axillary wounds, skin grafts, or other reconstructive methods
Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2. Consider surgical intervention concurrently with biologic therapy for extensive disease 2.
Critical Adjunctive Measures for All Patients
These interventions are mandatory regardless of disease severity 1, 2:
- Smoking cessation referral (tobacco use worsens outcomes) 1, 2
- Weight management referral if BMI elevated (obesity worsens disease course) 1, 2
- Pain management with NSAIDs for symptomatic relief 1, 2
- Appropriate wound dressings for draining lesions 1, 2
- Screen for depression/anxiety 1, 2
- Screen for cardiovascular risk factors (measure BP, lipids, HbA1c) 1, 2
- Screen for comorbidities: diabetes, hypertension, hyperlipidemia, inflammatory bowel disease 2
Therapies to Avoid for Long-Term Management
Do NOT offer 1:
- Adalimumab 40 mg every other week (ineffective dosing)
- Etanercept (ineffective)
- Isotretinoin (unless concomitant moderate-to-severe acne)
- Cryotherapy (painful, ineffective)
- Microwave ablation
Insufficient evidence exists to recommend methotrexate, azathioprine, oral prednisolone for long-term use, alitretinoin, anakinra, apremilast, atorvastatin, fumaric acid esters, or numerous other agents 1.
Monitoring Antimicrobial Resistance Risk
Balance the benefit of antibiotic therapy against antimicrobial resistance risk 1. Consider treatment breaks after 12-week antibiotic courses to assess need for ongoing therapy and limit resistance development 1, 2. Recurrence following antibiotic cessation is frequent 1.
Special Populations
Pediatric patients ≥12 years and ≥30 kg: Adalimumab is FDA-approved with weight-based dosing 5.
Pediatric patients ≥8 years requiring systemic antibiotics: Doxycycline 100 mg once or twice daily 2.
Pregnant patients: Avoid tetracyclines, retinoids, hormonal agents, most systemic antibiotics, and most immunosuppressive medications; use topical treatments, procedures, and safe systemic agents 1.
Breastfeeding patients: Limit doxycycline to ≤3 weeks without repeating courses; alternatives include amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole 2.