What is the recommended medical management for a patient with hidradenitis suppurativa, considering their past medical history and potential underlying conditions such as diabetes or inflammatory bowel disease?

Medical Management of Hidradenitis Suppurativa

Begin treatment based on Hurley staging: topical clindamycin 1% twice daily for 12 weeks for Hurley Stage I, clindamycin 300 mg plus rifampicin 300-600 mg orally twice daily for 10-12 weeks for Hurley Stage II, and adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4 for Hurley Stage III or antibiotic-refractory disease. 1, 2

Initial Assessment and Disease Staging

Diagnose HS using three criteria: typical lesions (inflamed nodules, open comedones, sinus tracts, bridging scars), predominantly flexural location (axillae, groins, perineum, inframammary), and chronicity (≥2 lesions in last 6 months or lifetime history of >5 lesions). 1

Record Hurley stage for the worst affected regions: Stage I (isolated nodules/abscesses without sinus tracts or scarring), Stage II (recurrent nodules with limited sinus tracts and scarring), Stage III (extensive sinus tracts and scarring across entire anatomic region). 1, 2

Measure baseline pain using Visual Analog Scale (VAS), inflammatory lesion count, number of flares in the last month, and quality of life using Dermatology Life Quality Index (DLQI). 1, 2

Screen for comorbidities: depression/anxiety, diabetes (HbA1c), hypertension (blood pressure), hyperlipidemia (lipids), and inflammatory bowel disease. 1, 2

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

Apply topical clindamycin 1% solution or gel 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, as topical clindamycin monotherapy significantly increases resistance rates. 1, 2, 3

Inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) directly into acutely inflamed nodules for rapid symptom relief within 1 day, with significant reductions in erythema, edema, suppuration, and pain. 1, 2, 3

Consider oral tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for 12 weeks for more widespread mild disease, though evidence is weak (only 30% abscess reduction in single RCT). 1, 2

Hurley Stage II (Moderate Disease)

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 such lesions. 1, 2

Prescribe clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks, achieving response rates of 71-93% in systematic reviews. 1, 2

Inject intralesional triamcinolone 10 mg/mL into acutely inflamed nodules and abscesses for immediate symptom control while awaiting antibiotic response. 1, 2

Consider treatment break after 10-12 weeks to assess need for ongoing therapy and limit antimicrobial resistance development. 1, 2

Hurley Stage III (Severe Disease) or Antibiotic Failure

Initiate adalimumab 160 mg subcutaneous at week 0 (given in one day or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2, 4

For adolescents ≥12 years weighing 30-60 kg: 80 mg at day 1, then 40 mg every other week starting day 8. 4

For adolescents ≥12 years weighing ≥60 kg: 160 mg at day 1,80 mg at day 15, then 40 mg weekly or 80 mg every other week starting day 29. 4

Assess response at 12-16 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas), with expected response rates of 42-59%. 1, 2

If adalimumab fails after 16 weeks, escalate to second-line biologics: infliximab 5 mg/kg at weeks 0,2,6, then every 2 months, secukinumab (response rates 64.5-71.4% in adalimumab-failure patients), or ustekinumab. 1, 2

Special Population Considerations

Pediatric Patients

For children ≥8 years requiring systemic antibiotics, use doxycycline 100 mg once or twice daily or clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks. 1, 2

For adolescents ≥12 years with moderate-to-severe disease, adalimumab is FDA-approved with weight-based dosing as outlined above. 1, 4

Pregnancy

Topical clindamycin and antiseptic washes have minimal systemic absorption and can be used similarly to the general population. 1

Avoid tetracyclines, retinoids, and adalimumab during pregnancy due to teratogenic risks. 1

Breastfeeding

Use amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole as preferred antibiotics. 2

Limit doxycycline to ≤3 weeks without repeating courses if used during breastfeeding. 2

Patients with Diabetes or Inflammatory Bowel Disease

Consider metformin in patients with concomitant diabetes or PCOS, as it may provide additional benefit for HS control. 2

Screen for inflammatory bowel disease, as HS shares immunological pathways with Crohn's disease and ulcerative colitis. 1, 2

Continue aminosalicylates and/or corticosteroids during adalimumab treatment if needed for inflammatory bowel disease. 4

Alternative Systemic Therapies for Refractory Disease

Consider acitretin 0.3-0.5 mg/kg/day in males and non-fertile females as an alternative option after adalimumab failure. 1, 2

Try dapsone starting at 50 mg daily, titrating up to 200 mg daily, as an alternative immunomodulator. 1, 2

Use ertapenem 1 g IV daily for 6 weeks as rescue therapy or during surgical planning for severe disease requiring intravenous antibiotics. 1

Do NOT offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk, as it is ineffective for HS. 2

Do NOT offer etanercept for moderate-to-severe HS, as it is ineffective. 2

Reserve oral prednisone only for acute widespread flares requiring rapid symptom control while awaiting response to definitive therapies, not for routine or long-term management. 2

Surgical Interventions

Refer to HS surgical multidisciplinary team for extensive excision when medical management fails, particularly for Hurley Stage III disease with extensive sinus tracts and scarring. 1, 2

Consider deroofing for recurrent nodules and tunnels in localized disease. 1, 2

Perform radical surgical excision for extensive disease, with healing by secondary intention, thoracodorsal artery perforator (TDAP) flap, or other reconstructive methods. 1, 2

Combine adalimumab with surgery for greater clinical effectiveness than adalimumab monotherapy in advanced disease. 2

Mandatory Adjunctive Measures for All Patients

Refer for smoking cessation, as tobacco use is associated with dramatically worse outcomes (odds ratio 36). 1, 2

Refer for weight management if BMI elevated, as obesity significantly worsens disease (odds ratio 33) and predicts poor antibiotic response. 1, 2

Manage pain with NSAIDs for symptomatic relief. 1, 2

Provide appropriate wound dressings for pus-producing and draining lesions. 1, 2

Screen for depression/anxiety and refer for mental health support as needed. 1, 2

Treatment Monitoring and Reassessment

Reassess at 12 weeks using pain VAS score, inflammatory lesion count, number of flares in the last month, and DLQI quality of life score. 1, 2

For patients on clindamycin-rifampicin, consider treatment break after 10-12 weeks to assess ongoing need and limit antimicrobial resistance. 1, 2

For patients on adalimumab, discontinue if no clinical response by 16 weeks and consider alternative biologics. 1, 2

For patients on adalimumab with response, continue 40 mg weekly as long as HS lesions are present and patient maintains response. 2

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. 2

Do NOT continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit. 2

Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective; weekly dosing is required. 2

Do NOT offer cryotherapy or microwave ablation for treating lesions during the acute phase. 1

Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 1, 2

Insufficient Evidence Therapies

There is insufficient evidence to recommend alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, hydrocortisone, hyperbaric oxygen therapy, intravenous antibiotics (except ertapenem), isoniazid, laser and photodynamic therapies, methotrexate, oral zinc, phototherapy, photochemotherapy, radiotherapy, spironolactone, staphage lysate, tolmetin sodium for HS unresponsive to conventional systemic therapy. 1