What is the best treatment approach for a patient with Hidradenitis?

Hidradenitis Suppurativa Treatment

For mild disease (Hurley Stage I), start with topical clindamycin 1% twice daily for 12 weeks; for moderate disease (Hurley Stage II), use clindamycin 300 mg plus rifampicin 300-600 mg orally twice daily for 10-12 weeks; and for severe disease (Hurley Stage III) or antibiotic failure, initiate adalimumab with loading doses of 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4. 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 and scarring), or Stage III (extensive sinus tracts and scarring across entire anatomic region) 1, 2
• Examine all intertriginous areas (axillae, groin, inframammary, perianal) to assess total disease burden 1
• Document baseline pain using Visual Analog Scale (VAS) and count inflammatory lesions (nodules, abscesses, draining tunnels) 1, 2

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
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1
• Adjunctive: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules provides rapid symptom relief within 1 day 1

Moderate Disease (Hurley Stage II)

• First-line: 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 (30% abscess reduction) 1
• Alternative first-line (for widespread mild disease without abscesses): Doxycycline 100 mg once or twice daily for 12 weeks OR tetracycline 500 mg twice daily for up to 4 months 1
  • Critical pitfall: 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 deep lesions 1

Severe Disease (Hurley Stage III) or Antibiotic Failure

• First-line biologic: Adalimumab with FDA-approved dosing 3:

  • Adults: 160 mg at week 0 (single dose or split over two consecutive days), 80 mg at week 15, then 40 mg every week OR 80 mg every other week starting day 29 1, 3
  • Adolescents ≥12 years weighing 60 kg or more: Same as adult dosing 3
  • Adolescents ≥12 years weighing 30-60 kg: 80 mg day 1, then 40 mg every other week starting day 8 3
  • HiSCR response rates: 42-59% at week 12 1

• Second-line biologics (after adalimumab failure):

  • Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1
  • Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients at 16-52 weeks) 1
  • Ustekinumab 1

Treatment Monitoring and Escalation

• Reassess at 12 weeks using: 1, 2

  • HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas)
  • Pain VAS score
  • Inflammatory lesion count
  • Quality of life (DLQI)

• Escalation pathway: 1

  • If topical clindamycin fails at 12 weeks → clindamycin-rifampicin combination
  • If clindamycin-rifampicin fails at 12 weeks → adalimumab
  • If adalimumab shows no response at 16 weeks → switch to alternative biologic 3

• Treatment breaks: Consider breaks after completing antibiotic courses (10-12 weeks) to assess ongoing need and limit antimicrobial resistance 1, 4

Surgical Interventions

• Indications: Extensive disease with sinus tracts and scarring when medical therapy fails, or for localized recurrent nodules 1, 2, 5
• Options: 1, 5
  • Deroofing for recurrent nodules and tunnels
  • Radical surgical excision for extensive disease (non-recurrence rates 81.25% after wide excision)
  • Wound closure via secondary intention, skin grafts, or flaps
• Combination approach: Adalimumab plus surgery demonstrates greater clinical effectiveness than adalimumab monotherapy 1, 4

Mandatory Adjunctive Measures (All Patients)

• Smoking cessation referral (tobacco use associated with 36-fold increased odds of worse outcomes) 1, 4
• Weight management referral if BMI elevated (obesity associated with 33-fold increased odds of worse disease) 1, 4
• Pain management with NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for draining lesions 1
• Screen for comorbidities: 1, 4, 2
  • Depression/anxiety
  • Cardiovascular risk factors (measure BP, lipids, HbA1c)
  • Diabetes, hypertension, hyperlipidemia
  • Inflammatory bowel disease if GI symptoms present

Special Populations

• Pediatric patients ≥8 years requiring systemic antibiotics: Doxycycline 100 mg once or twice daily OR clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks 1
• Breastfeeding patients: Use amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole; limit doxycycline to ≤3 weeks without repeating courses 1
• HIV patients: Avoid rifampicin due to drug interactions with certain HIV therapies 1

Critical Pitfalls to Avoid

• Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS (this dosing is ineffective; weekly dosing required) 1
• Do NOT use etanercept (ineffective for HS) 1
• Do NOT offer isotretinoin unless concomitant moderate-to-severe acneiform lesions of face/trunk present 1
• Do NOT continue doxycycline beyond 4 months without reassessment (increases antimicrobial resistance risk) 1
• Avoid long-term continuous antibiotic use without treatment breaks 1, 4