What is the recommended treatment for a patient with hidradenitis suppurativa?

Treatment for Hidradenitis Suppurativa

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 failed antibiotics, initiate adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4. 1, 2, 3

Disease Severity Assessment

Before initiating treatment, determine Hurley stage to guide therapy selection 1, 4:

• Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 1, 4
• Hurley Stage II: Recurrent nodules with limited sinus tracts and scarring 1, 4
• Hurley Stage III: Diffuse involvement with multiple interconnected sinus tracts and extensive scarring—requires immediate dermatology referral 1, 4

Document baseline pain using Visual Analog Scale (VAS), inflammatory lesion count, and quality of life using Dermatology Life Quality Index (DLQI) 4

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

First-line therapy:

• Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks 1, 2, 4
• Combine with antiseptic washes (chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione) daily to reduce Staphylococcus aureus colonization and antimicrobial resistance risk 1, 4

For acute inflamed nodules:

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) provides rapid symptom relief within 1 day, with significant reductions in erythema, edema, suppuration, and pain 1, 4

Reassess at 12 weeks using pain VAS, inflammatory lesion count, and DLQI 1, 4

Hurley Stage II (Moderate Disease)

First-line systemic therapy:

• Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks 1, 2, 4
• This combination achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy (30% abscess reduction) 1

Continue adjunctive topical therapy:

• Topical clindamycin 1% and antiseptic washes 1, 4
• Intralesional triamcinolone 10 mg/mL for individual inflamed lesions during acute flares 1, 4

Alternative first-line options (if clindamycin-rifampicin contraindicated):

• Doxycycline 100 mg once or twice daily for 12 weeks 1
• 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—these have minimal effect on deep lesions 1

Reassess at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas), pain VAS, and DLQI 1, 2

If inadequate response after 12 weeks, escalate to adalimumab 1, 2

Hurley Stage III (Severe Disease)

First-line biologic therapy:

• Adalimumab 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 1, 2, 4, 3
• This is the FDA-approved dosing for moderate-to-severe hidradenitis suppurativa in patients ≥12 years of age 3
• Achieves HiSCR response rates of 42-59% at week 12 in placebo-controlled trials 1, 2

Critical pitfall: Do NOT use adalimumab 40 mg every other week—this dosing is ineffective for hidradenitis suppurativa 1

Assess response at 12 weeks using HiSCR, pain VAS, and DLQI 1, 2

If no clinical response by week 16, consider alternative biologic options 1, 2:

• Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks 1, 4
• Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients at 16-52 weeks) 5, 1
• Ustekinumab 5, 1

Surgical intervention:

• Wide local excision (radical surgical excision) is necessary for lasting cure in extensive disease with sinus tracts and scarring when conventional systemic treatments have failed 1, 2, 4
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1
• Wound closure options include secondary intention healing, TDAP flap, delayed primary closure, skin grafts, or substitutes 4

Mandatory Adjunctive Measures for All Patients

Regardless of disease severity, address the following 1, 2, 4:

• Smoking cessation referral (smoking has an odds ratio of 36 for hidradenitis suppurativa) 4
• Weight management referral if BMI elevated (obesity has an odds ratio of 33) 4
• Pain management with NSAIDs for symptomatic relief; consider opioids for severe pain 4
• Appropriate wound dressings for draining lesions, selected based on drainage amount, anatomical location, and patient preference 4
• Screen for depression/anxiety 1, 4
• Screen for cardiovascular risk factors: measure blood pressure, lipids, and HbA1c 1, 4
• Screen for comorbidities: diabetes, hypertension, hyperlipidemia, inflammatory bowel disease 4

Special Population Considerations

Pediatric Patients (≥12 years old)

• Adalimumab is FDA-approved for moderate-to-severe hidradenitis suppurativa in patients ≥12 years of age 3
• Weight-based dosing for adalimumab:
  • 30 kg to <40 kg: 20 mg every other week 1
  • ≥40 kg: 40 mg every other week initially, then escalate to weekly if needed 1
• For systemic antibiotics in patients ≥8 years old: doxycycline 100 mg once or twice daily 1

Patients with Hepatitis B or C

• Screen for hepatitis B and C prior to initiating immunosuppressants or biologics 5
• In HBsAg-positive patients requiring biologics, coordinate care with hepatologist 5
• Avoid methotrexate if hepatic impairment present 5
• Use doxycycline, ciprofloxacin, or co-trimoxazole for systemic antibiotics; exercise caution with rifampicin due to hepatotoxicity risk 5

Patients with HIV

• Use doxycycline for systemic antibiotics due to added prophylactic benefit against bacterial STIs 5
• Exercise caution with rifampicin due to drug interactions with certain HIV therapies 5

Patients with Latent or Active Tuberculosis

• Screen for latent TB prior to anti-TNF therapy 5
• In patients with latent TB not at high risk, start prophylactic antibiotics at least 1 month before biologic initiation 5
• In patients with latent TB at high risk or from endemic areas, complete prophylactic antibiotics prior to biologic initiation 5
• In patients with active TB, complete TB treatment with symptom resolution before biologic (re)initiation and consider non-anti-TNF biologic classes 5

Long-Term Monitoring

Monitor patients with moderate-to-severe hidradenitis suppurativa for 4:

• Fistulating gastrointestinal disease
• Inflammatory arthritis
• Genital lymphoedema
• Cutaneous squamous cell carcinoma
• Anemia

Perform annual TB screening if patients are on glucocorticoids >15 mg prednisone equivalent daily for ≥4 weeks 4

Treatment Breaks and Antimicrobial Stewardship

Consider treatment breaks after completing antibiotic courses (10-12 weeks) to assess need for ongoing therapy and limit antimicrobial resistance risk 1

Avoid long-term continuous antibiotic use without treatment breaks 1