What is the initial management recommendation for a patient with hidradenitis suppurativa?

Hidradenitis Suppurativa Management

Begin with topical clindamycin 1% twice daily for 12 weeks for mild disease (Hurley Stage I), escalate to oral clindamycin 300 mg plus rifampicin 300-600 mg twice daily for 10-12 weeks for moderate disease (Hurley Stage II), and initiate adalimumab 40 mg weekly for severe disease (Hurley Stage III) or failed antibiotic therapy. 1, 2, 3

Initial Assessment

Before initiating treatment, document the following:

• Hurley staging for the worst-affected anatomical region: Stage I (isolated nodules/abscesses without sinus tracts), Stage II (recurrent nodules with limited sinus tracts and scarring), or Stage III (diffuse involvement with multiple interconnected sinus tracts) 1, 3
• Pain severity using Visual Analog Scale (VAS) 1
• Quality of life using Dermatology Life Quality Index (DLQI) 1
• Screen for comorbidities: depression, anxiety, diabetes, hypertension, hyperlipidemia, central obesity, and inflammatory bowel disease 1, 2

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 4, 1, 2
• Combine with antiseptic washes: chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione daily to reduce Staphylococcus aureus colonization and antimicrobial resistance risk 1, 3

For acute flares:

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) injected directly into inflamed nodules provides rapid symptom relief within 1 day, with significant reductions in erythema, edema, suppuration, and pain 1, 2

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 4, 1, 2
• This combination achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy (30% abscess reduction) 1, 2

Alternative first-line option (for widespread mild disease or mild Hurley Stage II without deep inflammatory lesions):

• Doxycycline 100 mg once or twice daily for 12 weeks OR tetracycline 500 mg twice daily for up to 4 months 4, 2
• Critical pitfall: Do NOT use tetracyclines as first-line for Hurley Stage II with abscesses or deep inflammatory nodules, as they have minimal effect on these lesions 2

Adjunctive therapy:

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

Hurley Stage III (Severe Disease)

Immediate dermatology referral is mandatory 2, 3

First-line biologic therapy:

• Adalimumab: 160 mg at Week 0 (single dose or split over two consecutive days), 80 mg at Week 2, then 40 mg weekly starting Week 4 4, 1, 5
• Achieves HiSCR response rates of 42-59% at week 12 1, 2
• Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective 4, 2

Second-line biologic options (if adalimumab fails after 16 weeks):

• Infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks 4, 1
• Secukinumab with response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 1, 2
• Ustekinumab as an alternative pathway targeting different cytokines 2

Surgical Interventions

Indications for surgery:

• Extensive disease with sinus tracts and scarring when conventional systemic treatments have failed 4, 1
• Surgery is often necessary for lasting cure in advanced disease 2, 6

Surgical options:

• Wide local excision (radical surgical excision) for extensive disease 4, 1
• Deroofing for recurrent nodules and tunnels 2
• Wound closure options: secondary intention healing, TDAP flap, delayed primary closure, skin grafts, or substitutes 4, 1

Combining surgery with biologics results in greater clinical effectiveness than adalimumab monotherapy 2

Mandatory Adjunctive Measures for All Patients

Regardless of disease severity, address the following:

• Smoking cessation referral: smoking has an odds ratio of 36 for HS 1, 6
• Weight management referral: obesity has an odds ratio of 33 for HS 1, 6
• Pain management: NSAIDs for symptomatic relief; consider opioids for severe pain 1, 2
• Appropriate wound dressings: select based on drainage amount, anatomical location, and patient preference 1, 7
• Screen for depression/anxiety and refer as needed 2, 6

Treatment Response Monitoring

Reassess at 12 weeks using:

• HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 1, 2
• Pain VAS score 1
• Inflammatory lesion count 1
• DLQI 1

Treatment escalation:

• If no response after 12 weeks of topical clindamycin, escalate to oral tetracyclines 2
• If no response after 12 weeks of tetracyclines, escalate to clindamycin-rifampicin combination 4, 2
• If no response after 12 weeks of clindamycin-rifampicin, escalate to adalimumab 1, 2
• If no clinical response to adalimumab after 16 weeks, consider alternative biologic therapies 1, 2

Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance risk 4, 2

Pediatric Considerations

For adolescents 12 years and older weighing ≥30 kg:

• 30-60 kg: Day 1: 80 mg; Day 8 and subsequent doses: 40 mg every other week 5
• ≥60 kg: Day 1: 160 mg; Day 15: 80 mg; Day 29 and subsequent doses: 40 mg every week or 80 mg every other week 5

For children ≥8 years requiring systemic antibiotics:

• Doxycycline 100 mg once or twice daily 2

Long-Term Monitoring

Monitor patients with moderate-to-severe HS for:

• Fistulating gastrointestinal disease 1
• Inflammatory arthritis 1
• Genital lymphoedema 1
• Cutaneous squamous cell carcinoma 1
• Anemia 1

Annual TB screening if patients are on glucocorticoids >15 mg prednisone equivalent daily for ≥4 weeks 1

Critical Pitfalls to Avoid

• Do NOT use isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 4
• Do NOT use etanercept for moderate-to-severe HS, as it is ineffective 4, 2
• Do NOT use cryotherapy to treat lesions during the acute phase due to pain from the procedure 4
• Do NOT use microwave ablation 4
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk 4, 2