What is the best approach to manage hidradenitis suppurativa (HS) in a postpartum patient?

Management of Hidradenitis Suppurativa in Postpartum Patients

For postpartum patients with hidradenitis suppurativa who are breastfeeding, continue or initiate treatment with safe systemic antibiotics (oral azithromycin, erythromycin, amoxicillin/clavulanic acid, or metronidazole), topical therapies, and biologics (particularly adalimumab), as these are compatible with breastfeeding and will prevent disease progression and improve quality of life. 1

Understanding Postpartum HS Disease Activity

• More than half of women with HS experience postpartum flares, making active management during this period critical rather than optional 2, 3
• The postpartum period represents a high-risk time for disease exacerbation, requiring proactive rather than reactive treatment strategies 2, 3

Treatment Algorithm for Breastfeeding Patients

First-Line Systemic Antibiotics (Safe During Breastfeeding)

Preferred options based on 2025 North American guidelines:

• Oral azithromycin is suggested as safe during breastfeeding and represents an excellent first-line choice 1
• Oral erythromycin is suggested as safe during breastfeeding, particularly for penicillin-allergic patients 1
• Oral amoxicillin/clavulanic acid is suggested as safe and effective during breastfeeding 1
• Oral metronidazole is suggested as safe during breastfeeding 1
• Oral rifampin can be used with an approach similar to other HS patient populations during breastfeeding 1

Antibiotics Requiring Caution

• Oral clindamycin should be used with caution as it may increase the risk of GI side effects (diarrhea, candidiasis) in the infant 1
• Oral doxycycline use should be limited to 3 weeks maximum without repeating courses, and only if no suitable alternative antibiotic is available 1

Topical Therapies (Safe During Breastfeeding)

• Topical antibiotics can be used with an approach similar to other HS patient populations during breastfeeding 1
• Chlorhexidine antiseptic washes are safe during breastfeeding based on mechanism of action 1
• Bleach baths are safe during breastfeeding based on mechanism of action 1
• Zinc pyrithione antiseptic washes are safe during breastfeeding based on mechanism of action 1

Biologic Therapy (Strongly Recommended for Moderate-to-Severe Disease)

Adalimumab is the preferred biologic during breastfeeding:

• Biologics are likely safe to use during breastfeeding based on pharmacokinetic data showing minimal transfer to breast milk 1
• For patients well-controlled on biologics during pregnancy, continue biologic therapy postpartum rather than interrupting treatment 1
• Adalimumab 40 mg weekly is the FDA-approved dosing for HS and has strong evidence for safety during breastfeeding 1, 4
• Infliximab and secukinumab can be used with an approach similar to other HS patient populations during breastfeeding 1

Anti-Androgens (Safe Options)

• Metformin is suggested as safe for use during breastfeeding and can help with metabolic modulation 1
• Oral contraceptives are suggested as safe during breastfeeding, especially when contraception is desired 1

Systemic Immunomodulators (Limited Use)

• Prednisone ≤20 mg daily can be used for acute, widespread flares during breastfeeding 1
• If prednisone dose >20 mg daily is required, patients should wait at least 4 hours prior to breastfeeding 1
• Cyclosporine use should be limited to select treatment-refractory cases during breastfeeding 1

Procedural Therapies

• Intralesional steroids are safe for acute, localized flares during breastfeeding (same approach as during pregnancy) 1
• Surgical intervention should be assessed based on type and extent of scarring, as surgery is considered the only curative therapy for severe HS 1, 5

Critical Pitfalls to Avoid

• Do not discontinue effective biologic therapy postpartum if the patient was well-controlled during pregnancy, as this increases risk of severe flares 1
• Avoid tetracyclines (doxycycline) except as a last resort for maximum 3 weeks, as they can affect infant bone and tooth development 1
• Avoid spironolactone during breastfeeding as it is contraindicated 2
• Do not delay treatment waiting for spontaneous improvement, as postpartum flares are common and untreated disease leads to progressive scarring and tunneling 2, 3

Infant Monitoring Considerations

• Monitor breastfed infants for gastrointestinal effects (diarrhea, gastroenteritis) when mother is taking systemic antibiotics 6
• For infants with in-utero biologic exposure from maternal HS management during pregnancy, consult with pediatrician about timing of administering live vaccines 1
• If using clindamycin, monitor infant closely for GI side effects including diarrhea and candidiasis 1

Pain Management During Breastfeeding

• NSAIDs can be used but should be avoided if the infant is premature, jaundiced, or has other risk factors 7
• Prednisone up to 20 mg daily can be used for acute pain without waiting before breastfeeding 7
• Short-term opioids (codeine, oxycodone) may be considered for severe pain while monitoring infant for sedation 7

Disease Severity Assessment

• Use Hurley staging and Physician Global Assessment (PGA) to guide treatment intensity 1
• Routinely assess patient-reported outcomes including DLQI, itch, and pain using Visual Analogue Scale 1
• HiSCR (Hidradenitis Suppurativa Clinical Response: ≥50% reduction in total abscess and inflammatory nodule count with no increase in abscess or draining fistula count) is the standard efficacy measure for biologics 4