What is the best treatment approach for a patient with hidradenitis suppurativa?

Hidradenitis Suppurativa: Evidence-Based Treatment Algorithm

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, 4

Initial Assessment and Staging

Before initiating treatment, determine disease severity using the Hurley staging system 1, 3:

• Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 1
• Hurley Stage II: Recurrent nodules with limited sinus tracts and scarring 1
• Hurley Stage III: Extensive disease with multiple interconnected sinus tracts and diffuse scarring 1

Document baseline inflammatory lesion count, pain using Visual Analog Scale (VAS), and quality of life using Dermatology Life Quality Index (DLQI) 1, 3. Screen for critical comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease 1, 3.

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

First-line therapy: Topical clindamycin 1% solution or gel applied 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 1.

Adjunctive therapy for inflamed lesions: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) provides rapid symptom relief within 1 day, with significant reductions in erythema, edema, suppuration, and pain 1.

If inadequate response at 12 weeks: Escalate to oral tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for 12 weeks 1, 2.

Moderate Disease (Hurley Stage II)

First-line therapy: Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks 1, 2, 3. This combination achieves response rates of 71-93%, far superior to tetracycline monotherapy (30% abscess reduction) 1.

Critical pitfall to avoid: Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses, as these have minimal effect on deep inflammatory lesions 1.

If inadequate response at 12 weeks: Escalate directly to adalimumab 1, 2.

Severe Disease (Hurley Stage III) or Antibiotic Failure

First-line biologic therapy: Adalimumab with the following FDA-approved dosing schedule 1, 2, 3, 4:

• Week 0: 160 mg (given in one day or split over two consecutive days)
• Week 2: 80 mg
• Week 4 and beyond: 40 mg weekly

This regimen achieves HiSCR (Hidradenitis Suppurativa Clinical Response: ≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) response rates of 42-59% at week 12 1.

Critical dosing error to avoid: Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective 1.

If adalimumab fails after 16 weeks: Consider second-line biologics 1:

• Infliximab: 5 mg/kg at weeks 0,2,6, then every 2 months 1
• Secukinumab: Response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 1
• Ustekinumab: Alternative IL-12/23 inhibitor 1

Pediatric Dosing

Adolescents 12 Years and Older with Moderate-to-Severe HS

Weight 30-60 kg: Day 1: 80 mg; Day 8 and subsequent doses: 40 mg every other week 1, 4

Weight ≥60 kg: Day 1: 160 mg (split over two days); Day 15: 80 mg; Day 29 and beyond: 40 mg weekly or 80 mg every other week 1, 4

Children 6 Years and Older with Crohn's Disease (applicable to HS off-label)

Weight 17-40 kg: Day 1: 80 mg; Day 15: 40 mg; Day 29 and beyond: 20 mg every other week 1

Weight ≥40 kg: Day 1: 160 mg; Day 15: 80 mg; Day 29 and beyond: 40 mg every other week 1

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 1, 3, 5.

Indications for surgery 1, 5:

• Extensive disease with sinus tracts and scarring (Hurley Stage III)
• Recurrent nodules and tunnels despite medical therapy
• Burnout phase with predominantly fibrotic lesions

Surgical options 1, 5:

• Deroofing: For recurrent nodules and tunnels
• Radical surgical excision: For extensive disease; non-recurrence rates of 81.25% after wide excision
• Reconstruction: Secondary intention healing, skin grafts, or flaps

Combining surgery with biologics: Adalimumab combined with surgery results in greater clinical effectiveness than adalimumab monotherapy 1.

Mandatory Adjunctive Measures for All Patients

Regardless of disease severity or treatment chosen, address the following 1, 3:

• Smoking cessation referral: Tobacco use is associated with worse outcomes 1
• Weight management referral if BMI elevated: Obesity is associated with increased HS severity 1, 2
• Pain management with NSAIDs for symptomatic relief 1
• Appropriate wound dressings for draining lesions 1
• Screen for depression/anxiety and refer as needed 1
• Screen for cardiovascular risk factors: Measure blood pressure, lipids, and HbA1c 1

Treatment Monitoring and Reassessment

At 12 weeks, reassess using 1, 3:

• Pain VAS score
• Inflammatory lesion count
• Number of flares
• Quality of life (DLQI)
• HiSCR for patients on biologic therapy

Consider treatment breaks after completing antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance risk 1.

Special Populations

Breastfeeding Patients

Use amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole; limit doxycycline to ≤3 weeks without repeating courses 1.

Patients with HIV

Avoid rifampicin due to drug interactions with certain HIV therapies; use doxycycline for added prophylactic benefit against bacterial STIs 1.

Patients with Prior Malignancy

For acute widespread flares, oral prednisone represents one of the safer immunosuppressive options for short-term use while awaiting response to definitive therapies 1.

Therapies with Insufficient Evidence

The following therapies lack sufficient evidence and are NOT recommended 1: alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, methotrexate, oral prednisolone (except acute flares), phototherapy, radiotherapy, cryotherapy, and microwave ablation.

Do NOT offer etanercept for moderate-to-severe HS, as it is ineffective 1.

Do NOT offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 1.

Critical Pitfalls Summary

• Never use doxycycline monotherapy for Hurley Stage II with abscesses 1
• Never use topical clindamycin alone for Hurley Stage II 1
• Never use adalimumab 40 mg every other week (ineffective dosing) 1
• Never continue antibiotics long-term without treatment breaks (antimicrobial resistance) 1
• Never delay surgical evaluation for extensive disease with sinus tracts 1, 5