What is the recommended treatment plan for a patient with hidradenitis suppurativa who is also taking medication for angina?

Treatment Plan for Hidradenitis Suppurativa in a Patient on Angina Medication

Treat hidradenitis suppurativa according to standard disease severity-based protocols, as there are no specific contraindications between HS therapies and angina medications, but screen for cardiovascular risk factors given the established association between HS and cardiovascular disease. 1

Initial Assessment and Cardiovascular Screening

Screen all HS patients for cardiovascular risk factors including blood pressure, lipids, and HbA1c, as this is a mandatory component of HS management regardless of angina history. 1 The British Journal of Dermatology specifically recommends this screening because HS patients have elevated cardiovascular disease risk 1. Document baseline cardiovascular status and current angina medications to identify potential drug interactions.

Determine Hurley stage by examining all intertriginous areas (axillae, groin, perianal, inframammary regions) to assess disease severity 1:

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

Record pain using Visual Analog Scale and quality of life using Dermatology Life Quality Index 1.

Treatment by Disease Severity

Mild Disease (Hurley Stage I)

Start 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.

Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) can be injected into acutely inflamed nodules for rapid symptom relief within 1 day 1.

Moderate Disease (Hurley Stage II)

First-line therapy is clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks, achieving response rates of 71-93%. 1 This combination is vastly superior to tetracycline monotherapy, which shows only 30% abscess reduction 1.

Alternative first-line option: Doxycycline 100 mg once or twice daily for 12 weeks can be used for widespread mild disease or mild Hurley Stage II without deep inflammatory lesions 1. However, do NOT use doxycycline as first-line for Hurley Stage II with abscesses or deep inflammatory nodules, as it has minimal effect on these lesions 1.

Severe Disease (Hurley Stage III) or Refractory Cases

Initiate adalimumab: 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1, 3 This is FDA-approved for moderate-to-severe HS in patients ≥12 years old, with HiSCR response rates of 42-59% at week 12 1, 3.

Refer immediately to dermatology and HS surgical multidisciplinary team for consideration of radical surgical excision, which is often necessary for definitive treatment of extensive disease with sinus tracts and scarring. 1, 4

Drug Interaction Considerations with Angina Medications

Rifampicin can induce hepatic cytochrome P450 enzymes and may reduce levels of certain cardiovascular medications including calcium channel blockers, beta-blockers, and anticoagulants. 5 Coordinate with the patient's cardiologist when prescribing clindamycin-rifampicin combination therapy to adjust angina medication dosing if necessary.

Adalimumab has no direct drug interactions with standard angina medications (nitrates, beta-blockers, calcium channel blockers, antiplatelet agents). 3 However, given the increased cardiovascular risk in HS patients, ensure optimal cardiovascular disease management is maintained during biologic therapy 1.

Mandatory Adjunctive Measures for All Patients

Implement these interventions regardless of disease severity 1:

• Smoking cessation referral (tobacco worsens HS outcomes and cardiovascular disease)
• Weight management referral if BMI elevated (obesity worsens both HS and cardiovascular risk)
• Pain management with NSAIDs for symptomatic relief (verify no contraindications with angina medications)
• Appropriate wound dressings for draining lesions
• Screen for depression/anxiety (common in HS patients)

Treatment Monitoring and Escalation

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

If inadequate response after 12 weeks of first-line therapy:

• Escalate from topical clindamycin to oral tetracyclines for mild disease 1
• Escalate from tetracyclines to clindamycin-rifampicin combination for moderate disease 1
• Escalate from clindamyclin-rifampicin to adalimumab for severe/refractory disease 1

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

Second-Line Biologic Options After Adalimumab Failure

If adalimumab fails after 16 weeks, consider 1:

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

Critical Pitfalls to Avoid

Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective—weekly dosing is required. 1

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

Do NOT use topical clindamycin alone for Hurley Stage II HS, as it only reduces superficial pustules, not inflammatory nodules or abscesses. 1

Avoid long-term continuous antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 1