What are the treatment options for a patient with Hidradenitis Suppurativa (HS)?

Hidradenitis Suppurativa Treatment

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; for severe disease (Hurley Stage III) or antibiotic failure, initiate adalimumab 160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4. 1, 2, 3

Disease Severity Assessment

Before initiating treatment, determine Hurley stage by examining all intertriginous areas (axillae, groin, inframammary, buttocks, perineum) 2:

• Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 2, 3
• Hurley Stage II: Recurrent nodules with limited sinus tracts and scarring 2, 3
• Hurley Stage III: Multiple/extensive sinus tracts and scarring across entire anatomic region 2, 3

Document baseline inflammatory lesion count, pain using Visual Analog Scale (0-10), and quality of life using Dermatology Life Quality Index 2, 3. Screen for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease 2, 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 2.

For acutely inflamed nodules, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) directly into lesions, which provides rapid symptom relief within 1 day with significant reductions in erythema, edema, suppuration, and pain 1, 2.

If inadequate response after 12 weeks, escalate to oral tetracycline 500 mg twice daily or doxycycline 100 mg once or twice daily for 12 weeks 1, 2, 3.

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% in systematic reviews, far superior to tetracycline monotherapy which shows only 30% abscess reduction 1, 2.

Critical pitfall: 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 2.

Add intralesional triamcinolone 10 mg/mL for acutely inflamed nodules and abscesses 1, 2.

Reassess at 12 weeks using pain VAS score, inflammatory lesion count, number of flares, and DLQI 2, 3. If no response, escalate to adalimumab 1, 2.

Consider treatment breaks after completing the 10-12 week course to assess need for ongoing therapy and limit antimicrobial resistance 1, 2.

Severe Disease (Hurley Stage III) or Antibiotic Failure

First-line biologic therapy: Adalimumab (the only FDA-approved biologic for moderate-to-severe HS) 4:

• Week 0: 160 mg subcutaneous (given in one day or split over two consecutive days) 1, 2, 4
• Week 2: 80 mg subcutaneous 1, 2, 4
• Week 4 and ongoing: 40 mg subcutaneous weekly 1, 2, 4

Adalimumab achieves HiSCR response rates (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) of 42-59% at week 12 1, 2, 3.

Critical pitfall: Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective 2.

If no clinical response after 16 weeks of adalimumab, consider second-line biologics 1, 2, 3:

• Infliximab: 5 mg/kg IV at weeks 0,2,6, then every 2 months 1, 2
• Secukinumab: Response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 2, 3
• Ustekinumab: Alternative IL-12/23 inhibitor for adalimumab failures 1, 2

Surgical Interventions

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 2, 3, 5. Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2.

Surgical options by extent of disease 1, 2, 5:

• Deroofing: For recurrent nodules and tunnels without extensive scarring 1, 3
• Radical surgical excision: For extensive disease with sinus tracts and scarring when conventional systemic treatments have failed, with non-recurrence rates of 81.25% after wide excision 2
• Wound closure options: Secondary intention healing, skin grafts, TDAP flap, or other reconstructive methods 1, 2

Special Populations

Adolescents (12 years and older)

Adalimumab is FDA-approved for adolescents 12 years and older with moderate-to-severe HS 3, 4:

• 30-60 kg: Day 1: 80 mg; Day 8 and subsequent doses: 40 mg every other week 1, 4
• ≥60 kg: Day 1: 160 mg; Day 15: 80 mg; Day 29 and subsequent: 40 mg weekly or 80 mg every other week 1, 4

For systemic antibiotics in children ≥8 years, use doxycycline 100 mg once or twice daily, or clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks 2.

Critical pitfall: Avoid tetracyclines in children younger than 9 years 1.

Pregnant Patients

Avoid retinoids, hormonal agents, most systemic antibiotics, and most immunosuppressive medications 1. Use topical treatments, procedures, and safe systemic agents 1. For breastfeeding patients, limit doxycycline to ≤3 weeks without repeating courses, or use amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole 2.

Female Patients

Consider hormonal agents (estrogen-containing combined oral contraceptives, spironolactone, cyproterone acetate, metformin, finasteride) as monotherapy for mild-to-moderate HS or in combination with other agents for more severe disease 1. Avoid progestogen-only contraceptives as they may worsen HS 1.

Adjunctive Therapies (Mandatory for All Patients)

These measures are essential regardless of disease severity 2, 3:

• Smoking cessation referral: Tobacco use is associated with worse outcomes 2, 3, 6
• Weight management referral if BMI elevated: Weight loss should be encouraged for patients with obesity 3, 6
• Pain management with NSAIDs for symptomatic relief 2, 3, 6
• Appropriate wound dressings for draining lesions 2, 3, 6
• Screen for depression/anxiety and refer for mental health support 1, 2, 3
• Screen for cardiovascular risk factors: Measure blood pressure, lipids, HbA1c 1, 2, 3

Alternative Systemic Therapies (When Biologics Contraindicated or Failed)

• Acitretin 0.3-0.5 mg/kg/day in males and non-fertile females 1, 2
• Dapsone starting at 50 mg daily, titrating up to 200 mg daily 1, 2
• IV ertapenem 1g daily for 6 weeks as rescue therapy or bridge to surgery for severe disease 1, 2

Therapies with Insufficient Evidence

The following therapies lack sufficient evidence and are NOT recommended 1, 2: alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine (as monotherapy), cyproterone, finasteride, fumaric acid esters, hydrocortisone, hyperbaric oxygen therapy, isoniazid, laser and photodynamic therapies, methotrexate, oral prednisolone (except for acute flares), oral zinc, phototherapy, photochemotherapy, radiotherapy, spironolactone, staphage lysate, tolmetin sodium, and etanercept.

Explicitly avoid: Cryotherapy and microwave ablation for treating lesions during the acute phase 1, 2.

Monitoring and Treatment Response Assessment

Reassess at 12 weeks using 2, 3, 6:

• HiSCR: ≥50% reduction in inflammatory lesion count (abscesses + inflammatory nodules) with no increase in abscesses or draining fistulas 2, 3, 6
• Pain VAS score (0-10 scale) 2, 3, 6
• Inflammatory lesion count 2, 3
• Number of flares 2
• DLQI (quality of life measure) 2, 3, 6

For adalimumab, if no clinical response after 16 weeks, discontinue and consider alternative biologics 3, 6. For antibiotics, if no response after 12 weeks, escalate therapy 2.