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

Treatment of Mild Hidradenitis Suppurativa

For mild hidradenitis suppurativa (Hurley Stage I), start with topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks as first-line therapy. 1, 2, 3

Initial Assessment

Before initiating treatment, confirm the diagnosis and severity:

• Verify Hurley Stage I disease: isolated nodules and abscesses without sinus tracts or scarring 1, 2
• Document baseline pain using Visual Analog Scale (VAS) 1
• Count inflammatory lesions (nodules and abscesses) 1
• Assess quality of life using Dermatology Life Quality Index (DLQI) 1
• Screen for comorbidities: depression/anxiety, diabetes, hypertension, hyperlipidemia 1

First-Line Treatment: Topical Clindamycin

• Apply clindamycin 1% solution or gel 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, 3
• Alternative antiseptic cleansers include zinc pyrithione 1

Critical pitfall: Topical clindamycin alone increases rates of Staphylococcus aureus resistance, so always combine with benzoyl peroxide or chlorhexidine 1

Adjunctive Measures for Acute Lesions

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) can be injected into acutely inflamed nodules for rapid symptom relief within 1 day, with significant reductions in erythema, edema, suppuration, and pain 1
• Resorcinol 15% cream can reduce pain and duration of abscesses, though irritant dermatitis is a common side effect 1

Mandatory Lifestyle Interventions

All patients with mild HS require these interventions regardless of medical therapy:

• Smoking cessation referral (tobacco use worsens outcomes) 1, 2, 3
• Weight management referral if BMI elevated (obesity contributes to disease progression) 1, 2, 3
• Pain management with NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for any draining lesions 1, 2

Reassessment at 12 Weeks

Evaluate treatment response using objective measures:

• Pain VAS score 1
• Inflammatory lesion count 1
• Number of flares 1
• Quality of life (DLQI) 1

Treatment Escalation for Inadequate Response

If no clinical response after 12 weeks of topical clindamycin:

For More Widespread Mild Disease

• Escalate to oral tetracycline 500 mg twice daily for up to 4 months (12-16 weeks) 1, 2
• Alternative: doxycycline 100 mg once or twice daily for 12 weeks 1
• Alternative: lymecycline 408 mg once or twice daily for 12 weeks 1

Important caveat: Tetracyclines have weak evidence (only 30% abscess reduction in a single RCT) and are not effective for deep inflammatory lesions or abscesses 1. They work best for superficial disease without sinus tracts.

For Progression to Moderate Disease

If disease progresses to Hurley Stage II (recurrent nodules with limited sinus tracts):

• Escalate to 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 1, 3

Treatment Breaks and Antimicrobial Stewardship

• Consider treatment breaks after completing antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1
• Do not use long-term continuous antibiotics without treatment breaks 1

When to Refer to Dermatology

• Inadequate response after 12 weeks of first-line therapy 1
• Progression to Hurley Stage II or III (sinus tracts, scarring) 1
• Consideration of biologic therapy (adalimumab) for severe or refractory disease 1, 2, 3