From the Guidelines
Hidradenitis suppurativa treatment should be initiated with topical Clindamycin 1% solution/gel applied twice daily for 12 weeks or Tetracycline 500 mg orally twice daily for 4 months for mild disease, and escalated to combination therapy with Clindamycin 300 mg orally twice daily plus Rifampicin 600 mg orally once daily for 10 weeks for more widespread disease, with consideration of Adalimumab 160 mg at week 0,80 mg at week 2, and then 40 mg subcutaneously weekly for moderate to severe disease, as supported by the highest quality evidence from 2019 1. The treatment approach should be tailored to disease severity, with consideration of patient-reported outcomes, including DLQI, itch, and pain assessment, as recommended by the European guidelines for hidradenitis suppurativa 1. Key considerations in the treatment of hidradenitis suppurativa include:
- Topical therapy with Clindamycin 1% solution/gel for mild disease
- Oral antibiotics, such as Tetracycline 500 mg twice daily, for moderate disease
- Combination therapy with Clindamycin 300 mg twice daily plus Rifampicin 600 mg once daily for 10 weeks for more severe or resistant cases
- Biologics, such as Adalimumab, for severe disease, with a dosing regimen of 160 mg at week 0,80 mg at week 2, and then 40 mg subcutaneously weekly, as demonstrated in the PIONEER 1 and PIONEER 2 trials 1
- Surgical interventions, ranging from incision and drainage to wide excision of chronically affected tissue, for definitive treatment
- Lifestyle modifications, including weight loss, smoking cessation, and avoiding shaving affected areas, to reduce disease severity and improve quality of life. The use of Adalimumab has been shown to be effective in achieving a clinical response, with a HiSCR response rate of 42% versus 26% for placebo in the PIONEER 1 trial, and 59% versus 28% in the PIONEER 2 trial 1. Overall, a multifaceted approach to hidradenitis suppurativa treatment, incorporating medical, surgical, and lifestyle modifications, is essential to improve patient outcomes and reduce morbidity, mortality, and impact on quality of life.
From the FDA Drug Label
Hidradenitis Suppurativa (HS) (1.8): treatment of moderate to severe hidradenitis suppurativa in patients 12 years of age and older. Hidradenitis Suppurativa (2. 6): Adults:◦ Day 1: 160 mg (given in one day or split over two consecutive days)◦ Day 15: 80 mg ◦ Day 29 and subsequent doses: 40 mg every week or 80 mg every other week Adolescents 12 years of age and older: Adolescent WeightRecommended Dosage 30 kg (66 lbs) to less than 60 kg (132 lbs)Day 1: 80 mg Day 8 and subsequent doses: 40 mg every other week 60 kg (132 lbs) and greaterDay 1: 160 mg (given in one day or split over two consecutive days)Day 15: 80 mg Day 29 and subsequent doses: 40 mg every week or 80 mg every other week
Treatment of Hidradenitis Suppurativa (HS): Adalimumab is indicated for the treatment of moderate to severe hidradenitis suppurativa in patients 12 years of age and older.
- Adults: The recommended dosage is 160 mg on Day 1 (given in one day or split over two consecutive days), 80 mg on Day 15, and 40 mg every week or 80 mg every other week starting on Day 29.
- Adolescents 12 years of age and older: The recommended dosage is based on weight. For adolescents weighing 30 kg to less than 60 kg, the dosage is 80 mg on Day 1 and 40 mg every other week starting on Day 8. For adolescents weighing 60 kg or greater, the dosage is 160 mg on Day 1 (given in one day or split over two consecutive days), 80 mg on Day 15, and 40 mg every week or 80 mg every other week starting on Day 29 2.
From the Research
Treatment Options for Hidradenitis Suppurativa
- Medical treatments for hidradenitis suppurativa (HS) include antibiotics, retinoids, and anti-inflammatory drugs 3.
- In mild cases, clindamycin lotion or resorcinol cream have proven effective, while tetracyclines are a first-line systemic option in more widespread or severe cases 3.
- The combination of clindamycin and rifampicin has been shown to be effective in treating HS, but the recurrence rate is high after discontinuation of this combination therapy 3, 4.
- Long-term treatment with retinoids, especially acitretin, is feasible, although teratogenicity must be taken into account in females of reproductive age 3.
- Biologics, such as infliximab or adalimumab, are considered the next step if common treatments have failed 3.
Antibiotic Treatment
- Tetracycline, doxycycline, and lymecycline have been shown to be effective in treating HS, with tetracycline providing the greatest clinical improvement measured by Hidradenitis Suppurativa Score (HSS) 5.
- Clindamycin monotherapy has been demonstrated to be effective in reducing HS severity scores and pain, and may be considered as an alternative to the combination of clindamycin and rifampicin 6.