What are the treatment options for a patient with hydradenitis suppurativa?

Hidradenitis Suppurativa Treatment

Treatment Algorithm Based on Disease Severity

For mild disease (Hurley Stage I), start with topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks, combined with daily antiseptic washes using chlorhexidine 4% or benzoyl peroxide. 1, 2, 3

For moderate disease (Hurley Stage II), the first-line treatment is oral clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg once or twice daily for 10-12 weeks, which achieves response rates of 71-93%—far superior to tetracycline monotherapy. 1, 2, 3, 4

For severe disease (Hurley Stage III) or failure of antibiotics after 12 weeks, escalate immediately to adalimumab: 160 mg subcutaneous at week 0 (given in one day or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2, 3, 5

Hurley Staging Assessment

Before initiating treatment, determine Hurley stage to guide therapy intensity 2, 3:

• Stage I: Isolated nodules and abscesses without sinus tracts or scarring
• Stage II: Recurrent nodules with limited sinus tracts and scarring
• Stage III: Diffuse involvement with multiple interconnected sinus tracts and extensive scarring

Acute Flare Management

For acutely inflamed nodules at any stage, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) directly into the lesion, which provides rapid symptom relief within 1 day with significant reductions in erythema, edema, suppuration, and pain. 1, 2, 3

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Detailed Treatment by Severity

Mild Disease (Hurley Stage I)

Topical Therapy:

• Apply topical 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 2, 3
• Topical clindamycin alone may increase rates of bacterial resistance; always combine with antiseptic washes 1, 2

Alternative topical option:

• Resorcinol 15% cream can reduce pain and duration of abscesses, though irritant dermatitis is a common side effect 2

When to escalate: If no response after 12 weeks of topical therapy, escalate to oral antibiotics for moderate disease. 2, 3

Moderate Disease (Hurley Stage II)

First-Line Systemic Therapy:

• Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks 1, 2, 3, 4
• This combination achieves response rates of 71-93% in systematic reviews 2, 3, 4
• Treatment typically lasts 10-12 weeks and can be repeated intermittently 1, 2, 4

Alternative first-line option (for widespread mild disease or mild Hurley Stage II WITHOUT deep inflammatory lesions or abscesses):

• Doxycycline 100 mg once or twice daily for 12 weeks 1, 2, 4
• Tetracycline 500 mg twice daily for up to 4 months 1, 2
• Critical caveat: Do NOT use tetracyclines as first-line for Hurley Stage II with abscesses or deep inflammatory nodules, as they have minimal effect on these lesions, showing only 30% abscess reduction 2, 4

When to escalate: If no clinical response after 12 weeks of clindamycin-rifampicin, escalate to adalimumab. 2, 3, 4

Severe Disease (Hurley Stage III) or Refractory Disease

First-Line Biologic Therapy:

• Adalimumab is the only FDA-approved biologic for moderate-to-severe HS in patients ≥12 years old 5
• Adult dosing: 160 mg subcutaneous at week 0 (given in one day or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting at week 4 1, 2, 3, 5
• Adolescent dosing (12 years and older, 60 kg and greater): Same as adult dosing 5
• Adolescent dosing (30 kg to less than 60 kg): 80 mg on Day 1, then 40 mg every other week starting Day 8 5
• HiSCR response rates of 42-59% at week 12 in placebo-controlled trials 2, 3

When to assess response: Reassess at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas). 2, 3 If no clinical response after 16 weeks, consider alternative treatments. 2, 3

Second-Line Biologic Options (after adalimumab failure):

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1, 2
• Secukinumab (conditional strength, moderate quality evidence) with response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 2
• Ustekinumab (conditional strength, moderate quality evidence) 2

Alternative systemic therapies (when biologics are not appropriate):

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

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Surgical Interventions

Surgical treatment is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 2, 3, 6

Surgical options:

• Deroofing for recurrent nodules and tunnels 1, 2
• Radical surgical excision for extensive disease with sinus tracts and scarring when conventional systemic treatments have failed 1, 2, 3
• Non-recurrence rates after wide excision: 81.25% 2
• Wound closure options include secondary intention healing, skin grafts, or flaps 1, 2

Combining surgery with medical therapy: Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy. 2, 3 Consider surgery concurrently with medical therapy for Hurley Stage II-III disease with established sinus tracts. 2

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Mandatory Adjunctive Measures for All Patients

Regardless of disease severity, ALL patients require the following 1, 2, 3:

• Smoking cessation referral (tobacco use worsens outcomes) 2, 3, 4
• Weight management referral if BMI elevated (obesity is associated with worse disease) 2, 3, 4
• Pain management with NSAIDs for symptomatic relief 1, 2, 3
• Appropriate wound dressings for draining lesions 2, 3
• Screen for depression/anxiety 1, 2, 3
• Screen for cardiovascular risk factors (measure BP, lipids, HbA1c) 1, 2, 3

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Treatment Monitoring and Reassessment

Reassess treatment response at 12 weeks using: 1, 2, 3, 4

• Pain VAS score
• Inflammatory lesion count (HiSCR: ≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas)
• Number of flares
• Quality of life (DLQI)

Consider treatment breaks after completing antibiotic courses (10-12 weeks) to assess need for ongoing therapy and limit antimicrobial resistance risk. 1, 2, 4

For adalimumab: If no clinical response after 16 weeks, consider alternative treatments. 2, 3

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Special Population Considerations

Pediatric Patients

For children ≥12 years old with moderate-to-severe disease:

• Adalimumab is FDA-approved with weight-based dosing 1, 5

For children ≥8 years old requiring systemic antibiotics:

• Doxycycline 100 mg once or twice daily 1, 4
• OR clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks 2, 4

For children ≥6 years old with Crohn's disease-associated HS:

• Adalimumab with weight-based dosing per FDA label 5

Patients with HIV

• Use doxycycline due to added prophylactic benefit against bacterial STIs 2
• Avoid rifampicin due to drug interactions with certain HIV therapies 2

Patients with Prior Malignancy

• Doxycycline is the safest choice with strong evidence of safety 4
• Prednisone for acute widespread flares only (short-term use, not maintenance) 2

Breastfeeding Patients

• Amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole 2
• Limit doxycycline to ≤3 weeks without repeating courses 2

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Critical Pitfalls 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, showing only 30% abscess reduction. 2, 4
• Do NOT use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules, not inflammatory nodules or abscesses. 2
• Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective. 2
• Do NOT offer etanercept for moderate-to-severe HS, as it is ineffective. 2
• Do NOT offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk. 2
• Avoid long-term continuous antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 1, 2, 4
• Do NOT continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit. 2

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Long-Term Monitoring for Complications

Patients with long-standing moderate-to-severe HS should be monitored for 3:

• Fistulating gastrointestinal disease
• Inflammatory arthritis
• Genital lymphoedema
• Cutaneous squamous cell carcinoma
• Anemia