What is the initial treatment approach for a 29-year-old female patient with Hidradenitis Suppurativa?

Initial Treatment for Hidradenitis Suppurativa in a 29-Year-Old Female

Begin with topical clindamycin 1% solution applied twice daily to all affected areas for 12 weeks if disease is mild (Hurley Stage I), or escalate immediately to oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks if disease is moderate (Hurley Stage II) with recurrent abscesses or nodules. 1, 2, 3

Disease Severity Assessment

Before initiating treatment, determine Hurley stage by examining all intertriginous areas (axillae, groins, perineum, inframammary regions) for the following features: 1, 4

• Hurley Stage I (Mild): Isolated nodules and abscesses without sinus tracts or scarring 1, 4
• Hurley Stage II (Moderate): Recurrent abscesses with limited sinus tracts and scarring, separated lesions 1, 4
• Hurley Stage III (Severe): Diffuse involvement with multiple interconnected sinus tracts and extensive scarring—refer immediately to dermatology 1, 4

Document baseline pain using Visual Analog Scale (VAS), count inflammatory lesions, measure quality of life with Dermatology Life Quality Index (DLQI), and record number of flares in the last month. 1, 2

Treatment Algorithm by Severity

Mild Disease (Hurley Stage I)

Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks is the first-line treatment. 1, 2, 3 Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk. 2, 3

For acutely inflamed nodules, 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. 2

Moderate Disease (Hurley Stage II)

Oral clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg once or twice daily for 10-12 weeks is the superior first-line choice, achieving response rates of 71-93%. 1, 2, 3 This combination far outperforms tetracycline monotherapy (which shows only 30% abscess reduction). 2

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 and abscesses. 2 Tetracyclines (doxycycline 100 mg once or twice daily for 12 weeks) may be considered only for more widespread mild disease or mild Hurley Stage II without deep inflammatory lesions. 1, 2

Severe Disease (Hurley Stage III) or Treatment Failure

If Hurley Stage III disease is present, immediately refer to dermatology and consider starting clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily while awaiting specialist evaluation. 1

For patients who fail antibiotic therapy after 12 weeks, escalate 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 This is the only FDA-approved biologic for moderate-to-severe HS, achieving HiSCR response rates of 42-59% at week 12. 2, 5

Critical: Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective. 2 The weekly 40 mg maintenance dose is required. 2, 5

Mandatory Adjunctive Measures for All Patients

Regardless of disease severity, implement the following at initial visit: 1, 2, 4

• Smoking cessation referral (smoking has odds ratio of 3.6 for HS) 4
• Weight management referral if BMI elevated (obesity has odds ratio of 3.3 for HS) 4
• Pain management with NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for draining lesions 1, 2
• Screen for depression/anxiety at baseline 1, 2, 4
• Screen for cardiovascular risk factors: measure blood pressure, lipids, HbA1c 1, 2, 4

Reassessment at 12 Weeks

Evaluate treatment response using: 1, 2

• Pain VAS score 1, 2
• Inflammatory lesion count 1, 2
• Number of flares in the last month 1, 2
• Quality of life (DLQI) 1, 2
• HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) for patients on biologics 2

Treatment Escalation Criteria

If no clinical response after 12 weeks of topical clindamycin or oral tetracyclines, escalate to clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks. 1, 2

If no clinical response after 12 weeks of clindamycin-rifampicin combination, escalate to adalimumab. 1, 2

If no clinical response after 16 weeks of adalimumab, consider second-line biologics: infliximab 5 mg/kg at weeks 0,2,6, then every 2 months; secukinumab (response rates 64.5-71.4% in adalimumab-failure patients); or ustekinumab. 2

Treatment Breaks and Antimicrobial Stewardship

Consider treatment breaks after completing 10-12 week antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance risk. 1, 2 Do not continue antibiotics long-term without reassessment. 2

Surgical Considerations

For extensive disease with established sinus tracts and scarring that fails medical management, refer to HS surgical multidisciplinary team for radical excision. 1, 2 Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy. 2 Non-recurrence rates after wide excision are 81.25%. 2

Critical Pitfalls to Avoid

• Do NOT use doxycycline as first-line for Hurley Stage II with abscesses or deep inflammatory nodules—it has minimal effect on these lesions 2
• Do NOT use topical clindamycin alone for Hurley Stage II—it only reduces superficial pustules, not inflammatory nodules or abscesses 2
• Do NOT use adalimumab 40 mg every other week—weekly dosing is required for efficacy 2
• Do NOT offer etanercept—it is ineffective for moderate-to-severe HS 2
• Do NOT continue antibiotics beyond 12-16 weeks without reassessment—this increases antimicrobial resistance risk 1, 2