What is the recommended treatment plan for hidradenitis suppurativa in a young adult woman with obesity and a smoking history?

Recommended Treatment Plan for Hidradenitis Suppurativa in a Young Adult Woman with Obesity and Smoking History

For this patient with moderate-to-severe hidradenitis suppurativa, smoking, and obesity, immediately initiate smoking cessation counseling and weight management referral alongside medical therapy, as these lifestyle factors directly worsen disease severity and treatment response. 1

Immediate Assessment and Screening

Determine Hurley stage by examining all intertriginous areas (axillae, groin, inframammary, buttocks) for isolated nodules (Stage I), recurrent nodules with limited sinus tracts (Stage II), or extensive sinus tracts and scarring (Stage III). 1

Screen for critical comorbidities at baseline:

• Depression and anxiety (44% prevalence in HS patients) 1
• Diabetes mellitus (1.5-3 fold increased risk, up to 30% prevalence) - check HbA1c or fasting glucose 1
• Polycystic ovary syndrome (3-fold increased risk, up to 9% affected) - assess for menstrual irregularity and signs of androgen excess 1
• Metabolic syndrome and hyperlipidemia - check blood pressure and lipid panel 1
• Inflammatory bowel disease - thorough review of GI symptoms 1

Document baseline disease activity using pain Visual Analog Scale (VAS), inflammatory lesion count, and Dermatology Life Quality Index (DLQI). 1, 2

Treatment Algorithm by Disease Severity

For Hurley Stage I (Isolated Nodules Without Sinus Tracts)

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, as topical clindamycin monotherapy increases resistance rates. 2, 3

Add intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules, providing rapid symptom relief within 1 day with significant reductions in erythema, edema, suppuration, and pain. 2, 3

Reassess at 12 weeks using pain VAS, inflammatory lesion count, and DLQI. If inadequate response, escalate to oral antibiotics. 1, 2

For Hurley Stage II (Recurrent Nodules with Limited Sinus Tracts)

First-line therapy: Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks. This combination achieves response rates of 71-93%, far superior to tetracycline monotherapy (30% abscess reduction). 1, 2, 3, 4

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, 3

Add intralesional triamcinolone 10 mg/mL for acutely inflamed nodules during treatment. 2, 3

Reassess at 12 weeks using pain VAS, inflammatory lesion count, DLQI, and number of flares. 1, 2

If inadequate response after 12 weeks, escalate directly to adalimumab. 2, 3

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

For Hurley Stage III or Failed Antibiotic Therapy

First-line biologic therapy: Adalimumab (FDA-approved for moderate-to-severe HS) with dosing of 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. This achieves HiSCR response rates of 42-59% at week 12. 1, 2, 3, 4, 5

Do NOT use adalimumab 40 mg every other week, as this dosing is ineffective for HS. 2

Assess treatment response at 16 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas). 2, 3

If adalimumab fails after 16 weeks, consider second-line biologics:

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 2, 3
• Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients at 16-52 weeks) 1, 2
• Ustekinumab (conditional recommendation, moderate quality evidence) 1, 2

Consider surgical intervention concurrently with medical therapy for extensive disease with sinus tracts and scarring, as combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy. 2, 3, 4

Mandatory Lifestyle Modifications

Smoking cessation is critical, as 70-75% of HS patients smoke, and smoking is associated with increased disease severity, duration, and treatment failure. Case reports document complete remission in women who stopped smoking. 1

Weight loss significantly improves outcomes, as >75% of HS patients are overweight or obese. With >15% weight reduction, 48.6% of patients reported complete remission, 20% reported improvement in one study of 35 patients who underwent bariatric surgery. 1

Refer to smoking cessation services and weight management programs immediately, as these interventions improve both HS outcomes and overall health. 1, 2

Adjunctive Therapies

Pain management with NSAIDs for symptomatic relief. 1, 2

Appropriate wound dressings for draining lesions. 1, 2

Consider zinc gluconate 90 mg daily for Hurley Stage I-II disease, as retrospective studies show improvement in mean DLQI scores and clinical response in patients with mild-to-moderate disease. 1

Screen for vitamin D deficiency, as 63% of vitamin D-deficient HS patients who received supplements achieved ≥20% decrease in inflammatory nodules. 1

Surgical Options

For recurrent nodules and tunnels: Deroofing procedure. 2, 3

For extensive disease with sinus tracts and scarring when medical therapy fails: Radical surgical excision with non-recurrence rates of 81.25% after wide excision. Wound closure options include secondary intention healing, skin grafts, or flaps. 2, 3, 4

The width of excision influences therapeutic outcome, so ensure adequate margins. 2

Critical Pitfalls to Avoid

Do not use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules, not inflammatory nodules or abscesses. 2

Do not continue antibiotics beyond 12 weeks without reassessment, as prolonged use increases antimicrobial resistance without proven additional benefit. 1, 2

Do not offer isotretinoin unless concomitant moderate-to-severe acneiform lesions of face or trunk are present. 2

Do not offer etanercept for moderate-to-severe HS, as it is ineffective. 2

Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 1, 2

Monitoring Schedule

At 12 weeks: Reassess using pain VAS score, inflammatory lesion count, number of flares, and DLQI. 1, 2

For patients on adalimumab: Assess HiSCR at 12-16 weeks. 2, 3

Ongoing: Periodic skin examination, particularly of chronic lesions on perineum and buttocks where squamous cell carcinoma is most common. 1

Annual screening for cardiovascular risk factors (blood pressure, lipids, HbA1c) given increased risk in HS patients. 1, 2