What is the stepwise management of hidradenitis suppurativa?

Stepwise Management of Hidradenitis Suppurativa

Begin by determining Hurley stage through examination of all intertriginous areas (axillae, groin, inframammary, perianal), then initiate topical clindamycin 1% twice daily for Stage I, oral clindamycin 300 mg plus rifampicin 300-600 mg twice daily for 10-12 weeks for Stage II, and adalimumab 160 mg week 0/80 mg week 2/40 mg weekly thereafter for Stage III or antibiotic-refractory disease. 1, 2

Initial Assessment and Staging

Confirm the diagnosis by identifying recurrent painful nodules or abscesses in intertriginous areas with at least two episodes within six months, plus the presence of comedones, sinus tracts, or scarring. 1 Do not order bacterial cultures unless clear signs of secondary infection (cellulitis, fever) exist, as mixed flora does not guide therapy. 1

Document Hurley stage to guide treatment intensity: 1, 2

• Stage I: Isolated nodules/abscesses without sinus tracts or scarring
• Stage II: Recurrent nodules with limited sinus tracts and scarring
• Stage III: Multiple/extensive sinus tracts and scarring across entire affected region

Record baseline metrics: Visual Analog Scale (VAS) pain score, inflammatory lesion count (nodules + abscesses), and Dermatology Life Quality Index (DLQI). 1, 2

Mandatory Comorbidity Screening (All Patients)

Screen every patient for the following at baseline: 3, 1

• Smoking status: 70-75% of HS patients smoke; document pack-years and refer for cessation 1
• Diabetes: Check HbA1c or fasting glucose (1.5-3× increased risk, up to 30% prevalence) 3, 1
• Metabolic syndrome: Measure blood pressure, lipid profile, and BMI 3, 1
• Depression/anxiety: Use validated screening tools 3, 1
• Inflammatory bowel disease: Review gastrointestinal symptoms 3, 1
• Squamous cell carcinoma risk: Examine chronic perineal/buttock lesions carefully 1

Treatment Algorithm by Hurley Stage

Hurley Stage I (Mild Disease)

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

For acute inflamed nodules: Inject intralesional triamcinolone acetonide 10 mg/mL (0.2-2.0 mL depending on lesion size) directly into the center of the lesion using a 25-30 gauge needle. 1, 4 This provides rapid pain relief within 24 hours and visible improvement by 7 days. 4 Avoid high concentrations (40 mg/mL) or large volumes in thin-skinned areas to prevent permanent atrophy. 4

Hurley Stage II (Moderate Disease)

First-line systemic therapy: Oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg once or twice daily for 10-12 weeks. 1, 2 This combination achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy (30% abscess reduction). 1, 2

Do NOT use doxycycline or tetracycline monotherapy as first-line for Stage II with abscesses, as these have minimal effect on deep inflammatory lesions. 1

Alternative first-line option (for widespread mild disease or mild Stage II without deep lesions): Doxycycline 100 mg once or twice daily for 12 weeks, or tetracycline 500 mg twice daily for up to 4 months. 1 However, evidence quality is weak (Level IIb) based on a single 46-patient trial. 1

Hurley Stage III (Severe Disease)

While awaiting specialist evaluation: Initiate clindamycin 300 mg + rifampicin 300 mg twice daily. 1

Definitive first-line biologic therapy: Adalimumab 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2 This achieves HiSCR response rates (≥50% reduction in abscess/nodule count without new abscesses or draining fistulas) of 42-59% at week 12. 1, 2

Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective. 1

Reassessment at 12 Weeks

Evaluate treatment response using: 1, 2

• Pain VAS score
• Inflammatory lesion count
• Number of flares
• DLQI score
• HiSCR (for biologic therapy)

If no clinical response after 12 weeks of first-line therapy, escalate treatment: 1, 2

• Stage I failure: Escalate to clindamycin-rifampicin combination
• Stage II failure: Escalate to adalimumab
• Adalimumab failure after 16 weeks: Consider second-line biologics

Treatment Escalation After Adalimumab Failure

Second-line biologic options (conditional strength, moderate quality evidence): 1

• Infliximab: 5 mg/kg at weeks 0,2,6, then every 2 months 3, 1
• Secukinumab: Response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 1
• Ustekinumab: Alternative pathway targeting different cytokines than TNF-alpha 1

For treatment-refractory disease, secukinumab can be combined with infliximab, targeting different inflammatory pathways. 1

Surgical Intervention

Indications for surgery: 3, 1, 2

• Extensive disease with sinus tracts and scarring when conventional systemic treatments have failed
• Hurley Stage II-III with established sinus tracts (consider concurrent with medical therapy)
• Recurrent nodules and tunnels (deroofing procedure)

Surgical options: 3, 1

• Deroofing: For recurrent nodules and tunnels
• Radical/wide excision: For extensive disease; non-recurrence rates of 81.25% after wide excision
• Wound closure options: Secondary intention healing, skin grafts, flaps, or delayed primary closure

Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy. 1

Post-operative antibiotic regimen: Continue clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks to prevent recurrence and manage residual disease. 1

Essential Adjunctive Measures (All Stages)

Implement the following for every patient: 1, 2

• Smoking cessation referral: Tobacco use worsens outcomes and increases treatment failure 1, 2
• Weight management referral: Obesity prevalence exceeds 75% in HS patients; weight loss improves outcomes 1, 2
• Pain management: NSAIDs for symptomatic relief 1, 2
• Wound care: Appropriate dressings for draining lesions 1, 2

Special Population Considerations

Pediatric patients (≥8 years): Doxycycline 100 mg once or twice daily, or clindamycin 300 mg + rifampicin 300 mg twice daily for 10-12 weeks. 1 For ages 12+, adalimumab is FDA-approved with weight-based dosing. 1

Breastfeeding patients: Use amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole; limit doxycycline to ≤3 weeks without repeating courses. 1

HIV patients: Use doxycycline for added prophylactic benefit against bacterial STIs; exercise caution with rifampicin due to drug interactions with certain HIV therapies. 1

Hepatitis B/C patients: Use doxycycline with standard approach for patients without cirrhosis; exercise caution with rifampicin due to potential hepatotoxicity. 1

Critical Pitfalls to Avoid

• Do NOT use incision and drainage except for acute abscesses to relieve pain; it does not prevent recurrence 3
• Do NOT continue antibiotics indefinitely; limit courses to 10-12 weeks with treatment breaks to minimize antimicrobial resistance 1, 2
• Do NOT use topical clindamycin alone for Stage II disease; it only reduces superficial pustules, not inflammatory nodules or abscesses 1
• Do NOT use etanercept for moderate-to-severe HS; it is ineffective 1
• Do NOT offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 1
• Do NOT use cryotherapy or microwave ablation for treating lesions during the acute phase 1

Alternative Systemic Therapies (Limited Evidence)

For patients unresponsive to adalimumab: 1

• Acitretin: 0.3-0.5 mg/kg/day (males and non-fertile females only)
• Dapsone: Start 50 mg daily, titrate up to 200 mg daily
• Metformin: Consider in patients with concomitant diabetes or PCOS
• Ertapenem: 1g daily IV for 6 weeks (rescue therapy or during surgical planning for severe disease)

Oral corticosteroids (prednisone) are reserved only for acute, widespread flares while awaiting response to definitive therapies, not for routine or long-term management (conditional strength, low-quality evidence). 1 If prednisone dose exceeds 15 mg daily for ≥4 weeks, annual screening for latent TB is mandatory. 1

Long-Term Monitoring

Monitor patients with long-standing moderate-to-severe HS for: 2

• Fistulating gastrointestinal disease
• Inflammatory arthritis
• Genital lymphedema
• Cutaneous squamous cell carcinoma (especially chronic perineal/buttock lesions)
• Anemia