Treatment for Hidradenitis Suppurativa Flare-Up
For an acute HS flare, immediately start oral clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg daily for 10-12 weeks, combined with intralesional triamcinolone 10 mg/mL injected directly into inflamed nodules for rapid symptom relief within 24 hours. 1, 2, 3
Immediate Management of Acute Flare
Inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) directly into acutely inflamed nodules and abscesses to achieve significant reduction in erythema, edema, suppuration, and pain within 1 day 2, 3.
Start oral clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg once or twice daily immediately, as this combination achieves response rates of 71-93% and is the superior first-line choice for moderate-to-severe flares 1, 2, 3.
Provide NSAIDs for pain management and appropriate wound dressings for draining lesions 1, 3.
Treatment Duration and Monitoring
Continue the clindamycin-rifampicin combination for 10-12 weeks, then reassess using pain VAS score, inflammatory lesion count, and quality of life measures 1, 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.
When to Escalate Beyond Antibiotics
If no clinical response after 12 weeks of clindamycin-rifampicin, escalate to adalimumab: 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 1, 2, 4.
For severe acute widespread flares, consider short-term oral prednisone as bridge therapy while awaiting response to definitive treatments, but limit to acute exacerbations only—not for maintenance 1, 2.
Critical Adjunctive Measures During Flare
Refer immediately to smoking cessation services, as tobacco use dramatically worsens outcomes (odds ratio 36) and predicts treatment failure 2, 3, 5.
Apply topical clindamycin 1% twice daily to all affected areas as adjunctive therapy, combined with benzoyl peroxide or chlorhexidine 4% wash to reduce Staphylococcus aureus resistance risk 2, 3, 5.
Screen for depression/anxiety and cardiovascular risk factors (blood pressure, lipids, HbA1c), as these comorbidities are highly prevalent in HS 1, 2, 3.
Common Pitfalls to Avoid
Do NOT use doxycycline or tetracycline monotherapy for acute flares with abscesses, as these have minimal effect on deep inflammatory lesions, showing only 30% abscess reduction 2, 5.
Do NOT use topical clindamycin alone for moderate-to-severe flares, 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 risk without proven additional benefit 1, 2, 3.
Do NOT use adalimumab 40 mg every other week, as this dosing is ineffective; weekly dosing (40 mg) is required for moderate-to-severe HS 1, 4.