What is the appropriate treatment plan for hidradenitis suppurativa in an adult woman with polycystic ovary syndrome?

Hidradenitis Suppurativa Treatment in Women with Polycystic Ovary Syndrome

Women with hidradenitis suppurativa and polycystic ovary syndrome should receive combination antiandrogen therapy (spironolactone 100-150 mg daily) alongside standard HS treatment, as this population has a 2-fold increased risk of HS and demonstrates superior response rates (85% improvement, 55% complete remission) compared to antibiotics alone (26% response). 1, 2, 3, 4

Disease Assessment and Comorbidity Recognition

Establish the diagnosis and severity:

• Confirm HS by identifying recurrent painful nodules/abscesses in intertriginous areas (axillary, inguinal, anogenital) with at least two episodes within 6 months 1
• Determine Hurley stage: Stage I (isolated nodules without sinus tracts), Stage II (recurrent nodules with limited sinus tracts/scarring), or Stage III (extensive sinus tracts and scarring) 1, 5
• Document baseline pain using Visual Analog Scale and count inflammatory lesions (nodules + abscesses) 1, 5

Screen for PCOS and metabolic comorbidities:

• The prevalence of PCOS among women with HS ranges from 9-38%, representing a 2-fold increased risk compared to controls 1, 3, 4
• Women with PCOS have a significantly elevated risk of developing HS (HR: 2.061,95% CI: 1.910-2.225), with the highest risk in younger women aged 18-39 4
• Screen for metabolic syndrome components: measure blood pressure, lipid profile, HbA1c, and BMI, as up to 50% of HS patients have metabolic syndrome 1
• Screen for depression and anxiety using validated tools, as prevalence of depression reaches 30% in HS populations 1

Treatment Algorithm Based on Disease Severity

Hurley Stage I (Mild Disease)

First-line topical therapy:

• Topical clindamycin 1% solution/gel applied twice daily to all affected areas for 12 weeks 1, 5
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules provides rapid relief within 24 hours 1, 5

Add antiandrogen therapy early in PCOS patients:

• Spironolactone 100-150 mg daily resulted in improvement in 85% of women with HS, including complete remission in 55% 1, 2
• Patients reporting HS flares around menses are more likely to benefit from hormonal therapies 1, 2
• Combined oral contraceptives (ethinyl estradiol with cyproterone acetate) showed improvement in 55% of women in retrospective series 1

Hurley Stage II (Moderate Disease)

First-line systemic antibiotic combination:

• Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks achieves response rates of 71-93% 1, 5
• This combination is superior to doxycycline monotherapy (26-30% response) and should be the preferred first-line systemic regimen 1, 5
• Intralesional triamcinolone 10 mg/mL for acutely inflamed nodules provides rapid symptom control 1, 5

Concurrent antiandrogen therapy in PCOS patients:

• Add spironolactone 100-150 mg daily as adjunctive therapy to antibiotics 1, 2
• Metformin 500 mg 2-3 times daily showed significant improvement in Sartorius score in 72% of patients (18/25), with most being females with PCOS features 1
• Finasteride 1.25-5 mg daily has been beneficial in case reports, especially in patients with refractory HS or endocrine comorbidities 1

Critical pitfall: Do NOT use progestogen-only contraceptive regimens, as these may worsen HS in some cases and should be discontinued if disease worsens 1, 2, 6

Hurley Stage III (Severe Disease) or Antibiotic Failure

Escalate to biologic therapy:

• Adalimumab is the only FDA-approved biologic for moderate-to-severe HS 7
• Dosing: 160 mg subcutaneous at week 0 (single dose or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting at week 4 1, 5, 7
• HiSCR response rates: 42-59% at week 12 1, 5
• If no clinical response after 16 weeks, consider second-line biologics: infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1, 5

Continue antiandrogen therapy alongside biologics:

• Maintain spironolactone 100-150 mg daily as adjunctive therapy 1, 2
• The hormonal component of disease pathogenesis persists regardless of biologic use 2, 8

Surgical considerations:

• Radical surgical excision for extensive disease with sinus tracts and scarring when medical management fails 1, 5
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1, 5

Reassessment and Treatment Monitoring

12-week evaluation:

• Reassess using HiSCR (≥50% reduction in abscess/nodule count without increase in abscesses or draining fistulas) 1, 5
• Measure pain VAS score, inflammatory lesion count, number of flares, and quality of life (DLQI) 1, 5
• If no response after 12 weeks of first-line antibiotics, escalate to adalimumab 1, 5

Treatment breaks:

• Consider treatment breaks after completing 10-12 week antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1, 5
• Continue antiandrogen therapy (spironolactone) long-term, as hormonal influence persists 1, 2

Mandatory Adjunctive Measures for All Patients

Lifestyle modifications:

• Smoking cessation referral: 70-75% of HS patients are smokers, and tobacco use worsens outcomes 1, 5
• Weight management referral if BMI elevated: obesity prevalence exceeds 75% in HS patients and contributes significantly to pathogenesis 1, 8
• Pain management with NSAIDs for symptomatic relief 1, 5
• Appropriate wound dressings for draining lesions 1, 5

Ongoing comorbidity screening:

• Annual screening for cardiovascular risk factors (blood pressure, lipids, HbA1c) 1, 5
• Screen for inflammatory bowel disease symptoms annually 1
• Monitor for depression and anxiety 1, 5

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 (only 30% abscess reduction) 1, 5
• Do NOT prescribe adalimumab 40 mg every other week for moderate-to-severe HS; weekly dosing (40 mg) is required for efficacy 1, 5
• Do NOT use progestogen-only contraceptives in women with HS and PCOS, as these may worsen disease 1, 2, 6
• Do NOT extend antibiotic therapy beyond 12 weeks without reassessment, as prolonged use increases antimicrobial resistance without proven additional benefit 1, 5
• Do NOT overlook PCOS screening in women presenting with HS, as the prevalence is 9-38% and antiandrogen therapy is highly effective in this population 1, 3, 4