What is the optimal management strategy for a patient with Hurley stage III hidradenitis suppurativa?

Optimal Management of Hurley Stage III Hidradenitis Suppurativa

Immediate Treatment Initiation

For Hurley Stage III hidradenitis suppurativa, initiate adalimumab as first-line definitive therapy with a loading dose of 160 mg subcutaneously at week 0,80 mg at week 2, followed by 40 mg weekly (not every other week) starting at week 4, while simultaneously planning radical surgical excision for extensive sinus tracts and scarring. 1, 2

• While awaiting specialist evaluation or biologic approval, bridge with oral clindamycin 300 mg twice daily plus rifampicin 300–600 mg daily for 10–12 weeks to control acute inflammation. 3, 1
• Add intralesional triamcinolone 10 mg/mL (0.2–2.0 mL per lesion) into acutely inflamed nodules for rapid symptom relief within 24 hours. 3, 1

Surgical Planning (Essential for Lasting Cure)

Radical surgical excision is the only intervention that achieves lasting cure in Hurley Stage III disease, with non-recurrence rates of approximately 81% after wide excision. 1

• Plan wide local excision of all affected tissue including sinus tracts and scarring; the width of excision directly influences therapeutic outcome. 3, 1
• Wound closure options include secondary intention healing (preferred for extensive disease), split-thickness skin grafts, or local flaps such as thoracodorsal artery perforator (TDAP) flaps. 3, 1
• Combining adalimumab with surgery produces superior clinical effectiveness compared to adalimumab monotherapy—consider concurrent medical and surgical management rather than sequential approaches. 1

Biologic Therapy Algorithm

• Adalimumab is the only FDA-approved biologic for moderate-to-severe HS in patients ≥12 years old, with HiSCR response rates of 42–59% at week 12. 1, 2
• Critical dosing error to avoid: Do NOT prescribe adalimumab 40 mg every other week for Hurley Stage III—this dosing is ineffective; weekly 40 mg dosing is mandatory. 1
• Assess response at week 12 using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas). 1, 2
• If inadequate response after 16 weeks of adalimumab, escalate to second-line biologics: infliximab 5 mg/kg at weeks 0,2,6, then every 2 months; or secukinumab (response rates 64.5–71.4% in adalimumab-failure patients); or ustekinumab. 1

Mandatory Adjunctive Measures (All Patients)

• Smoking cessation referral is non-negotiable—tobacco use carries an odds ratio of 36 for HS severity and dramatically worsens treatment outcomes. 1, 4
• Weight management referral for elevated BMI—obesity (odds ratio 33) predicts poor antibiotic response and surgical complications. 1, 4
• Pain management with NSAIDs for symptomatic relief throughout treatment. 3, 1
• Appropriate wound dressings for draining lesions; dressing choice based on drainage volume, location, and periwound skin condition. 5

Comorbidity Screening (Baseline Assessment)

• Screen for depression and anxiety using validated tools—HS patients have higher rates of completed suicide compared to the general population. 3, 1
• Measure blood pressure, lipid profile, and HbA1c—cardiovascular mortality risk is nearly doubled in HS patients, and diabetes prevalence reaches 30%. 3, 1
• Perform gastrointestinal symptom review to detect inflammatory bowel disease, particularly Crohn's disease. 3, 1
• Carefully examine chronic perineal and buttock lesions for squamous cell carcinoma, the most frequent malignancy in these sites. 1

Treatment Monitoring and Reassessment

• Reassess at 12 weeks using pain VAS score, inflammatory lesion count, HiSCR, and Dermatology Life Quality Index (DLQI). 3, 1
• Document baseline pain using Visual Analog Scale and inflammatory lesion count before initiating therapy. 3, 1
• After completing 10–12 week antibiotic courses, incorporate treatment breaks to assess ongoing need and limit antimicrobial resistance risk. 3, 1

Critical Pitfalls to Avoid

• Do NOT rely on antibiotics alone for Hurley Stage III—non-surgical methods rarely achieve lasting cure in advanced disease with extensive sinus tracts. 1
• Do NOT use topical clindamycin or oral tetracyclines as monotherapy for Stage III—these have minimal effect on deep inflammatory lesions and established sinus tracts. 1
• Do NOT extend antibiotic therapy beyond 12 weeks without formal reassessment—prolonged use increases antimicrobial resistance without proven additional benefit. 3, 1
• Do NOT offer isotretinoin, etanercept, or cryotherapy—these are ineffective for moderate-to-severe HS. 1

Expected Disease Course and Patient Counseling

• Hurley Stage III is defined by multiple or extensive sinus tracts and scarring affecting entire body regions, resulting in persistent purulent discharge from numerous draining tracts. 5
• Patients experience chronic purulent discharge, severe pain, persistent malodor, and involvement of intimate sites—all contributing to significant morbidity with average DLQI scores of 8.9. 5
• Chronic disease leads to fibrosis, contractures, and scarring that reduce mobility; potential complications include fistula formation (urethra, bladder, rectum), lymphedema, anemia, and dermatologic contractures. 1
• Median time to relapse after treatment withdrawal is approximately 5 months, emphasizing the need for long-term maintenance therapy. 2