What is the treatment for suspected hidradenitis suppurativa?

Treatment for Suspected Hidradenitis Suppurativa

For suspected hidradenitis suppurativa, begin with topical clindamycin 1% twice daily for 12 weeks if you see isolated nodules or abscesses without sinus tracts (Hurley Stage I), escalate immediately to oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks if you observe recurrent abscesses or limited sinus tracts (Hurley Stage II), and refer urgently to dermatology while starting clindamycin-rifampicin if you identify extensive sinus tracts and scarring (Hurley Stage III). 1

Confirm the Diagnosis Before Treatment

• Verify three diagnostic criteria: (1) typical painful nodules, abscesses, sinus tracts, or comedones; (2) location in axillae, groin, perianal, or inframammary areas; and (3) recurrence—at least two episodes in six months or chronic lesions persisting ≥3 months. 2, 3
• Do not order bacterial cultures unless you see cellulitis, fever, or systemic signs of secondary infection, because mixed skin flora does not guide hidradenitis suppurativa therapy. 1
• Document baseline pain using a 0-10 numeric scale and count all inflammatory nodules plus abscesses to track treatment response at 12 weeks. 1

Determine Hurley Stage to Guide Treatment Intensity

• Hurley Stage I (mild): isolated nodules or abscesses with minimal scarring and no sinus tracts. 2, 1
• Hurley Stage II (moderate): recurrent nodules with one or limited sinus tracts and scarring confined to a single region. 2, 1
• Hurley Stage III (severe): multiple or extensive sinus tracts and scarring involving an entire anatomic area. 2, 1

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

• Start topical clindamycin 1% solution or gel applied twice daily to all affected intertriginous areas for 12 weeks; this is the guideline-endorsed first-line therapy for isolated nodules without sinus tracts. 1
• Add benzoyl peroxide 10% wash daily to reduce Staphylococcus aureus resistance risk when using topical clindamycin. 1, 4
• Inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) into acutely inflamed nodules for rapid symptom relief within 24 hours. 1

Hurley Stage II (Moderate Disease)

• Initiate oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg once or twice daily for 10-12 weeks; this combination achieves 71-93% clinical response rates and is the preferred first-line systemic regimen. 1
• Do not use doxycycline or tetracycline monotherapy for Hurley Stage II with abscesses, because these agents show only 30% abscess reduction and have minimal effect on deep inflammatory lesions. 1
• Combine systemic antibiotics with intralesional triamcinolone 10 mg/mL for any acutely inflamed nodules to provide immediate pain relief while antibiotics take effect. 1

Hurley Stage III (Severe Disease)

• Start clindamycin 300 mg plus rifampicin 300 mg twice daily as bridge therapy while arranging urgent dermatology referral. 1
• Definitive therapy requires adalimumab 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 (FDA-approved biologic for moderate-to-severe hidradenitis suppurativa in patients ≥12 years old). 1, 5
• Do not prescribe adalimumab 40 mg every other week; weekly dosing is required for efficacy in hidradenitis suppurativa. 1
• Refer to surgery for radical excision when extensive sinus tracts and scarring fail medical management; wide excision yields 81% non-recurrence rates. 1

Reassess Treatment Response at 12 Weeks

• Measure treatment success using HiSCR (Hidradenitis Suppurativa Clinical Response): ≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas. 1
• Re-evaluate pain score, inflammatory lesion count, number of flares, and quality of life (DLQI). 1
• If no clinical response after 12 weeks of clindamycin-rifampicin, escalate to adalimumab using the dosing schedule above. 1
• If adalimumab fails after 16 weeks, consider second-line biologics: infliximab 5 mg/kg at weeks 0,2,6, then every 2 months; secukinumab; or ustekinumab. 1

Mandatory Adjunctive Measures for All Patients

• Refer for smoking cessation; 70-75% of hidradenitis suppurativa patients smoke, and tobacco worsens outcomes. 1
• Refer for weight management if BMI is elevated; obesity prevalence exceeds 75% in hidradenitis suppurativa and increases mechanical friction plus pro-inflammatory cytokines. 1
• Prescribe NSAIDs for pain management and apply appropriate wound dressings to draining lesions. 1
• Screen for depression and anxiety using validated tools; these psychiatric comorbidities are highly prevalent in hidradenitis suppurativa. 1
• Screen for cardiovascular risk factors by measuring blood pressure, lipid profile, and HbA1c; hidradenitis suppurativa patients have nearly doubled cardiovascular mortality. 1

Critical Pitfalls to Avoid

• Do not continue antibiotics beyond 12 weeks without formal reassessment; prolonged use increases antimicrobial resistance without proven additional benefit. 1
• Do not use topical clindamycin alone for Hurley Stage II or III; it only reduces superficial pustules and does not address nodules, abscesses, or sinus tracts. 1
• Do not treat hidradenitis suppurativa as recurrent bacterial abscesses; this is a chronic inflammatory follicular disease requiring systemic anti-inflammatory therapy, not incision and drainage alone. 1
• Do not prescribe oral corticosteroids for routine management; reserve prednisone only for acute widespread flares as bridge therapy, not maintenance. 1
• Avoid rifampicin in patients with HIV due to drug interactions with antiretroviral therapies; use doxycycline instead for added prophylactic benefit against bacterial STIs. 1

Special Population Considerations

• Adolescents 12-17 years old weighing 30-60 kg: give adalimumab 80 mg on day 1, then 40 mg every other week starting day 8. 1, 5
• Adolescents ≥60 kg: use the adult adalimumab dosing schedule (160 mg, 80 mg, then 40 mg weekly). 1, 5
• Breastfeeding patients: avoid clindamycin due to infant GI side-effect risk; use amoxicillin-clavulanate, erythromycin, azithromycin, or metronidazole instead. 1
• Pediatric patients ≥8 years requiring systemic antibiotics: use doxycycline 100 mg once or twice daily for 12 weeks. 1