Treatment for Hidradenitis Suppurativa

Disease Severity Assessment and Staging

Determine Hurley stage by examining all intertriginous areas (axillae, groin, perineum, inframammary folds, buttocks) to guide treatment intensity. 1, 2

Hurley Stage I – Isolated nodules and abscesses without sinus tracts or scarring 1, 2
Hurley Stage II – Recurrent nodules with one or limited sinus tracts and scarring 1, 2
Hurley Stage III – Multiple or extensive sinus tracts and scarring involving entire regions 1, 2

Document baseline pain using Visual Analog Scale (VAS) and count inflammatory lesions (nodules + abscesses) to monitor treatment response. 2

Screen all patients for comorbidities: depression/anxiety, diabetes (HbA1c), hypertension, hyperlipidemia, and inflammatory bowel disease. 2, 3

Treatment Algorithm by Hurley Stage

Hurley Stage I (Mild Disease)

First-line therapy is topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 2, 3

Combine with antiseptic washes (chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione) applied daily to reduce Staphylococcus aureus resistance risk 1, 2
Intralesional triamcinolone 10 mg/mL (0.2–2.0 mL per lesion) provides rapid symptom relief within 24 hours for acutely inflamed nodules, with significant reductions in erythema, edema, suppuration, and pain 1, 2
Resorcinol 15% cream applied twice daily during flares and daily between flares reduces pain and abscess duration, though irritant dermatitis occurs frequently 1

Reassess at 12 weeks using pain VAS, inflammatory lesion count, and Dermatology Life Quality Index (DLQI). 2

If no response after 12 weeks, escalate to oral antibiotics for moderate disease. 2

Hurley Stage II (Moderate Disease)

First-line systemic therapy is oral clindamycin 300 mg twice daily PLUS rifampicin 300–600 mg once or twice daily for 10–12 weeks, achieving response rates of 71–93%. 1, 2, 3

This combination is vastly superior to tetracycline monotherapy (which shows only 30% abscess reduction) and is the preferred regimen for Hurley Stage II with abscesses or inflammatory nodules. 1, 2

Alternative first-line option for widespread mild disease or mild Hurley Stage II without deep inflammatory lesions: Doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for 12 weeks 1, 2, 3
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 1, 2

Combine systemic antibiotics with intralesional triamcinolone 10 mg/mL for acutely inflamed nodules to achieve rapid symptom control. 2

After completing the 10–12 week course, institute a treatment break to assess need for ongoing therapy and limit antimicrobial resistance risk. 1, 2

Reassess at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas), pain VAS, and DLQI. 2, 3

If no clinical response after 12 weeks of clindamycin-rifampicin, escalate to adalimumab. 2

Hurley Stage III (Severe Disease) or Refractory Moderate Disease

First-line biologic therapy is adalimumab: 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2, 3

Adalimumab is the only FDA-approved biologic for moderate-to-severe HS in patients ≥12 years old, achieving HiSCR response rates of 42–59% at week 12. 1, 2, 3

Do NOT prescribe adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective 2, 3
If no clinical response after 16 weeks of adalimumab, consider second-line biologics 2, 3

Second-line biologic options after adalimumab failure:

Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1, 2
Secukinumab (response rates 64.5–71.4% in adalimumab-failure patients at 16–52 weeks) 2
Ustekinumab 2

Bridge therapy for severe acute flares: Short-term oral prednisone may be used while awaiting response to definitive therapies, but only for acute episodes—not for maintenance. 1, 2

While awaiting specialist evaluation for Hurley Stage III: Initiate clindamycin 300 mg + rifampicin 300 mg twice daily. 2

Surgical Interventions

Radical surgical excision is recommended for extensive disease with sinus tracts and scarring when conventional systemic treatments have failed. 1, 2, 3

Wide excision yields non-recurrence rates of approximately 81% 2
Wound closure options include secondary intention healing, split-thickness skin grafts, or local flaps (e.g., thoracodorsal artery perforator flap) 1, 2
Deroofing is appropriate for recurrent nodules and tunnels in less extensive disease 1
Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2

Do NOT offer cryotherapy or microwave ablation during the acute phase, as these cause excessive pain without proven benefit. 2, 3

Mandatory Adjunctive Measures (All Stages)

Smoking cessation referral is essential, as 70–75% of HS patients are current smokers and tobacco use worsens outcomes. 1, 2, 3

Weight management referral is critical for patients with elevated BMI, as >75% of HS patients are obese and excess adiposity increases mechanical friction and pro-inflammatory cytokines. 1, 2, 3

Pain management with NSAIDs for symptomatic relief 1, 2

Appropriate wound dressings for draining lesions 1, 2

Screen for depression/anxiety using validated tools, as these conditions are highly prevalent in HS and associated with increased suicide risk 2, 3

Screen for cardiovascular risk factors (blood pressure, lipids, HbA1c), as HS patients have nearly doubled mortality risk from cardiovascular disease 2, 3

Special Population Considerations

Pediatric Patients (≥8 years old)

Doxycycline 100 mg once or twice daily OR clindamycin 300 mg + rifampicin 300 mg twice daily for 10–12 weeks 2
Adalimumab is FDA-approved for adolescents ≥12 years old with moderate-to-severe disease (weight-based dosing) 1, 2, 3

Pregnant Patients

Topical treatments, procedural treatments (intralesional steroids, deroofing), and lifestyle modifications are first-line 1
Systemic agents are second-line; retinoids and hormonal therapies are contraindicated 1
Metformin for patients requiring anti-androgens 3
Adalimumab for patients requiring biologics 3

Breastfeeding Patients

Amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole are preferred 2
Limit doxycycline to ≤3 weeks without repeating courses 2
Exercise caution with oral clindamycin due to potential gastrointestinal side effects in the infant 2

Patients with HIV

Doxycycline is preferred due to added prophylactic benefit against bacterial sexually transmitted infections 2
Avoid rifampicin due to drug interactions with certain HIV therapies 2

Patients with Hepatitis B or C

Doxycycline is appropriate for patients without cirrhosis 2
Exercise caution with rifampicin due to potential hepatotoxicity 2

Treatments NOT Recommended

The following therapies have insufficient evidence or proven ineffectiveness and should NOT be offered: 2, 3

Isotretinoin (unless concomitant moderate-to-severe acne of face/trunk is present) 2, 3
Etanercept (proven ineffective for moderate-to-severe HS) 2, 3
Alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, hydrocortisone, hyperbaric oxygen, intravenous antibiotics (except ertapenem as rescue therapy), isoniazid, laser/photodynamic therapies, methotrexate, oral prednisolone (except short-term for acute flares), oral zinc, phototherapy, photochemotherapy, radiotherapy, spironolactone, staphage lysate, tolmetin sodium 2

Critical Pitfalls to Avoid

Do NOT continue any antibiotic beyond 12 weeks without formal reassessment, as prolonged use increases antimicrobial resistance without proven additional benefit. 1, 2

Do NOT use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules, not inflammatory nodules or abscesses. 1, 2

Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with deep inflammatory lesions or abscesses, as they have minimal effect on these lesions. 1, 2

Do NOT prescribe adalimumab 40 mg every other week, as weekly dosing (40 mg) is required for efficacy. 2, 3

Topical clindamycin increases rates of Staphylococcus aureus resistance; combine with benzoyl peroxide wash to mitigate this risk. 1, 2

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