Simplest First-Line Treatment for Hurley Stage I Hidradenitis Suppurativa
For Hurley Stage I hidradenitis suppurativa, apply topical clindamycin 1% solution or gel twice daily to all affected areas for 12 weeks. 1, 2
Treatment Regimen
Topical clindamycin 1% solution or gel should be applied twice daily to all affected intertriginous areas (axillae, groin, inframammary folds) for a full 12-week course. 1, 2, 3
Combine with an antiseptic wash (chlorhexidine 4%, benzoyl peroxide, or zinc pyrithione) applied daily to reduce the risk of Staphylococcus aureus resistance that develops with topical clindamycin monotherapy. 1, 2, 3
Adjunctive Measures for Acute Flares
Intralesional triamcinolone 10 mg/mL (0.2–2.0 mL per lesion) can be injected directly into acutely inflamed nodules to provide rapid symptom relief within 24 hours, significantly reducing erythema, edema, suppuration, and pain. 1, 2
Resorcinol 15% cream applied twice daily during active flares (and once daily between flares) reduces pain and shortens abscess duration, though irritant dermatitis is a common side effect. 2
Mandatory Lifestyle Interventions
Smoking cessation referral is essential, as 70–75% of HS patients smoke and tobacco use dramatically worsens outcomes (odds ratio 36 compared to non-smokers). 1, 3
Weight management referral should be provided if BMI is elevated, since >75% of HS patients are obese and excess adiposity increases mechanical friction and pro-inflammatory cytokine production (odds ratio 33). 1, 3
NSAIDs should be prescribed for symptomatic pain relief. 1, 2
Appropriate wound dressings must be applied to any draining lesions. 1, 2
Reassessment at 12 Weeks
Evaluate treatment response using pain visual analogue scale (VAS), inflammatory lesion count (nodules + abscesses), number of flares, and Dermatology Life Quality Index (DLQI). 1, 2
If no clinical response after 12 weeks, escalate to oral antibiotics: either doxycycline 100 mg once or twice daily for 12 weeks (for widespread mild disease without deep lesions) or clindamycin 300 mg twice daily plus rifampicin 300–600 mg daily for 10–12 weeks (for moderate disease or presence of abscesses). 1, 2
Critical Pitfalls to Avoid
Do not use topical clindamycin alone for Hurley Stage II disease, as it only reduces superficial pustules and has no effect on inflammatory nodules or abscesses. 1, 2
Do not skip the antiseptic wash, because topical clindamycin monotherapy significantly increases Staphylococcus aureus resistance rates. 1, 2
Do not continue topical therapy beyond 12 weeks without reassessment, as failure to respond indicates the need for systemic treatment escalation. 1, 2