What is the recommended treatment approach for an adolescent with hidradenitis suppurativa?

Treatment of Hidradenitis Suppurativa in Adolescents

For adolescents with hidradenitis suppurativa, begin with topical clindamycin 1% twice daily for mild disease (Hurley Stage I), escalate to oral doxycycline 100 mg once or twice daily for 12 weeks in patients ≥8 years with moderate disease (Hurley Stage II), and use adalimumab for severe or refractory disease in patients ≥12 years old. 1, 2, 3

Initial Assessment and Staging

• Determine Hurley stage by examining all intertriginous areas (axillae, groin, perianal, inframammary) for nodules, abscesses, sinus tracts, and scarring 1, 2
• Stage I: Isolated nodules/abscesses without sinus tracts or scarring 1, 2
• Stage II: Recurrent nodules with limited sinus tracts and scarring 1, 2
• Stage III: Multiple/extensive sinus tracts and scarring across entire regions 1, 2
• Screen every adolescent patient for metabolic syndrome (measure BP, lipids, HbA1c), hormonal imbalances, depression/anxiety, and inflammatory bowel disease at diagnosis, as 48% already have scarring at initial presentation 2, 3

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

• First-line: 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) to reduce bacterial resistance 1, 2, 3
• Add intralesional triamcinolone 10 mg/mL (0.2–2.0 mL) for acutely inflamed nodules, providing rapid relief within 24 hours 1, 2

Hurley Stage II (Moderate Disease)

• First-line systemic therapy: Oral doxycycline 100 mg once or twice daily for 12 weeks in patients ≥8 years old 1, 2, 3
• Treatment can be extended up to 4 months (16 weeks) for more widespread disease 1, 2
• Second-line (if doxycycline fails after 12 weeks): 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
• Continue topical clindamycin and antiseptic washes as adjunctive therapy 1, 3

Hurley Stage III (Severe/Refractory Disease)

• First-line biologic: Adalimumab is FDA-approved for adolescents ≥12 years weighing ≥30 kg 1, 4
• Dosing for 30–60 kg: Day 1: 80 mg; Day 8 and subsequent: 40 mg every other week 1, 4
• Dosing for ≥60 kg: Day 1: 160 mg (single dose or split over two days); Day 15: 80 mg; Day 29 and subsequent: 40 mg weekly OR 80 mg every other week 1, 4
• Adalimumab achieves HiSCR response rates of 42–59% at week 12 1, 2
• For ages 2–11 years, adalimumab is suggested (conditional recommendation) but not FDA-approved 1, 3

Hormonal Therapy for Adolescent Females

• Spironolactone is suggested for adolescent females requiring anti-androgens 1, 3
• Combined oral contraceptives are suggested for adolescent females 1, 3
• Metformin is suggested especially in cases of insulin resistance or PCOS 1, 2
• Finasteride is suggested in select cases, particularly in male patients 1

Second-Line Biologic Options (After Adalimumab Failure)

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months for patients ≥6 years old 1, 2
• Secukinumab for patients ≥6 years old, with response rates of 64.5–71.4% in adalimumab-failure patients 1, 2
• Ustekinumab for patients ≥6 years old (conditional recommendation, moderate evidence) 1, 2

Surgical Considerations

• Surgery is often necessary for lasting cure in advanced disease with sinus tracts and scarring 2, 3
• Deroofing for recurrent nodules and tunnels in localized disease 2, 3
• Radical excision for extensive disease with sinus tracts, achieving non-recurrence rates of ~81% 2, 5
• Combining adalimumab with surgery produces greater clinical effectiveness than adalimumab monotherapy 1, 2

Mandatory Adjunctive Measures (All Stages)

• Smoking cessation referral: 70–75% of HS patients are smokers; tobacco worsens outcomes 1, 2, 6
• Weight management referral: >75% of HS patients are obese; obesity increases mechanical friction and inflammation 1, 2, 6
• Pain management: NSAIDs for symptomatic relief 1, 2, 3
• Wound care: Appropriate dressings for draining lesions 1, 2, 3

Treatment Monitoring and Reassessment (12-Week Review)

• Reassess using pain VAS score, inflammatory lesion count (nodules + abscesses), number of flares, and DLQI 1, 2
• Evaluate HiSCR response (≥50% reduction in abscess/nodule count without increase in abscesses or draining fistulas) 1, 2
• After completing 10–12 week antibiotic courses, institute treatment breaks to assess need for ongoing therapy and limit antimicrobial resistance 1, 2

Critical Pitfalls to Avoid

• Do NOT use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses, as it has minimal effect on these lesions (only ~30% abscess reduction) 1, 2
• Do NOT continue antibiotics beyond 12 weeks without formal reassessment, as prolonged use increases resistance without proven additional benefit 1, 2
• Do NOT use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules, not nodules or abscesses 1, 2
• Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS; weekly dosing (40 mg) is required for efficacy 1, 2
• Do NOT use isotretinoin for HS unless moderate-to-severe acne vulgaris is present (co-occurs in 29% of pediatric HS patients) 1, 3