What are the current evidence‑based long‑term treatment options and state‑of‑the‑art management for hidradenitis suppurativa?

Long-Term Treatment Options for Hidradenitis Suppurativa

Treatment Algorithm by Disease Severity

The cornerstone of long-term HS management is Hurley staging, which dictates the entire treatment pathway: topical clindamycin for Stage I, oral clindamycin-rifampicin for Stage II, and adalimumab or surgery for Stage III. 1

Hurley Stage I (Mild Disease) – Long-Term Maintenance

• Topical clindamycin 1% solution or gel applied twice daily to all affected areas serves as first-line long-term maintenance therapy. 1, 2
• Combine topical clindamycin with benzoyl peroxide wash or chlorhexidine 4% wash daily to mitigate Staphylococcus aureus resistance rates, which increase with prolonged topical clindamycin monotherapy. 1, 2
• Tetracyclines (doxycycline 100 mg once or twice daily OR tetracycline 500 mg twice daily) can be used for 12-week courses as long-term maintenance therapy for more widespread mild disease. 1, 2
• After each 12-week tetracycline course, institute a treatment break to assess ongoing need and limit antimicrobial resistance risk. 1, 2

Hurley Stage II (Moderate Disease) – Long-Term Systemic Therapy

• Oral clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg once or twice daily for 10-12 weeks is the superior first-line choice, achieving response rates of 71-93%. 1, 2
• This regimen can be repeated intermittently as maintenance therapy in patients with moderate disease, with treatment breaks between courses to assess need for ongoing therapy and limit antimicrobial resistance. 1
• Reassess at 12 weeks using pain VAS score, inflammatory lesion count (nodules + abscesses), number of flares, and Dermatology Life Quality Index (DLQI). 1
• If no clinical response after 12 weeks of clindamycin-rifampicin, escalate directly to adalimumab rather than continuing antibiotics indefinitely. 1

Hurley Stage III (Severe Disease) – Long-Term Biologic Therapy

• Adalimumab is the FDA-approved first-line biologic for long-term management of moderate-to-severe HS, with dosing of 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2, 3
• Adalimumab achieves HiSCR response rates (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) of 42-59% at week 12. 1
• Continue adalimumab 40 mg weekly as long as HS lesions are present and the patient maintains response. 1
• Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective. 1

Second-Line Biologic Options After Adalimumab Failure

• Secukinumab (IL-17 inhibitor) demonstrates response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks. 1, 3
• Secukinumab dosing: 300 mg subcutaneous at weeks 0,1,2,3, and 4, followed by 300 mg every 2 weeks (preferred) or every 4 weeks. 3
• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months is an alternative second-line biologic. 1
• Ustekinumab (IL-12/23 inhibitor) is another alternative biologic option after adalimumab failure. 1

Surgical Integration with Long-Term Medical Management

• Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring. 1, 2
• Deroofing is recommended for recurrent nodules and tunnels. 4
• Wide local scalpel, CO2, or electrosurgical excision (with or without reconstruction) is appropriate for extensive chronic lesions. 4
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy. 1
• Non-recurrence rates after wide excision reach 81.25%. 1

Alternative Systemic Therapies for Refractory Disease

• Acitretin 0.3-0.5 mg/kg/day in males and non-fertile females is an alternative systemic therapy for patients unresponsive to adalimumab. 1
• Dapsone, starting at 50 mg daily and titrating up to 200 mg daily, can be considered as an alternative option. 1
• Metformin should be considered in patients with concomitant diabetes or polycystic ovarian syndrome. 1

Mandatory Adjunctive Measures for All Patients (All Stages)

• Smoking cessation referral is critical, as 70-75% of HS patients are smokers and tobacco use has an odds ratio of 36 for HS. 1, 2
• Weight management referral is essential when BMI is elevated, as obesity has an odds ratio of 33 for HS and prevalence exceeds 75% in this population. 1, 2
• Pain management with NSAIDs for symptomatic relief. 1, 2
• Appropriate wound dressings for draining lesions. 1, 2
• Screen for depression/anxiety at baseline and throughout treatment, as these conditions are highly prevalent in HS. 1, 2
• Screen for cardiovascular risk factors (blood pressure, lipids, HbA1c) at baseline, as HS patients have nearly doubled cardiovascular mortality risk. 1, 2
• Screen for inflammatory bowel disease, particularly Crohn disease, based on review of gastrointestinal symptoms. 4, 1

Critical Pitfalls to Avoid in Long-Term Management

• Never continue antibiotics beyond 12 weeks without formal reassessment, as prolonged use increases antimicrobial resistance without proven additional benefit. 1, 2
• Do not use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses, as they have minimal effect on deep inflammatory lesions (only 30% abscess reduction). 1
• Do not rely on topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules and does not address nodules or abscesses. 1
• Avoid long-term continuous antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 1, 2
• Do not offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk. 1
• Do not offer etanercept for moderate-to-severe HS, as it is ineffective. 1

Monitoring Treatment Response

• Assess treatment response at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas), pain VAS score, inflammatory lesion count, and DLQI. 1, 2
• For adalimumab, if clinical response is not achieved after 16 weeks, consider alternative biologic treatments. 1