Pharmacologic Treatment of Hidradenitis Suppurativa by Disease Severity
For mild disease (Hurley Stage I), start with topical clindamycin 1% twice daily for 12 weeks; for moderate disease (Hurley Stage II), use oral clindamycin 300 mg twice daily PLUS rifampicin 300–600 mg daily for 10–12 weeks; for severe or refractory disease (Hurley Stage III or failed antibiotics), initiate adalimumab with loading doses of 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2
Treatment Algorithm by Hurley Stage
Hurley Stage I (Mild Disease: Isolated Nodules Without Sinus Tracts)
- First-line: Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 2
- Adjunctive topical therapy: Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk when using topical clindamycin. 1, 2
- Intralesional therapy for inflamed nodules: Inject triamcinolone 10 mg/mL (0.2–2.0 mL per lesion) directly into acutely inflamed nodules for rapid symptom relief within 24 hours, with significant reductions in erythema, edema, suppuration, and pain. 1
Hurley Stage II (Moderate Disease: Recurrent Nodules with Limited Sinus Tracts)
First-line systemic therapy: 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
Alternative for widespread mild disease or mild Hurley II without deep abscesses: Oral tetracycline 500 mg twice daily OR doxycycline 100 mg once or twice daily for 12 weeks. 1, 4
- Critical pitfall: Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses or deep inflammatory nodules—they have minimal effect on these lesions. 1
Treatment duration and breaks: Complete the full 10–12 week course, then institute a treatment break to assess ongoing need and limit antimicrobial resistance risk. 1, 2
Hurley Stage III (Severe Disease: Multiple/Extensive Sinus Tracts and Scarring)
First-line biologic therapy: Adalimumab with loading dose of 160 mg subcutaneously at week 0,80 mg at week 2, then 40 mg weekly (NOT every other week) starting at week 4. 1, 4, 5
Bridge therapy while awaiting specialist evaluation: Initiate clindamycin 300 mg + rifampicin 300 mg twice daily. 1
Second-line biologics after adalimumab failure (no response after 16 weeks):
Surgical intervention: Radical surgical excision is recommended for extensive disease with sinus tracts and scarring when conventional systemic treatments have failed, with non-recurrence rates of ~81% after wide excision. 1
- Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy. 1
Treatment Reassessment at 12 Weeks
Objective measures: Assess using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas), pain VAS score, inflammatory lesion count, and DLQI quality-of-life score. 1, 2, 4
Escalation pathway if no response:
- After 12 weeks of topical clindamycin or tetracyclines → escalate to clindamycin 300 mg + rifampicin 300–600 mg daily for 10–12 weeks. 1
- After 12 weeks of clindamycin-rifampicin → escalate to adalimumab. 1
- After 16 weeks of adalimumab → consider second-line biologics (infliximab, secukinumab, ustekinumab) or surgical intervention. 1
Mandatory Adjunctive Measures (All Stages)
Smoking cessation referral: 70–75% of HS patients smoke; tobacco use is associated with dramatically worse outcomes (odds ratio 36) and treatment failure. 7, 1, 8
Weight management referral: Obesity prevalence exceeds 75% in HS patients (odds ratio 33); weight loss may improve or resolve disease. 7, 1, 8
Wound care: Appropriate dressings for draining lesions. 1, 8
Comorbidity screening: Screen for depression/anxiety, diabetes (HbA1c), hypertension (blood pressure), hyperlipidemia (lipid profile), and inflammatory bowel disease. 7, 1, 9
Special Population Considerations
Pediatric Patients (≥12 Years Old)
- Adalimumab is FDA-approved for moderate-to-severe HS in adolescents ≥12 years with weight-based dosing. 1, 4
- For children ≥8 years requiring systemic antibiotics, use doxycycline 100 mg once or twice daily. 1
Breastfeeding Patients
- Avoid clindamycin due to risk of infant gastrointestinal side effects; use amoxicillin-clavulanic acid, erythromycin, azithromycin, or metronidazole instead. 1
- Limit doxycycline to ≤3 weeks without repeating courses. 1
Patients with HIV
- Use doxycycline for added prophylactic benefit against bacterial STIs. 1
- Avoid rifampicin due to drug interactions with certain HIV therapies. 1
Critical Pitfalls to Avoid
Do NOT use doxycycline or tetracycline monotherapy for Hurley Stage II with abscesses—they have minimal effect on deep inflammatory lesions (only 30% abscess reduction). 1
Do NOT use topical clindamycin alone for Hurley Stage II—it only reduces superficial pustules, not nodules or abscesses. 1
Do NOT continue antibiotics beyond 12 weeks without formal reassessment—prolonged use increases antimicrobial resistance without proven additional benefit. 1
Do NOT prescribe adalimumab 40 mg every other week—weekly dosing (40 mg) is required for efficacy. 1
Do NOT use isotretinoin, etanercept, or oral corticosteroids for routine HS management—insufficient evidence or proven inefficacy. 1
Treatments with Insufficient Evidence
The British Association of Dermatologists states there is insufficient evidence to recommend: alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, finasteride, fumaric acid esters, methotrexate, oral zinc, phototherapy, secukinumab (as first-line), spironolactone, and ustekinumab (as first-line). 1