What is the recommended treatment approach for moderate-to-severe hidradenitis suppurativa (Hurley stage II–III or IHS4 ≥10)?

Treatment of Moderate-to-Severe Hidradenitis Suppurativa (Hurley Stage II–III or IHS4 ≥10)

For moderate-to-severe hidradenitis suppurativa, initiate adalimumab 160 mg subcutaneously at week 0,80 mg at week 2, then 40 mg weekly starting at week 4, as this is the only FDA-approved biologic with proven efficacy (HiSCR response rates of 42–59% at week 12) and represents the definitive first-line systemic therapy for this severity of disease. 1

Disease Severity Assessment

Before initiating treatment, determine the Hurley stage by examining all intertriginous areas for recurrent nodules, sinus tracts, and scarring. 2, 3

• Hurley Stage II is characterized by recurrent abscesses with one or limited sinus tracts and scarring. 2, 3
• Hurley Stage III involves multiple or extensive sinus tracts and scarring affecting entire anatomic regions. 2, 3
• Document baseline pain using a Visual Analog Scale (VAS) and count inflammatory lesions (nodules + abscesses). 2, 3
• Assess quality of life using the Dermatology Life Quality Index (DLQI). 2, 3

First-Line Biologic Therapy

Adalimumab is the cornerstone of treatment for moderate-to-severe HS (Hurley Stage II–III or IHS4 ≥10). 1

• Dosing schedule: 160 mg subcutaneously at week 0 (can be split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting at week 4. 4, 2, 1
• This regimen achieves HiSCR (≥50% reduction in abscess/nodule count without increase in abscesses or draining fistulas) in 42–59% of patients at week 12. 2, 3
• Critical pitfall: Do NOT use adalimumab 40 mg every other week for moderate-to-severe HS—this dosing is ineffective. 2
• Adalimumab is FDA-approved for patients 12 years of age and older with moderate-to-severe HS. 1

Adjunctive Antibiotic Therapy

While initiating adalimumab, consider concurrent antibiotic therapy for active inflammatory lesions. 2

• Clindamycin 300 mg orally twice daily plus rifampicin 300–600 mg daily for 10–12 weeks can be safely combined with adalimumab and achieves response rates of 71–93%. 4, 2
• This combination is particularly useful for patients with active abscesses or nodules requiring immediate symptom control. 2
• Intralesional triamcinolone 10 mg/mL (0.2–2.0 mL) injected into acutely inflamed nodules provides rapid relief within 24 hours. 2

Second-Line Biologic Options

If adalimumab fails after 16 weeks (no clinical response), escalate to alternative biologics. 2, 3

• Secukinumab (IL-17A inhibitor) demonstrates response rates of 64.5–71.4% in adalimumab-failure patients at 16–52 weeks. 2
• Bimekizumab (IL-17A/F inhibitor) is FDA-approved for moderate-to-severe HS with dosing of 320 mg subcutaneously at weeks 0,2,4,6,8,10,12,14, and 16, then every 4 weeks thereafter. 5
• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months is recommended for patients who fail adalimumab. 4, 2
• Ustekinumab (IL-12/23 inhibitor) is suggested as an alternative pathway targeting different cytokines. 2

Surgical Intervention

Surgery is often necessary for lasting cure, especially in advanced disease with established sinus tracts. 2, 3

• Deroofing is recommended for recurrent nodules and sinus-tract tunnels as a targeted procedure. 2
• Radical surgical excision is appropriate for extensive disease with sinus tracts and scarring when medical therapy fails, achieving non-recurrence rates of 81.25%. 2
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy. 2
• Refer patients with Hurley Stage III disease or lack of response to medical therapy after 12 weeks to a hidradenitis suppurativa surgical multidisciplinary team. 6, 3

Mandatory Comorbidity Screening and Adjunctive Measures

All patients with moderate-to-severe HS require comprehensive screening and lifestyle interventions. 2, 3

• Screen for tuberculosis prior to initiating adalimumab or other biologics. 1
• Screen for depression and anxiety using validated tools, as these conditions are highly prevalent in HS. 2, 3
• Screen for cardiovascular risk factors: measure blood pressure, lipid profile, and HbA1c. 2, 3
• Screen for inflammatory bowel disease by reviewing gastrointestinal symptoms. 2
• Smoking cessation referral is mandatory—70–75% of HS patients are smokers, and tobacco use predicts poor treatment response. 2, 6, 3
• Weight management referral is essential—obesity prevalence exceeds 75% in HS patients and is strongly associated with disease severity. 2, 6, 3
• Pain management with NSAIDs for symptomatic relief. 2, 3
• Appropriate wound dressings for draining lesions; use absorptive foam or hydro-fiber dressings rather than petroleum-based products. 2

Treatment Monitoring and Response Assessment

Reassess treatment response at 12 weeks using objective measures. 2, 3

• HiSCR (≥50% reduction in inflammatory lesion count without increase in abscesses or draining fistulas) is the primary outcome measure. 2, 3
• Measure pain VAS score, inflammatory lesion count, and DLQI. 2, 3
• If no clinical response after 16 weeks of adalimumab, consider switching to second-line biologics (secukinumab, bimekizumab, infliximab, or ustekinumab). 2

Critical Pitfalls to Avoid

• Do NOT use tetracyclines (doxycycline, lymecycline) as first-line therapy for Hurley Stage II–III disease—they have minimal effect on deep inflammatory lesions and abscesses, showing only 30% abscess reduction. 2, 3
• Do NOT use topical clindamycin alone for moderate-to-severe HS—it only reduces superficial pustules, not nodules or abscesses. 2
• Do NOT continue ineffective antibiotics beyond 12 weeks without reassessment—this increases antimicrobial resistance risk without proven benefit. 2, 6, 3
• Do NOT use adalimumab 40 mg every other week—weekly dosing is required for efficacy in moderate-to-severe HS. 2
• Do NOT delay surgical referral for Hurley Stage III disease—non-surgical methods rarely result in lasting cure for advanced disease. 2