Diagnosis and Treatment of Hidradenitis Suppurativa

Diagnostic Criteria

Hidradenitis suppurativa is diagnosed clinically when three criteria are met: typical lesions (painful nodules, abscesses, sinus tracts, bridged scars, or open comedones), typical anatomic sites (axillae, groin, perineal/perianal region, inframammary/intermammary folds, or buttocks), and chronic recurrent course. 1

Key Clinical Features to Identify

Lesion morphology: Look for paired ("double-headed") comedones, painful subcutaneous nodules, abscesses that rupture and drain thick mucopurulent foul-smelling fluid, dermal sinus tracts/tunnels beneath the skin surface, and ropelike fibrotic scarring 1, 2
Distribution pattern: Examine all intertriginous areas systematically—axillae (most common site), inguinal/genital region, perianal/perineal area, submammary/intermammary folds, buttocks, medial thighs, and posterior auricular region 1, 2
Chronicity markers: Document recurrence pattern (at least two episodes within six months qualifies as recurrent), duration of symptoms, and presence of scarring or contractures 1, 3
Pain assessment: Use a 0–10 Visual Analog Scale at baseline, as severe pain is the cardinal symptom 1

Diagnostic Testing Has Limited Utility

Do not order bacterial cultures unless signs of secondary infection (surrounding cellulitis, fever, systemic symptoms) are present, because mixed normal flora does not guide therapy 1, 3
Do not order genetic or biomarker testing, as these have no current role in diagnosis despite identified γ-secretase mutations in familial cases 1, 3
Histopathology is not required; HS is a clinical diagnosis 1

Disease Severity Staging

Use the Hurley staging system in clinical practice because it is simple and directly guides treatment intensity. 1, 4

Hurley Classification

Stage I: Isolated nodules and abscesses with minimal or no scarring; no sinus tracts 1, 4
Stage II: Recurrent nodules with one or a limited number of sinus tracts and scarring within a single body region 1, 4
Stage III: Multiple or extensive sinus tracts and scarring affecting an entire anatomic region 1, 4

Baseline Documentation

Record Hurley stage for each affected region (axillae, groin, etc.) separately 3
Count inflammatory lesions (nodules + abscesses) to establish baseline for HiSCR response monitoring 1
Measure pain using VAS (0–10 scale) 1
Assess quality of life with Dermatology Life Quality Index (DLQI) 1

Mandatory Comorbidity Screening

Screen all patients at baseline for smoking, diabetes, metabolic syndrome components, depression/anxiety, inflammatory bowel disease, and squamous cell carcinoma risk. 1, 3

Specific Screening Actions

Smoking: Document pack-years and refer for cessation services; 70–75% of HS patients are current smokers with odds ratio of 36 compared to controls 1, 3, 5
Diabetes: Check HbA1c or fasting glucose; HS patients have 1.5–3-fold increased diabetes risk with prevalence up to 30% 1, 3
Cardiovascular risk: Measure blood pressure, lipid profile, and BMI; HS patients have nearly doubled cardiovascular mortality risk 1, 3
Psychiatric comorbidity: Screen for depression and anxiety using validated tools; HS patients have higher rates of depression and completed suicide 1, 3
Inflammatory bowel disease: Perform thorough review of gastrointestinal symptoms; strong association exists with Crohn disease but not ulcerative colitis 1, 3
Malignancy: Examine chronic perineal and buttock lesions carefully for squamous cell carcinoma, the most frequent malignancy in these sites 1, 3

Treatment Algorithm by Hurley Stage

Hurley Stage I (Mild Disease)

Initiate topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1, 3

Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 3, 5
Add intralesional triamcinolone 10 mg/mL (0.2–2.0 mL per lesion) for acutely inflamed nodules, providing rapid symptom relief within 24 hours 1, 3
Do not use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules and does not address nodules or abscesses 3

Hurley Stage II (Moderate Disease)

First-line therapy is 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, 3

This combination is markedly superior to tetracycline monotherapy (which shows only ~30% abscess reduction) 1, 3
Add intralesional triamcinolone 10 mg/mL for acutely inflamed nodules 3
Alternative for widespread mild disease or mild Stage II without deep inflammatory lesions: Doxycycline 100 mg once or twice daily for 12 weeks, though this is not recommended as first-line for Stage II with abscesses 1, 3
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 1, 3

Hurley Stage III (Severe Disease)

Initiate adalimumab: 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1, 3

HiSCR response rates are 42–59% at week 12 1, 3
Do not use adalimumab 40 mg every other week, as this dosing is ineffective for moderate-to-severe HS 3
While awaiting specialist evaluation or biologic approval, bridge with clindamycin 300 mg + rifampicin 300 mg twice daily 1, 3
Refer for surgical consultation; combining adalimumab with surgery produces greater clinical effectiveness than adalimumab monotherapy 1, 3

Treatment Duration and Monitoring

12-Week Reassessment Protocol

Reassess all patients at 12 weeks using pain VAS score, inflammatory lesion count, number of flares, and DLQI. 1, 3

Measure HiSCR response (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 1, 3
After completing 10–12 week antibiotic courses, institute a treatment break to assess need for ongoing therapy and limit antimicrobial resistance risk 1, 3
Do not continue any antibiotic beyond 12 weeks without formal reassessment, as prolonged use increases resistance without proven additional benefit 1, 3

Escalation Pathways

If no response after 12 weeks of topical clindamycin (Stage I): Escalate to oral doxycycline 100 mg once or twice daily for 12 weeks 3
If no response after 12 weeks of doxycycline: Escalate to clindamycin 300 mg + rifampicin 300–600 mg twice daily for 10–12 weeks 1, 3
If no response after 12 weeks of clindamycin-rifampicin: Escalate to adalimumab 1, 3
If adalimumab fails after 16 weeks: Consider second-line biologics—infliximab 5 mg/kg at weeks 0,2,6, then every 2 months; secukinumab (response rates 64.5–71.4% in adalimumab-failure patients); or ustekinumab 1, 3

Surgical Management

Radical surgical excision is recommended for extensive disease with sinus tracts and scarring when conventional systemic treatments have failed, achieving non-recurrence rates of ~81% after wide excision. 1, 3

Surgical Options by Disease Pattern

Deroofing: For recurrent nodules and sinus-tract tunnels; removes epithelialized tunnel lining 3
Wide local excision: For extensive chronic lesions involving large areas; performed with scalpel, CO₂ laser, or electrosurgical techniques 3
Wound closure options: Secondary intention healing, split-thickness skin grafts, or local flaps (e.g., thoracodorsal artery perforator flap) 1, 3
Timing: Consider surgery concurrently with medical therapy for Hurley Stage II–III disease with established sinus tracts 3

Essential Adjunctive Measures (All Stages)

Every patient requires smoking-cessation referral, weight-management referral if BMI elevated, pain management with NSAIDs, appropriate wound dressings for draining lesions, and screening for depression/anxiety and cardiovascular risk factors. 1, 3

Wound Care Specifics

Use absorptive foam dressings or hydro-fiber (e.g., Aquacel) rather than petroleum-based dressings for draining sinus tracts 3
Do not use collagen-based dressings (e.g., gentamicin-collagen sponges), as RCT data show no difference in 3-month recurrence rates versus standard saline-based care 3

Lifestyle Modification Impact

Smoking cessation improves outcomes; tobacco use is associated with worse disease and treatment failure 1, 3, 5
Weight loss is critical; obesity prevalence exceeds 75% in HS patients with odds ratio of 33 compared to controls 1, 3, 5

Special Population Considerations

Pediatric Patients

For children ≥12 years with moderate-to-severe disease, adalimumab is FDA-approved with weight-based dosing 1, 3
For children ≥8 years requiring systemic antibiotics, oral doxycycline is recommended 1, 3

Breastfeeding Patients

Limit doxycycline to ≤3 weeks without repeating courses 3
Alternative antibiotics: amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole 3
Exercise caution with oral clindamycin due to increased risk of gastrointestinal side effects in the infant 3

Patients with HIV

Use doxycycline for added prophylactic benefit against bacterial STIs 3
Avoid rifampicin due to drug interactions with certain HIV therapies 3

Patients with Hepatitis B or C

Use doxycycline with standard approach for patients without cirrhosis 3
Exercise caution with rifampicin due to potential hepatotoxicity 3

Critical Pitfalls to Avoid

Do not interpret purulent drainage as solely representing bacterial infection requiring only antimicrobial therapy; the drainage primarily reflects chronic inflammation 3, 4
Do not offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 3
Do not offer etanercept for moderate-to-severe HS, as it is ineffective 3
Do not use oral corticosteroids for routine or long-term management; reserve prednisone only for acute widespread flares as bridge therapy, not maintenance 3
Do not use cryotherapy or microwave ablation for treating lesions during the acute phase 1

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