Medical Management of Hidradenitis Suppurativa
Initial Assessment and Staging
Begin with Hurley staging to determine treatment intensity: Stage I (isolated nodules without sinus tracts), Stage II (recurrent nodules with limited sinus tracts and scarring), or Stage III (extensive sinus tracts and scarring across an entire region). 1
Document baseline pain using a 0–10 Visual Analog Scale, count all inflammatory lesions (nodules plus abscesses), and measure quality of life with the Dermatology Life Quality Index (DLQI). 1 Examine all intertriginous areas—axillae, groin, perineum, inframammary folds, buttocks—to capture total disease burden. 1
Screen every patient for smoking status (70–75% of HS patients smoke), obesity (prevalence exceeds 75%), diabetes (HbA1c), hypertension, hyperlipidemia, depression, anxiety, and inflammatory bowel disease at baseline. 1
Treatment Algorithm by Disease Severity
Hurley Stage I (Mild Disease)
Start topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks. 1 Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk. 1
For acutely inflamed nodules, inject intralesional triamcinolone 10 mg/mL (0.2–2.0 mL per lesion) to achieve rapid symptom relief within 24 hours. 1
Hurley Stage II (Moderate Disease)
Prescribe 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 This combination is markedly superior to tetracycline monotherapy, which produces only 30% abscess reduction. 1
Do not use doxycycline or tetracycline monotherapy as first-line for Stage II with abscesses or deep inflammatory nodules, as these agents have minimal effect on deep lesions. 1 Doxycycline 100 mg once or twice daily for 12 weeks may be used only for widespread mild disease or early Stage II without deep inflammatory lesions. 1
Hurley Stage III (Severe Disease)
Initiate adalimumab with a loading dose of 160 mg subcutaneously at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1 This regimen achieves Hidradenitis Suppurativa Clinical Response (HiSCR—defined as ≥50% reduction in abscess/nodule count without increase in abscesses or draining fistulas) in 42–59% of patients at week 12. 1
While awaiting biologic approval or specialist evaluation, bridge with clindamycin 300 mg plus rifampicin 300 mg twice daily. 1
Reassessment and Treatment Escalation
Reassess at 12 weeks using pain VAS, inflammatory lesion count, number of flares in the prior month, DLQI, and HiSCR. 1
If no clinical response after 12 weeks of topical clindamycin (Stage I), escalate to oral clindamycin 300 mg twice daily plus rifampicin 300–600 mg daily for 10–12 weeks. 1
If no clinical response after 12 weeks of clindamycin-rifampicin (Stage II), escalate to adalimumab. 1
If adalimumab fails after 16 weeks, consider second-line biologics: infliximab 5 mg/kg at weeks 0,2,6, then every 2 months (response rates of 71.4% in adalimumab-failure patients); secukinumab (response rates 64.5–71.4% at 16–52 weeks in adalimumab-failure patients); or ustekinumab. 1
After completing any 10–12 week antibiotic course, institute a treatment break to assess need for ongoing therapy and limit antimicrobial resistance risk. 1 Do not extend antibiotics beyond 12 weeks without formal reassessment, as prolonged use increases resistance without proven additional benefit. 1
Surgical Considerations
Radical surgical excision is indicated for extensive disease with sinus tracts and scarring when conventional systemic treatments have failed, achieving non-recurrence rates of approximately 81%. 1 Wound closure options include secondary intention healing, split-thickness skin grafts, or local flaps (e.g., thoracodorsal artery perforator flap). 1
Combining adalimumab with surgery produces greater clinical effectiveness than adalimumab monotherapy. 1 Consider deroofing for recurrent nodules and sinus-tract tunnels as a targeted procedure. 1
Mandatory Adjunctive Measures (All Stages)
Refer all patients for smoking-cessation services; tobacco use worsens outcomes and increases treatment failure. 1 Provide weight-management referral when BMI is elevated; obesity prevalence exceeds 75% in HS. 1
Prescribe NSAIDs for pain management. 1 Apply appropriate wound dressings (absorptive foam or hydro-fiber dressings, not petroleum-based) for draining lesions. 1
Screen for depression and anxiety using validated tools; rates of depression and completed suicide are higher in HS patients. 1 Measure blood pressure, lipid profile, and HbA1c; HS nearly doubles cardiovascular mortality risk. 1
Special Populations
For adolescents ≥12 years with moderate-to-severe disease, adalimumab is FDA-approved with weight-based dosing. 1 For children ≥8 years requiring systemic antibiotics, oral doxycycline is recommended. 1
For breastfeeding patients, use amoxicillin-clavulanic acid, erythromycin, azithromycin, or metronidazole; limit doxycycline to ≤3 weeks without repeating courses. 1 Exercise caution with oral clindamycin in breastfeeding patients due to potential gastrointestinal side effects in the infant; consider alternative antibiotics. 1
For patients with HIV, use doxycycline for added prophylactic benefit against bacterial sexually transmitted infections, and exercise caution with rifampicin due to drug interactions with certain HIV therapies. 1
Critical Pitfalls to Avoid
Do not use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules and does not address nodules or abscesses. 1
Do not prescribe adalimumab 40 mg every other week for moderate-to-severe HS; weekly dosing (40 mg) is required for efficacy. 1
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
Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 1
Acute Flare Management
For acute, widespread flares, initiate oral clindamycin 300 mg twice daily plus rifampicin 300–600 mg daily for 10–12 weeks, and inject intralesional triamcinolone 10 mg/mL into each inflamed nodule for rapid relief within 24 hours. 1 Provide NSAIDs for analgesia and apply appropriate wound dressings. 1
Oral corticosteroids (prednisone) may be used as bridge therapy during biologic initiation for severe acute flares, but should be reserved for short-term use only and not for maintenance therapy. 1 If prednisone dose exceeds 15 mg daily for at least 4 weeks, annual screening for latent tuberculosis is mandatory. 1