What are the treatment options for hidradenitis suppurativa?

Treatment for Hidradenitis Suppurativa

Treatment of hidradenitis suppurativa requires a multimodal, severity-based approach combining topical therapies, systemic antibiotics, biologics, and surgical interventions, with early aggressive treatment critical to prevent irreversible skin damage and tunnel formation. 1

Initial Assessment and Disease Staging

Evaluate disease severity using Hurley staging to guide treatment selection, assess extent of inflammatory lesions (nodules, abscesses, draining tunnels), and screen for comorbidities including metabolic syndrome, inflammatory arthritis, and inflammatory bowel disease at initial diagnosis. 1, 2

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

Topical and Local Therapies:

• Topical clindamycin 1% solution is the only studied topical antibiotic, reducing pustules but not inflammatory nodules or abscesses in 12-week trials. 1
• Antiseptic washes with chlorhexidine, benzoyl peroxide, or zinc pyrithione based on expert opinion (no comparative data exist). 1
• Resorcinol 15% cream twice daily for flares and daily between flares reduces pain and abscess duration, though irritant dermatitis is common. 1
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) into inflamed lesions significantly reduces erythema, edema, suppuration, and pain within 1 day. 1

Systemic Antibiotics for Mild Disease:

• Tetracycline 500 mg twice daily achieves 30% reduction in abscesses. 1
• Combination therapy with clindamycin and rifampin is preferred over monotherapy for more reliable responses. 1

Moderate-to-Severe Disease (Hurley Stage II-III)

First-Line Biologic Therapy:

• Adalimumab (anti-TNF) is FDA-approved and should be initiated early in moderate-to-severe disease to prevent irreversible skin damage and tunnel formation. 2, 3, 4
• Secukinumab (IL-17A inhibitor) is the second FDA-approved biologic, offering an alternative mechanism for patients who fail or lose response to adalimumab. 3, 4
• Bimekizumab (dual IL-17A/F inhibitor) represents an emerging IL-17 pathway option with promising efficacy data. 2, 5

Adjunctive Systemic Antibiotics:

• In advanced disease, antibiotics play an adjunctive role due to lower response rates and increased recurrence when used alone. 1
• Combination regimens (clindamycin plus rifampin, or ertapenem) are preferred over monotherapy. 1

Hormonal Therapies (Off-Label):

• Oral contraceptive pills, spironolactone, and finasteride can be considered as adjunctive therapy, particularly in women. 1

Surgical and Procedural Interventions

Surgical excision is critical for:

• The destructive phase (combined with drug therapy). 2
• The burnout phase with extensive scarring and tunnel formation (surgery alone may suffice). 2
• Laser and light-based procedures can improve symptoms when combined with medical therapy. 6

Treatment Stacking Approach

The multimodal "treatment stacking" strategy combines:

• Topical therapies (antiseptics, topical antibiotics). 7
• Systemic antibiotics (as adjunctive therapy). 7
• Biologics or small molecule inhibitors (JAK inhibitors like povorcitinib under investigation). 7, 5
• Hormonal/metabolic therapies. 7
• Surgical interventions. 7
• Pain management and wound care. 7
• Lifestyle modifications including weight management and smoking cessation. 7

Safety Considerations

Infection-related adverse events are most common with IL-17 inhibitors, while serious adverse events remain rare across biologic classes. 5

• Mild gastrointestinal and neurological adverse events occur frequently but are generally tolerable. 5
• Therapeutic drug monitoring can increase longevity of biologic treatments and identify loss of response. 3

Critical Pitfalls to Avoid

• Delaying biologic therapy in moderate-to-severe disease leads to irreversible tunnel formation and morbid scarring. 2
• Using antibiotic monotherapy in advanced disease results in poor response rates and high recurrence. 1
• Combining topical clindamycin without benzoyl peroxide increases Staphylococcus aureus resistance rates. 1
• Failing to screen for comorbidities at diagnosis misses opportunities for systemic inflammation management. 2

Special Populations

Pregnancy:

• Cephalexin, azithromycin, and clindamycin are safe systemic antibiotics. 1
• Topical antibiotics and antiseptic washes have minimal risk based on mechanism of action. 1
• Resorcinol 15% safety is unconfirmed with potential fetal neurodevelopment risks. 1
• Zinc supplementation does not adversely affect pregnancy outcomes. 1
• Intralesional steroids for acute flares are based on expert opinion. 1

Pediatric, breastfeeding, malignancy, tuberculosis, hepatitis B/C, and HIV populations require specialized considerations detailed in the 2025 North American guidelines. 1

Emerging Therapies

The robust pipeline includes:

• IL-36 inhibitors (spesolimab). 5
• JAK inhibitors (povorcitinib). 5
• Novel targets like PSMA4 identified through genomic studies, particularly relevant for CD4+ T cell-mediated TNF pathway inflammation. 8