What is the recommended treatment approach for hidradenitis suppurativa?

Recommended Treatment Approach for Hidradenitis Suppurativa

Hidradenitis suppurativa requires a multimodal treatment strategy that combines medical and surgical approaches based on Hurley staging, with topical clindamycin for mild disease, systemic antibiotics for moderate disease, and adalimumab (weekly dosing) plus surgical intervention for severe disease. 1

Initial Assessment and Staging

Evaluate disease severity using Hurley staging and the International Hidradenitis Suppurativa Severity Score System (IHS4) to guide treatment selection 1, 2. Screen for critical comorbidities including metabolic syndrome, depression, diabetes, polycystic ovarian syndrome, inflammatory bowel disease, and tobacco abuse at initial diagnosis 3. Refer patients with obesity, hypertension, hyperlipidemia, or acanthosis nigricans for HbA1c and fasting glucose testing 3.

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

• Topical clindamycin 1% solution is the only topical antibiotic with evidence for HS and should be applied to affected areas 1, 4
• Use antiseptic cleansers including chlorhexidine, benzoyl peroxide, or zinc pyrithione based on expert opinion 1
• Consider resorcinol 15% cream (keratolytic and antiseptic) applied twice daily during flares and daily between flares, though irritant dermatitis occurs frequently 1
• Implement lifestyle modifications: loose-fitting clothing, weight loss if overweight, and mandatory smoking cessation 4

Moderate Disease (Hurley Stage II)

• Combine topical clindamycin with oral antibiotics such as tetracyclines 4
• The North American guidelines support systemic antibiotic use for moderate disease, though specific regimens require individualization based on response 1
• Continue antiseptic cleansers and lifestyle modifications 1, 4
• Consider hormonal therapies (oral contraceptives, spironolactone, finasteride) as adjunctive treatment 1

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

Adalimumab administered weekly (not every other week) is superior to placebo, reducing Sartorius scores (standardized mean difference = -0.32, P < 0.0001) and pain (risk ratio = 1.42, P = 0.02) 5. This represents the highest quality evidence for biologic therapy in HS.

• Initiate adalimumab as first-line biologic therapy for moderate-to-severe disease 5, 4
• Continue medical therapy in the perioperative period when surgical intervention is planned 3
• Adalimumab remains underutilized in adolescents despite demonstrated efficacy 6

Surgical Management

Incision and drainage should only be used for acute abscesses to relieve pain, not as definitive treatment 3. Recurrent nodules and tunnels require deroofing or excision 3.

• Deroofing or local excision for recurrent nodules and tunnels provides better outcomes than incision and drainage 3
• Wide local excision (scalpel, CO2 laser, or electrosurgical) with or without reconstruction is appropriate for extensive chronic lesions 3
• Wound healing options include secondary intention, primary closure, delayed primary closure, flaps, grafts, or skin substitutes 3
• Medical optimization before surgery improves outcomes 2

Emerging and Adjunctive Therapies

Laser and Energy-Based Treatments

• Nd:YAG laser shows promise for follicular destruction with settings of 30 to 50 J/cm² for skin types I-III and 25 to 40 J/cm² for skin types IV-VI 3
• Fractional microneedling radiofrequency (FMR) demonstrates 94.1% clinical improvement rates with 52.9% achieving IHS4-55 response (≥55% reduction), with highest response in face, chest, and gluteal regions 7
• CO2 lasers for excision, marsupialization, and vaporization show consistently positive outcomes in Hurley stage II-III disease 3
• Three to four treatment sessions are typically performed for laser therapies 3

Pain Management and Flare Therapy

Address pain as a primary outcome, particularly during acute flares 1, 8. Hospitalization for severe flares provides opportunities for specialized consultations, rescue therapy, surgical planning, and early biologic initiation 8.

Special Populations

Skin of Color

Start lower concentrations of retinoids to minimize postinflammatory hyperpigmentation risk 6. Early aggressive therapy is essential to prevent scarring, which carries heightened psychosocial burden in underrepresented groups 6.

Transgender and Gender Diverse Youth

Masculinizing hormone therapy in transmasculine individuals may exacerbate disease, requiring careful treatment planning 6.

Critical Pitfalls to Avoid

• Never rely on incision and drainage as definitive treatment—it only provides temporary pain relief and does not address underlying disease 3
• Avoid every-other-week adalimumab dosing—weekly administration is required for efficacy 5
• Do not delay comorbidity screening—metabolic syndrome, depression, and inflammatory bowel disease significantly impact outcomes 3
• Never treat HS in isolation—the disease requires addressing systemic inflammation, pain, psychiatric comorbidities, and lifestyle factors simultaneously 3, 9

Treatment Stacking Approach

The most recent expert algorithm emphasizes treatment stacking: combining topical therapies, systemic antibiotics, biologics, hormonal therapies, surgical interventions, pain management, and lifestyle modifications rather than sequential monotherapy 10. This multimodal approach addresses the multifaceted pathoetiology of HS more effectively than single-agent therapy 2.