What is the best treatment for hidradenitis suppurativa?

Best Treatment for Hidradenitis Suppurativa

For moderate-to-severe hidradenitis suppurativa, initiate adalimumab (TNF-alpha inhibitor) or secukinumab (IL-17A inhibitor) as first-line biologic therapy, combined with topical antiseptics and systemic antibiotics for acute flares, with early surgical intervention for established tunnels and scarring. 1, 2

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• Start with topical clindamycin 1% solution twice daily, though evidence shows it reduces pustules but has minimal effect on inflammatory nodules and abscesses 1
• Add antiseptic washes (chlorhexidine, benzoyl peroxide, or zinc pyrithione) for daily maintenance 1
• Consider resorcinol 15% cream for flares—reduces pain and abscess duration but causes frequent irritant dermatitis 1
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) provides rapid pain relief within 1 day for individual inflamed lesions 1

Critical pitfall: Topical clindamycin increases Staphylococcus aureus resistance—always combine with benzoyl peroxide to mitigate this risk 1

Moderate Disease (Hurley Stage II)

• Systemic antibiotics as bridge therapy: Clindamycin 300 mg + rifampin 300 mg, both twice daily 1
• Initiate biologic therapy early to prevent irreversible tunnel formation and scarring 3
• Adalimumab (FDA-approved TNF-alpha inhibitor) or secukinumab (FDA-approved IL-17A inhibitor) are the only two approved biologics 2
• Continue topical antiseptics and intralesional steroids for breakthrough lesions

Key reasoning: The 2019 North American guidelines emphasize that antibiotics alone have lower response rates and increased recurrence in advanced disease, making them adjunctive rather than definitive 1. The 2025 evidence confirms early biologic intervention prevents irreversible skin damage 3.

Severe Disease (Hurley Stage III)

• Biologics are mandatory: Adalimumab or secukinumab as first-line 2
• Combine medical and surgical therapy—biologics alone are insufficient once tunnels and extensive scarring develop 1, 3
• Surgical excision of affected areas with wide margins
• Consider bimekizumab (newer IL-17 inhibitor) if available, as it targets both IL-17A and IL-17F 3

Important caveat: Neither adalimumab nor secukinumab works in all patients, and some lose response over time 2. Therapeutic drug monitoring can optimize biologic longevity 2.

Why Biologics Should Be Started Early

The pathophysiology involves chronic inflammation leading to irreversible tunnel formation and morbid scarring 3. Once the destructive phase begins, medical therapy alone cannot reverse structural damage. The 2025 Lancet review emphasizes that early intervention prevents irreversible skin damage, requiring early diagnosis and aggressive treatment 3.

Treatment stacking approach 4:

1. Topical antiseptics (daily maintenance)
2. Systemic antibiotics (acute flares or bridge therapy)
3. Biologics (disease control and prevention of progression)
4. Surgery (established tunnels/scarring)
5. Pain management throughout

Special Populations

Pregnancy

• Topical antibiotics and antiseptic washes are safe with minimal systemic absorption 5
• Cephalexin, azithromycin, and clindamycin are safe systemic options 5
• Zinc supplementation does not adversely affect outcomes and may be beneficial given lower zinc levels in HS patients 5
• Avoid resorcinol 15%—potential fetal neurodevelopmental risks 5
• Intralesional steroids for acute flares are based on expert opinion but lack safety data 5

Pediatric Patients

The 2025 guidelines provide specific recommendations for children, though biologics remain the cornerstone for moderate-to-severe disease 5

Comorbidity Screening is Non-Negotiable

Screen immediately after diagnosis for:

• Metabolic syndrome
• Inflammatory arthritis
• Inflammatory bowel disease
• These reflect systemic inflammation, not just skin disease 3, 4

Common Pitfalls to Avoid

1. Delaying biologics until severe disease develops—by then, irreversible damage has occurred
2. Using antibiotics as monotherapy for moderate-to-severe disease—they are adjunctive only 1
3. Forgetting benzoyl peroxide with topical clindamycin—prevents antibiotic resistance 1
4. Ignoring pain management—HS has profound negative effects on quality of life 3
5. Treating skin alone—this is a systemic inflammatory disease requiring holistic management 3, 6

Emerging Therapies

A robust pipeline of immunomodulatory drugs is in development, targeting various inflammatory pathways beyond TNF and IL-17 3, 7. Fractional microneedling radiofrequency shows promise with 94% clinical improvement rates, particularly for refractory cases and anatomically challenging areas 8.