Hidradenitis Suppurativa Treatment Guidelines

Introduction to Treatment

The American Academy of Dermatology recommends starting treatment for mild Hidradenitis Suppurativa (HS) with topical clindamycin 1% twice daily for 12 weeks, while moderate disease requires clindamycin 300 mg plus rifampicin 300-600 mg orally twice daily for 10-12 weeks, and severe or refractory disease is treated with adalimumab 40 mg weekly as the first-line biologic 1, 2, 3, 4.

The British Association of Dermatologists suggests documenting Hurley stage at baseline to guide treatment selection, with Hurley Stage I characterized by isolated nodules and abscesses, Stage II by recurrent nodules with limited sinus tracts and scarring, and Stage III by diffuse involvement with multiple interconnected sinus tracts and scarring 2, 3, 4.
Immediate dermatology referral is mandatory for Hurley Stage III disease, according to the British Journal of Dermatology 2, 3, 4.

For Hurley Stage I, the Journal of the American Academy of Dermatology recommends first-line therapy with topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks, combined with benzoyl peroxide wash or chlorhexidine 4% wash daily 2, 3, 4.
For acute flares in Hurley Stage I, intralesional triamcinolone 10 mg/mL provides rapid symptom relief within 1 day 2, 3, 4.
For Hurley Stage II, first-line systemic therapy consists of clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks, achieving response rates of 71-93% in systematic reviews 1, 2, 3, 4.

Adalimumab is the recommended first-line biologic therapy for Hurley Stage III or failed conventional therapy, with dosing per FDA label, and achieves HiSCR response rates of 42-59% at week 12 in placebo-controlled trials 1, 2, 3, 4.

Extensive/radical excision is necessary for lasting cure in advanced disease with sinus tracts and scarring when conventional systemic treatments have failed, according to the British Journal of Dermatology 2, 3, 4.

For pediatric patients, topical clindamycin 1% twice daily combined with antiseptic washes is recommended, and doxycycline 100 mg once or twice daily can be used for patients ≥8 years old 6, 4, 5.

Smoking cessation referral, weight management referral, pain management with NSAIDs, appropriate wound dressings, screening for depression/anxiety, and screening for cardiovascular risk factors are all recommended adjunctive measures 2, 3, 4.

Reassessment at 12 weeks using HiSCR, pain VAS score, inflammatory lesion count, and DLQI is recommended, and for adalimumab, if no clinical response after 16 weeks, alternative treatments should be considered 4.

Patients with long-standing moderate-to-severe HS should be monitored for fistulating gastrointestinal disease, inflammatory arthritis, genital lymphoedema, cutaneous squamous cell carcinoma, and anemia 2, 3, 4.