Hidradenitis Suppurativa Treatment Guidelines

Introduction to Treatment

The American Academy of Dermatology recommends oral clindamycin 300 mg twice daily combined with rifampicin 300-600 mg daily for 10-12 weeks as first-line systemic therapy for moderate hidradenitis suppurativa in penicillin-allergic patients, or oral doxycycline 100 mg once or twice daily for 12 weeks for mild disease 1, 2

Determine Hurley stage to guide treatment selection, with stages ranging from I (isolated nodules without sinus tracts) to III (extensive sinus tracts and scarring) 2
Assess inflammatory lesion count, pain using Visual Analog Scale, and quality of life using DLQI to determine disease severity 2

For mild disease (Hurley Stage I), start with topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks, and combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1, 2, 3
For moderate disease (Hurley Stage II), use 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, 4
For severe or refractory disease (Hurley Stage III or failed antibiotics), escalate to adalimumab: 160 mg subcutaneous at week 0, 80 mg at week 2, then 40 mg weekly starting at week 4, with HiSCR response rates of 42-59% at week 12 1, 2

Reassess at 12 weeks using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas), pain VAS score, inflammatory lesion count, and DLQI to determine treatment response 2, 4
Consider treatment break after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 2, 4

Do not use penicillin-based antibiotics in penicillin-allergic patients, and ensure rifampicin dose is 300-600 mg daily for systemic effect 1, 4
Avoid long-term antibiotics without treatment breaks to reduce antimicrobial resistance risk 2, 4

Refer patients for smoking cessation, as tobacco use is associated with worse outcomes and higher AISI scores [2, @8@]
Refer patients for weight management if BMI is elevated, as high BMI predicts poor response to antibiotics 2
Use pain management with NSAIDs for symptomatic relief, and appropriate wound dressings for draining lesions 2, 3
Screen for depression/anxiety and cardiovascular risk factors (BP, lipids, HbA1c), as hidradenitis suppurativa patients have increased cardiovascular mortality 2, 4

Radical surgical excision should be considered for extensive disease with sinus tracts and scarring that fails medical management 1, 2