Hidradenitis Suppurativa Management with Intralesional Triamcinolone

Introduction to Intralesional Corticosteroids

The American Academy of Dermatology recommends intralesional triamcinolone injections for short-term control of individual inflamed lesions in hidradenitis suppurativa, but only as an adjunctive therapy for acute flares, with a weak recommendation based on Level III evidence (expert consensus and limited case series) 1, 2

Intralesional triamcinolone is specifically indicated for acute inflamed nodules and abscesses requiring rapid symptom relief, with dosing of triamcinolone 10 mg/mL, injected at 0.2-2.0 mL per lesion, and expected outcomes of significant reduction in erythema, edema, suppuration, and pain within days 3, 4
The evidence level for this recommendation is Level III (expert consensus and limited case series), making this a weak recommendation based primarily on clinical experience rather than robust trials 1, 2

Intralesional steroids do not address the underlying disease process and should never be used as monotherapy, providing only temporary symptomatic relief for individual lesions, with no effect on disease progression, sinus tract formation, or scarring 1, 2, 5, 6

For mild disease (Hurley Stage I), the first-line treatment is topical clindamycin 1% twice daily for 12 weeks, with adjunctive intralesional triamcinolone for inflamed lesions 1, 2, 3
For moderate disease (Hurley Stage II), the first-line treatment is tetracycline 500 mg twice daily for up to 4 months or doxycycline 100 mg once or twice daily, with second-line treatment of clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks (response rates 71-93%) 1, 3
For severe disease (Hurley Stage III), the first-line treatment is adalimumab 160 mg at week 0, 80 mg at week 2, then 40 mg weekly starting week 4, with surgical consultation for definitive management 1, 3, 5, 6, 7

Beyond medications, it is essential to address factors that impact morbidity and quality of life, including smoking cessation, weight loss in patients with obesity, screening for depression/anxiety, cardiovascular risk factor screening, and appropriate wound care for draining lesions 3, 4, 7