Evidence‑Based Management of Hidradenitis Suppurativa

Assessment and Baseline Staging

• The worst‑affected anatomical region should be classified using the Hurley system (Stage I: isolated abscesses; Stage II: recurrent abscesses with sinus tracts; Stage III: diffuse interconnected tracts) to direct therapy selection【2】【3】.
• Patients with Hurley Stage III disease require immediate referral to a dermatologist for combined medical‑surgical planning【2】【3】.

Screening for Comorbidities and Lifestyle Factors

• All individuals should be screened for depression, anxiety, diabetes, hypertension, dyslipidaemia, central obesity, and inflammatory bowel disease when gastrointestinal symptoms are present【1】【2】【3】.
• Referral to smoking‑cessation and weight‑management programmes is advised because these factors markedly worsen disease severity【1】【2】【3】.

Topical and Intralesional Options (American Academy of Dermatology)

• Topical clindamycin 1 % solution may be used in mild disease; it reduces pustules but has limited impact on nodules and abscesses【4】【5】【6】【1】.
• Adding benzoyl‑peroxide to topical clindamycin can lower the risk of Staphylococcus aureus resistance【4】【5】【6】.
• Intralesional triamcinolone (10 mg/mL, 0.2–2 mL) provides rapid pain relief (within 1 day) and diminishes erythema, edema, and suppuration in selected acute lesions【4】【5】【6】【1】.
• Antiseptic cleansers (chlorhexidine, benzoyl‑peroxide, zinc pyrithione) are endorsed by expert consensus despite the absence of controlled trials【4】【5】【6】.

Systemic Antibiotic Therapy (British Association of Dermatology)

First‑Line – Tetracyclines

• Oral doxycycline or lymecycline for ≥ 12 weeks is the initial systemic treatment for Hurley I–II disease【1】【2】【3】 (moderate‑quality evidence).
• Planned treatment breaks may be employed to assess ongoing need and mitigate antimicrobial resistance【1】【2】【3】.
• Monotherapy is sufficient for mild disease; in advanced stages it serves as adjunctive therapy【4】【5】【6】.

Second‑Line – Clindamycin + Rifampin

• Clindamycin 300 mg + rifampin 300 mg twice daily for 10–12 weeks is recommended for patients who fail tetracyclines【4】【5】【6】【1】【2】【3】.
• Systematic review of 187 patients reported 71–93 % clinical response【4】【5】【6】 (high‑level evidence).
• The regimen can be repeated intermittently or used as an adjunct in severe disease【4】【5】【6】.

Third‑Line – Triple Antibiotic Regimen

• For refractory cases, a combination of moxifloxacin 400 mg daily, metronidazole 500 mg three times daily, and rifampin 300 mg twice daily is employed【4】【5】.
• Metronidazole should be stopped after 6 weeks to avoid neurologic toxicity【4】【5】.
• Reported complete response rates: 100 % (Hurley I), 80 % (Hurley II), 17 % (Hurley III); the regimen is intended as a bridge to surgery or long‑term therapy【4】【5】.

Alternative Antibiotics

• Dapsone 50–200 mg daily for ≥ 3 months yields a 38 % response, is ineffective in Hurley III, and is reserved for Hurley I–II disease【4】【5】.
• Ertapenem 1 g IV daily for 6 weeks is highly effective but limited to rescue use because of practical and resistance concerns【4】.

Biologic Therapies (American Academy of Dermatology)

First‑Line – Adalimumab (FDA‑approved)

• Adalimumab 40 mg weekly is indicated for moderate‑to‑severe HS unresponsive to conventional systemic agents【7】【1】【2】【3】 (strong RCT evidence).
• Loading schedule: 160 mg at week 0, 80 mg at week 2, then 40 mg weekly from week 4【7】.
• PIONEER trials demonstrated HiSCR response 42–59 % versus 26–28 % with placebo at 12 weeks【7】.
• Approximately 40 % of week‑12 non‑responders achieve response by week 36 with continued therapy; early discontinuation should be avoided【7】.
• Dosing every other week (40 mg Q2W) failed to meet efficacy endpoints and should not be used【1】【2】.
• Approved for patients aged ≥ 12 years【1】【2】【3】.

Second‑Line – Infliximab

• Infliximab 5 mg/kg every 8 weeks is recommended for patients who do not respond adequately to adalimumab【7】【1】【2】【3】 (moderate evidence).

Agents to Avoid

• Etanercept is ineffective for moderate‑to‑severe HS and should be avoided【1】【2】.

Hormonal and Metabolic Adjuncts (British Association of Dermatology)

• Acitretin 0.3–0.5 mg/kg/day may be used in males and non‑fertile females who fail antibiotics【1】【2】【3】 (low‑to‑moderate evidence).
• Metformin is considered in patients with co‑existing diabetes, polycystic ovary syndrome, or pregnancy【1】【2】.
• Spironolactone and oral contraceptives are mentioned in guidelines but lack robust supporting data【4】【6】.

Systemic Immunosuppressants (American Academy of Dermatology)

• Systemic corticosteroids (prednisone 0.5–1 mg/kg daily) provide rapid control of flares and can bridge to long‑term therapy; response rates of 46–85 % when added to existing regimens【7】 (moderate evidence).
• Methotrexate, azathioprine, and cyclosporine demonstrate poor efficacy and should be avoided【7】.
• Colchicine monotherapy is not recommended; modest benefit observed only when combined with minocycline【7】.

Surgical Management (British Association of Dermatology)

• Extensive excision should be considered when systemic therapies have failed to reduce recurrence risk【1】【2】.
• Post‑excision reconstruction with secondary intention healing or a TDAP flap is preferred for axillary wounds【1】【2】.

Therapies to Avoid (British Association of Dermatology)

• Isotretinoin is not indicated unless the patient has concurrent moderate‑to‑severe facial or truncal acne【1】【2】.
• Cryotherapy is discouraged due to procedural pain【1】【2】.
• Microwave ablation should not be offered【1】【2】.

Pain Management and Monitoring (American Academy of Dermatology)

• Proactive pain control and appropriate dressings for draining lesions are essential components of care【1】【2】【3】.
• Treatment response should be quantified with validated instruments assessing pain, quality of life, and inflammatory lesion counts, especially when using adalimumab【1】【2】【3】.

Long‑Term Surveillance (British Association of Dermatology)

• In chronic moderate‑to‑severe HS, monitor for fistulating gastrointestinal disease, inflammatory arthritis, genital lymphedema, cutaneous squamous cell carcinoma, and anemia【1】【2】【3】.