Approach

The intent of management is to reduce the formation of new inflammatory lesions, sinus tracts, and scarring; to treat existing lesions and reduce associated symptoms (e.g., pain, infection); and to improve associated comorbidities.

Treatment depends on disease severity and impact on quality of life. The Hurley classification scale approximates disease severity at presentation and can be used to stratify patients into groups who receive increasing intensity of treatment. It is useful to guide treatment choice.[4][36][41]

Treatment is often multidisciplinary.[1][42] Early referral to a dermatologist is recommended if patients don’t respond to one to two courses of long-term (3 months) antibiotics in the community. Medical therapy includes use of topical and oral antibiotics, retinoids, and in moderate to severe disease, biological agents. Discussion of surgical options should also be considered.

Acute symptoms

In the acute setting, oral antibiotics should be initiated. Guidelines recommend a 12-week course of a tetracycline antibiotic.[42][43][44]

In severe HS presenting with a disease flare, rescue therapy in the form of a 6-week course of intravenous ertapenem, followed by a 6-week course of consolidation treatment with moxifloxacin plus metronidazole plus rifampicin, may be considered.[43][44][45][46]

If the patient is well, intralesional corticosteroids may provide relief from pain and inflammation, in combination with oral antibiotics if required.[42][43][44][47]

If the patient is unwell or disease does not improve with antibiotics and/or intralesional corticosteroids, incision and drainage may be considered.[44] Incision and drainage is a supplemental measure; it should not be considered as the sole treatment because recurrence is very common.

Ongoing management: mild disease (Hurley Stage I)

Stage I is defined as the presence of localised disease with inflammatory papules, pustules, nodules, and abscesses but without sinus tracts or scarring.[4][Figure caption and citation for the preceding image starts]: Hidradenitis suppurativa stage I: discrete inflamed nodules and papules with intervening normal skin and lack of scarringFrom R.A. Lee, MD, PhD [Citation ends].com.bmj.content.model.Caption@26faf097

Topical therapies

It is recommended that all patients use an antimicrobial wash, but there is no strong evidence for specific agents; use of chlorhexidine, benzoyl peroxide, and zinc pyrithione is supported by expert opinion. Concomitant use of an antimicrobial wash may be associated with lower rates of antibiotic resistance in HS lesions.[43][48]

Topical antibiotics are useful treatments in mild HS.[41] Topical clindamycin has been shown to be effective in a clinical trial setting.[43][49] Topical metronidazole is another option. Topical therapy should be continued for a minimum of 8 weeks before evaluation of efficacy.

Antibiotic therapy

Systemic antibiotics are widely used and recommended in multiple HS treatment guidelines.[42][43][44] Oral tetracyclines are recommended first-line for mild disease. They can attenuate neutrophil activity and reduce pain and inflammation. A 12-week treatment course is recommended before evaluation of efficacy.[43][44][42]

Analgesia

The degree of pain usually correlates with the degree of inflammation. Thus, treatments directed at inflammation are often effective at alleviating pain. Non-steroidal anti-inflammatory drugs should be used as required before other pain medications such as paracetamol.

Lifestyle modifications

A high proportion of patients with hidradentitis suppurativa are active smokers or have a history of smoking, and are obese. Obesity is an independent risk factor for development of the disease and contributes to HS disease severity.[21][24] All patients should be advised to stop smoking, to lose weight if obese, and to be evaluated for cardiovascular disease.[44][50]

Ongoing management: moderate disease (Hurley Stage II)

Stage II is defined as the presence of inflammatory papules and nodules, ≥1 recurring, widely separated abscesses with sinus tracts and scarring.[4][41][Figure caption and citation for the preceding image starts]: Hidradenitis suppurativa stage II: inflamed nodules and scars with areas of intervening normal skinFrom R.A. Lee, MD, PhD [Citation ends].com.bmj.content.model.Caption@14de11b9

Antibiotic therapy

Tetracyclines are recommended for 12 weeks.[42][43]

Clindamycin plus rifampicin is an effective combination and should be continued for 10 to 12 weeks.[42][43][44] However, patients often relapse within 4 to 5 months of stopping therapy.[43][44][51]

Diarrhoea may reduce tolerability of clindamycin plus rifampicin in some patients.[42][43][44] Patients who are aged ≥50 years or ever-smokers are less likely to tolerate this combination.[36][52][53]

Rifampicin induces the cytochrome P450 system; check for potential drug interactions with existing medication including the oral contraceptive pill. Clindamycin plus rifampicin may also select for rifampicin-resistant strains of Mycobacterium tuberculosis; tuberculosis screening or avoiding this regimen may be indicated in high-risk populations.[54]

Triple antibiotic therapy with moxifloxacin plus metronidazole plus rifampicin is a second-line option for moderate HS.[43]

Dapsone

Dapsone is reserved for patients with moderate disease who have failed multiple courses of combination antibiotics.[42][43] Evidence is limited; in one published case series, 25% patients experienced clinically significant improvement but with rapid disease recurrence upon cessation.[55]

Anti-androgens

North American guidelines suggest that hormonal agents, including spironolactone, may be considered in women with clear premenstrual flares (while recognising that recommendations regarding hormonal therapies are based on limited evidence).[43]

Use of spironolactone should be limited to women who are practising adequate birth control.

UK guidelines conclude that there is insufficient evidence to recommend anti-androgens for the treatment of HS.[42][56]

Oral retinoids

Patients with concomitant acne vulgaris may consider using oral isotretinoin.[42][43][57] Oral isotretinoin should be continued for at least 6 months.

Acitretin has demonstrated moderate efficacy in HS.[43][58] Treatment duration in excess of 6 months has been reported.[59]

These medications are teratogenic and should be avoided in women of child-bearing potential.

Surgical management

Wide excision with wide and deep margins is the standard of care for surgical therapy. Because of the size of the excision and its corresponding repair, and the availability of specific lasers, referral to plastic surgery and/or a dermatological surgeon is advisable.[60][61][62][63]

Local excision is possible for smaller, quiescent lesions where the clinical margins can be clearly defined.

Adjunctive therapies and self-management

Topical therapies, analgesia, and lifestyle modifications may be considered (as for patients with mild disease).

Ongoing management: severe disease (Hurley Stage III)

Stage III disease is defined as multiple abscesses and interconnected sinus tracts and scars.[4][Figure caption and citation for the preceding image starts]: Hidradenitis suppurativa stage III: interconnected scars, cysts, comedones, and inflamed nodulesFrom R.A. Lee, MD, PhD [Citation ends].com.bmj.content.model.Caption@2245a915

The strategies for stage III disease overlap with those for stage I and II disease. In practice, patients in this group will have previously used oral tetracyclines, and they may be used again in between other measures to maintain disease control in stage III disease. However, once disease reaches stage III more aggressive treatment is usually required.

Antibiotic therapy

In selected stage III patients with severe HS presenting with a disease flare (usually after failure of a tetracycline [for 12 weeks] or clindamycin plus rifampicin), a 6-week course of intravenous ertapenem, followed by a 6-week course of consolidation treatment with moxifloxacin plus metronidazole plus rifampicin, may be considered.[43][44][45][46]

Biological agents

Adalimumab has demonstrated efficacy in phase 3 trials of HS.[64] It is the only approved biologic for HS, and is therefore considered the first-choice biological agent in moderate/severe HS refractory to conventional treatments.[42][43][44]

Infliximab may be considered as a second-line biological agent, and is used off-label for HS.[42][43][44]

Other biological agents may be considered if adalimumab or infliximab fail or are contraindicated, but their use is off-label and should be under specialist guidance.[43]

Therapy with biologics is continued for at least 12 weeks and the efficacy of treatment assessed at this time.

Surgical management

Wide excision with wide and deep margins is the standard of care for surgical therapy. Because of the size of the excision and its corresponding repair, and the availability of specific lasers, referral to plastic surgery and/or a dermatological surgeon is advisable.[60][61][62][63]

Local excision is possible for smaller, quiescent lesions where the clinical margins can be clearly defined.

Adjunctive therapies and self-management

Topical therapies, analgesia, and lifestyle modifications may be considered (as for patients with mild disease).

Women with clear premenstrual flares should consider using anti-androgen medications such as spironolactone.[43] Oral retinoids may be considered in patients with concomitant acne vulgaris.[42][43]

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