Hidradenitis Suppurativa (HS) — Treatment

Hurley Staging (Severity Classification)

General/Preventive Measures (All Stages)

• Daily cleansing with chlorhexidine gluconate (Hibiclens) or benzoyl peroxide wash
• Weight loss (obesity is a strong risk factor)
• Wear loose-fitting clothing to reduce friction
• Smoking cessation (smoking is a major modifiable risk factor)
• Laser hair removal at unaffected sites (prophylactic)
• Reduce sweating: topical aluminum chloride or botulinum toxin A injections
• Avoid heat exposure
• Treat comorbidities (metabolic syndrome, IBD, depression)

Medical Treatment

Topical Therapy

• Topical clindamycin (1% solution/gel) — first-line for mild disease (Hurley I); reduces surface bacterial load
• Used in combination with early intralesional steroids for earliest lesions

Intralesional Corticosteroids

• Triamcinolone acetonide injected intralesionally into early, tender nodules — rapid anti-inflammatory effect, most useful for acute flares

Systemic Antibiotics

• Tetracyclines (doxycycline or minocycline) — most commonly used; anti-inflammatory and antimicrobial properties
• Clindamycin + rifampin (300 mg each, twice daily) — one of the most extensively studied and effective oral regimens in Europe
• Other options: amoxicillin, TMP-SMX, dapsone
• IV ertapenem for severe flares requiring hospitalization, to allow transition back to oral therapy
• Culture-directed therapy is preferred; avoid prolonged empirical antibiotics to limit resistance

⚠️ Incision and drainage is strongly discouraged — it does not address the underlying sinus tracts and leads to scarring without cure.

Hormonal Therapy

• Spironolactone and oral contraceptives (OCPs) — useful adjuncts in women (anti-androgenic effect)
• Finasteride — in men or postmenopausal women
• Isotretinoin — most effective in young women with mild-to-moderate disease; remission is uncommon; secondary S. aureus infection may occur

Biologics (Moderate-to-Severe Disease)

Other Systemic Agents

• Cyclosporine and acitretin — select refractory cases
• Short-course oral prednisone — adjunct for acute flares only; limited duration

Procedural and Light-Based Therapies

• Nd:YAG laser — Randomized controlled trial of 22 patients showed significant improvement after 3 monthly sessions
• CO₂ laser — Can destroy lesions and sinus tracts; wound left to heal secondarily or closed primarily
• Photodynamic therapy (PDT) with methyl-aminolevulinate or 5-ALA — some positive reports but inconsistent results; inconvenient, painful, costly; not yet routinely recommended
• Laser hair removal (Nd:YAG or diode) — meta-analysis (PMID: 38769894) supports efficacy, particularly for milder disease

Surgical Management

• Wounds may be closed primarily, skin-grafted, or left to heal by secondary intention
• Surgery + medical therapy is now considered the gold standard holistic approach per 2024 European S2k guidelines — combining medical therapy to reduce inflammation with surgery to remove irreversibly damaged tissue

2024–2025 Guideline Updates

1. New phenotype classification: Active (inflammatory) → medical therapy; Inactive (non-inflammatory/fibrotic) → surgical therapy; Combined = optimal approach
2. IHS4 scoring used for active disease severity; Hurley staging retained for surgical planning

Special Situations

• Pregnancy: avoid tetracyclines, retinoids, and biologics where possible; topical clindamycin and short-term oral antibiotics with good safety profiles are preferred
• Pediatric HS: hormonal evaluation is essential; finasteride has been used in adolescents
• SCC risk: long-standing HS (average 19 years) carries a risk of squamous cell carcinoma in sinus tracts — any non-healing ulcer or induration should be biopsied

Summary Treatment Algorithm

Hurley I (Mild):
  → Topical clindamycin ± intralesional triamcinolone
  → Lifestyle + preventive measures
  → Oral antibiotics (doxycycline) if inadequate

Hurley II (Moderate):
  → Clindamycin + rifampin OR tetracyclines
  → Add adalimumab/secukinumab/bimekizumab if failing antibiotics
  → Deroofing or limited excision for persistent tracts

Hurley III (Severe):
  → Biologics (adalimumab or bimekizumab preferred)
  → IV ertapenem bridge if hospitalized
  → Wide local or regional excision after inflammation controlled
  → Multidisciplinary care (dermatology + surgery)