Management of hidradenitis suppurativa in adults

HS: hidradenitis suppurativa; ND:YAG: neodymium-doped yttrium aluminum garnet.

* The presence of skin tunnels or scarring correlates with Hurley stage II or III HS. The absence of these features correlates with Hurley stage I HS.

¶ Initial treatment with topical clindamycin is an alternative to doxycycline. However, in our experience, topical clindamycin monotherapy is rarely effective for controlling HS.

Δ We tend to add antiandrogenic agents (oral contraceptive or spironolactone) in female patients who report menses-related flares or have features of polycystic ovary syndrome. We tend to add metformin in patients with obesity. The selection of an antiandrogenic agent is based on contraceptive needs, comorbidities, and patient preference. We assess responses to antiandrogenic agents and metformin after 3 to 6 months of treatment.

◊ We typically reserve initial treatment with clindamycin and rifampin for patients presenting with severe disease (eg, Hurley stage III HS).

§ Recurrences may be managed with repetition of the previously effective antibiotic (usually for patients with <2 relapses per year) or proceeding to next-line treatment.

¥ Treatment selection involves consideration of treatment risks and patient preference. ND:YAG laser therapy is an additional procedural treatment option.

‡ For patients initially treated with doxycycline, a trial of clindamycin plus rifampin is also reasonable. We primarily reserve acitretin for patients of nonchildbearing potential who prefer to avoid or cannot receive biologic therapy. Pregnancy is contraindicated during and for 3 years after acitretin therapy. The response to acitretin can be assessed after 12 to 16 weeks.