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Chapter 76: Hidradenitis Suppurativa

Jazzmin C. Williams; Haley B. Naik

HIDRADENITIS SUPPURATIVA

Therapeutic Approach

Hidradenitis suppurativa (HS) is a progressive and debilitating inflammatory skin disease that affects intertriginous regions. Disease severity can be classified using the Hurley staging system. Stage I is characterized by recurrent nodules and abscesses without tunnels or scar. Stage II is characterized by recurrent abscesses with tunnels and scar. Stage III is characterized by broad skin involvement with interconnected tunnels, abscesses, and scar. A combination of medical and surgical approaches is often required for optimal treatment outcomes. In the authors’ experience, stage I HS is typically treated with topical or oral antibiotics. Stage II-III disease requires biologic agents with or without broad-spectrum systemic antibiotics. Nonbiologic systemic agents may be used as adjunctive therapy for medical disease management. Permanently damaged or disfigured tissue (tunnels and scarring) requires surgical removal. Tunnels observed in stage II disease can often be managed with deroofing procedures, whereas surgical excisions are typically required for stage III disease. See Table 76-1.

Table 76-1Hidradenitis Suppurativa Treatment Table
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Table 76-1 Hidradenitis Suppurativa Treatment Table
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MEDICATION NAME HURLEY STAGE MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Antibiotics
Clindamycin I, II Antibacterial 1% solution; apply BID Increased risk of S. aureus resistance None IB1,2
Oral Antibiotics
Rifampin + clindamycin I-III Antibacterial 300 mg each BID Nausea, diarrhea, orange discoloration of body fluids, CYP450-drug interactions, C. difficile colitis Baseline CBC, LFTs II3,4
Rifampin + moxifloxacin + metronidazole I-III Anti-inflammatory, antimicrobial

Rifampin: 300 mg BID

Moxifloxacin: 400 mg daily

Metronidazole: 500 mg TID

 Nausea, diarrhea, orange discoloration of bodily fluids, CYP-450 drug interactions, tendonitis, QT prolongation, torsades de pointes, headache, metallic taste, dizziness, peripheral neuropathy Baseline CBC, LFTs, ECG IIB5
Doxycycline/tetracycline I, II Antibacterial

Doxycycline: 50-100 mg BID

Tetracycline: 500 mg BID

 Nausea, diarrhea, photosensitivity None IIB3,6
Ertapenem II, III Antibacterial 1g IV daily Diarrhea, C. difficile colitis, candidiasis, seizures, elevated transaminases Baseline CBC, LFTs, BUN/Cr III7,8
Biologic Systemic Agents
Adalimumaba II, III Tumor necrosis factor inhibitor 40 mg SQ weekly TB reactivation, injection site reaction, increased risk of infection Annual TB, CBC, LFTs, BUN/Cr, HCV, HBV, HIV IB9
Infliximab II, III Tumor necrosis factor inhibitor 5-10 mg/kg IV q4-8wk TB reactivation, increased risk of infection, infusion reaction Annual TB, CBC, LFTs, BUN/Cr, HCV, HBV, HIV IB10,11
Anakinra II, III IL-1-inhibitor 100 mg SQ daily Injection site reactions, increased risk of infection Annual TB, CBC, LFTs, BUN/Cr, HCV, HBV, HIV IB12
Ustekinumab II, III IL-12/IL-23 inhibitor 45/90 mg SQ q12wk Increased risk of infection Annual TB, CBC, LFTs, BUN/Cr, HCV, HBV, HIV IIB13,14
Bimekizumab II, III IL-17 inhibitor 320 mg SQ q2wk Increased risk of infection Annual TB, CBC, LFTs, BUN/Cr, HCV, HBV, HIV IB15
Secukinumab II, III IL-17A inhibitor 300mg SQ q2-4w

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