A practical guide to hidradenitis suppurativa
Early diagnosis and treatment of hidradenitis suppurativa is key to avoiding severe disease and minimizing its negative psychological impact.
PRACTICE RECOMMENDATIONS
› Screen patients with hidradenitis suppurativa (HS) for depression, anxiety, history of smoking, metabolic syndrome, and type 2 diabetes. A
› Look into early surgical and dermatology referrals for patients with mild diffused, moderate, and severe disease. B
› Consider biopsy to rule out skin cancer in patients with severe and longstanding HS refractory to treatment. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Antibiotic therapy
Topical antibiotics are considered first-line treatment for mild and moderate uncomplicated HS.63,64 Clindamycin 1%, the only topical antibiotic studied in a small double-blind RCT of patients with Hurley stage I and stage II HS, demonstrated significant clinical improvement after 12 weeks of treatment (twice- daily application), compared to placebo.84 Topical clindamycin is also recommended to treat flares in patients with mild disease.2,64
Oral antibiotics. Tetracycline (500 mg twice daily for 4 months) is considered a second-line treatment for patients with mild HS.64,68 Doxycycline (200 mg/d for 3 months) may also be considered as a second-line treatment in patients with mild disease.85
Combination oral clindamycin (300 mg) and rifampicin (300 mg) twice daily for 10 weeks is recommended as first-line treatment for patients with moderate HS.2,64,69 Combination rifampin (300 mg twice daily), moxifloxacin (400 mg/d), and metronidazole (500 mg three times a day) is not routinely recommended due to increased risk of toxicity.2
Ertapenem (1 g intravenously daily for 6 weeks) is supported by lower-level evidence as a third-line rescue therapy option and as a bridge to surgery; however, limitations for home infusions, costs, and concerns for antibiotic resistance limit its use.2,86
Corticosteroids and systemic immunomodulators
Intralesional triamcinolone (2-20 mg) may be beneficial in the early stages of HS, although its use is based on a small prospective open study of 33 patients.87 A recent double-blind placebo-controlled RCT comparing varying concentrations of intralesional triamcinolone (10 mg/mL and 40 mg/mL) vs normal saline showed no statistically significant difference in inflammatory clearance, pain reduction, or patient satisfaction.88
Continue to: Short-term systemic corticosteroid tapers...
