How is Hidradenitis Suppurativa Treated?

Hidradenitis suppurativa (HS) is a painful, chronic inflammatory skin disease that does not have a cure. The symptoms and severity of HS can be different from person to person. Since the exact cause of HS is not known, a blend of medicines and lifestyle changes is often used in treatment. The goals of treatments are to:1,2

  • Reduce symptoms
  • Relieve pain
  • Heal wounds

HS is a complex disease that is difficult to treat, and there is not a “gold standard” for treatment. This means there is no single, agreed-upon best therapy for the disease. The expected benefits of many treatments are based on use in specific cases, instead of results of research in clinical trials. Many studies do not have long-term follow-up prove the changes are not due to the natural cycles in which HS worsens and improves again.1,2,4

Lack of accepted treatment approaches for HS may contribute to patient dissatisfaction. In response to questions about treatment in a large global survey, almost half of people with HS said that they were dissatisfied with medications. More than a third said they were dissatisfied with procedures.5

Guidelines for HS treatment

Until recently, there were not even any guidelines for treatment. In 2015, the European Academy of Dermatology and Venereology published treatment guidelines in its journal. In 2019, a joint expert committee of the U.S. and Canadian Hidradenitis Suppurativa Foundations published clinical management guidelines in the Journal of the American Academy of Dermatology.6-8

The guidelines draw from a combination of approaches, including: 6-8

Both sets of guidelines advise that treatment be tailored to the person with HS. Doctors should take into account the severity of the disease and its impact on the person. The treatment plan should also deal with related pain, mental health, and comorbidities (other diseases occurring at the same time). The guidelines recommend more research.6-8

HS treatments based on stages of severity

Both sets of guidelines use the Hurley staging system to rate HS symptom severity and organize treatments according to that severity. The Hurley staging system is the simplest scoring system and the most widely used by doctors treating people with HS.9

The Hurley system classifies HS into 3 stages:6-8

  • Stage 1 – One or more lesions (sores) or abscesses, without sinus tracts and scarring; 68 percent of people with HS are in this stage
  • Stage 2 – Recurrent abscesses with limited amount of widely separated abscesses, sinus tracts, and scarring; 28 percent of people with HS
  • Stage 3 – Widespread abscesses or multiple interconnected sinus tracts, abscesses, and scarring; 4 percent of people with HS

The guidelines from the US and Canadian Hidradenitis Suppurativa Foundations recommend the following approach to treatments.

Treating stage 1 (mild) and stage 2 (moderate)

Local excision – cutting out the lesion or abscess7,8

Treating stage 2 (moderate) and stage 3 (severe)

Medical treatment:8,10

  • Biologics – drugs derived from living material. They affect parts of the immune system to reduce inflammation.M/li>
    • Anti-TNF (adalimumab, infliximab)
    • Other biologics (anakinra, ustekinumab)
  • Antibiotics
    • Moxifloxacin, metronidazole, and rifampin in combination
    • IV ertapenem

Treating Stage 3 (severe)

Wide surgical excision (or carbon dioxide laser) – cutting out, or evaporating with a laser, the abscess or sinus tract with enough surrounding tissue to be sure that all diseased tissue is removed7,8,11

Treating all stages, regardless of severity

Supportive general therapy and lifestyle modification:8

  • Pain management
  • Mental health
  • Wound care directions
  • Avoidance of triggers
  • Smoking cessation
  • Weight reduction

Medical treatments:8

  • Tetracycline – antibiotic
  • Rifampin plus clindamycin – combination of antibiotics
  • Hormonal agents – reduce effects of androgen (male hormone)
  • Retinoids – vitamin A-based medications

Procedures:6-8

  • Nd:Yag laser – neodymium-doped yttrium-aluminum-garnet laser designed for hair removal
  • Deroofing (surgery or carbon dioxide laser) – inexpensive, outpatient procedure in which the top layer and the contents of a lesion or abscess are removed

For acute lesions:7,8

  • Antiseptic washes
  • Warm compresses
  • Short-term oral steroids
  • Steroids in the lesions
  • Incision and drainage of the lesions
  • Topical (applied to the surface) resorcinol – antiseptic that softens and sheds scaly skin
  • Deroofing

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Written by: Ina Fried and Heather Morse | Last reviewed: December 2020