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-ups. Follow-ups are needed to prove the changes are not due to natural cycles where HS worsens and improves again.^1-4

Lack of accepted treatment approaches for HS may contribute to dissatisfaction among people with the condition. In a large global survey on HS, nearly half of respondents said they were dissatisfied with medicines used to treat the condition. More than a third said they were dissatisfied with procedures.⁵

Guidelines for HS treatment

Until recently, no standard guidelines existed for treatment. In 2015, the European Academy of Dermatology and Venereology published treatment guidelines. 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

• Medicines
• Surgery
• Diet
• Home remedies
• Lifestyle changes
• Complementary and alternative medicine

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

HS treatments for all stages

Some treatment for HS will depend on the stage, or severity of the disease. However, some treatments will be the same for all stages.⁸

Supportive general therapy and lifestyle modifications include:⁸

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

Medical treatments include:⁸

• Tetracycline (antibiotic)
• Rifampin plus clindamycin (combination of antibiotics)
• Hormonal agents (reduce effects of androgen)
• Retinoids (vitamin A-based drugs)
• TNF-Inhibitors (adalimumab and infliximab)

Procedures include:^6-8

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

For acute lesions, treatment includes:^7,8

• Antiseptic washes
• Warm compresses
• Short-term oral steroids
• Intralesional steroids
• Incision and drainage of the lesions
• Topical antibiotics (clindamycin solution, gel)
• Topical resorcinol (antiseptic that softens and sheds scaly skin)
• Deroofing

HS treatments based on stages of severity

Both sets of guidelines use the Hurley staging system to categorize HS symptom severity and tailor treatments according to their 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 U.S. and Canadian Hidradenitis Suppurativa Foundations recommend the following approach to treatments:

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

Using local excision, which means cutting out the lesion or abscess.^7,8

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

Medical treatment including:^8,10

• Biologics, which are drugs made from living material. They affect parts of the immune system to reduce inflammation. They include:
• Anti-TNF (adalimumab, infliximab)
• Other biologics (anakinra, ustekinumab)
• Antibiotics
• Moxifloxacin, metronidazole, and rifampin in combination
• IV ertapenem

Treating stage 3 (severe)

Using wide surgical excision to cut out the abscess or sinus tract with enough surrounding tissue to be sure that all diseased tissue is removed. A carbon dioxide laser may also be used to evaporate the abscess or sinus tract.^7,8,11