Hidradenitis Suppurativa - Topical, Intralesional, and Systemic Medical Management

Publication Date: July 1, 2019
Last Updated: March 14, 2022

Recommendations

Topical and Intralesional Therapies

Topical clindamycin may reduce pustules in HS, but it carries a high risk of bacterial resistance. (C, )
(II, III)
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Resorcinol 15% cream is recommended but may induce contact dermatitis. (C, III)
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Washing with chlorhexidine, zinc pyrithione, or other antibacterial washes is supported by expert opinion. (C, III)
(Chlorhexidine - Expert opinion)
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Intralesional corticosteroid for inflamed lesions is recommended on the basis of weak evidence for short-term control of HS flares. (C, III)
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Systemic Antibiotics

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Tetracyclines are recommended in mild-to-moderate HS for a 12-week course or as long-term maintenance when appropriate. (C, III)
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Clindamycin and rifampin in combination is effective as a second-line treatment for mild-to-moderate disease or as a first-line or adjunct treatment in severe disease. (B, II)
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Moxifloxacin, metronidazole, and rifampin in combination are recommended as second- or third-line treatment in moderate-to-severe disease. (C, II)
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Dapsone may be effective for a minority of patients with Hurley stage I or II disease as long-term maintenance therapy. (C, III)
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IV ertapanem is recommended for severe disease as a 1-time rescue therapy or as a bridge to surgery or other long-term maintenance. (C, III)
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Determining the duration and frequency of antibiotic use should balance the benefit received by each patient with the risk of antibiotic resistance. Recurrence following cessation is frequent. (, )
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Hormonal Agents

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Hormonal agents, including estrogen-containing combined oral contraceptives, spironolactone, cyproterone acetate, metformin, and finasteride, should be considered in appropriate female patients, either as monotherapy for mild-to-moderate HS or in combination with other agents for more severe disease. (C, III)
(Antiandrogen contraceptives - II)
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Anecdotal data suggest that progestogen-only contraceptives may worsen HS and should potentially be avoided. (, )
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Small samples sizes, variable outcome measures and methods, and reporting bias are major limitations in all described evidence of hormonal therapies. (, )
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Retinoids

Results from isotretinoin studies have been mixed. Its use should be considered only as a second- or third-line treatment or in patients with severe concomitant acne. (B, II)
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Acitretin may be superior to isotretinoin for the treatment of HS, but robust comparative studies are lacking. It should be considered a second- or third-line treatment. (B, II)
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Alitretinoin is supported by a single study in women. It is available in Canada and many other countries but not in the United States. (, )
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Immunosuppressants

The available limited evidence does not support the use of methotrexate or azathioprine in the treatment of HS. (, III)
(Not recommended)
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Weak evidence supports the use of colchicine in combination with minocycline in refractory mild-to-moderate disease, but not colchicine monotherapy. (C, III)
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Cyclosporine can be considered in patients with recalcitrant moderate-to-severe HS who have failed or are not candidates for standard therapy. (C, III)
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Short-term pulse steroid therapy can be considered for acute flares or to bridge patients to other treatment. (C, III)
May be considered as low-dose adjunctive treatment or pulse dosing for acute flares or to bridge to other treatment.
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Long-term systemic corticosteroids tapered to the lowest possible dose can be considered in cases of severe HS, as an adjunct therapy in patients with suboptimal response to standard therapy. (, )
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Biologics

Adalimumab at the approved HS dosing is recommended to improve disease severity and quality of life in patients with moderate-to-severe HS. (A, I)
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Infliximab is recommended for moderate-to-severe disease; however, dose-ranging studies are needed to determine the optimal dosage for management. (B, II)
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Anakinra, 100 mg daily, may be effective for HS; however, dose-ranging studies are needed to determine the optimal dosage for management. (B, II)
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Ustekinumab, 45 to 90 mg administered every 12 weeks, may be effective for HS; however, placebo-controlled dose-ranging studies are needed to determine the optimal dosage for management. (B, II)
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The limited available evidence does not support etanercept for the management of HS. (C, II)
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Golimumab (C, III)
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Pediatric and Pregnant Patients

Perform laboratory evaluation for precocious puberty in pediatric patients with HS who are age 11 or younger when other suspicious physical examination findings are present. (, )
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Avoid tetracyclines in children younger than 9 years and acitretin in female patients during the childbearing years. (, )
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Avoid retinoids, hormonal agents, most systemic antibiotics, and most immunosuppressive medications in pregnant patients. (, )
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Use topical treatments, procedures, and safe systemic agents in pregnant patients. (, )
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Recommendation Grading

Overview

Title

Hidradenitis Suppurativa - Topical, Intralesional, and Systemic Medical Management

Authoring Organization

Hidradenitis Suppurativa Foundation

Publication Month/Year

July 1, 2019

Last Updated Month/Year

January 31, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adolescent, Child

Health Care Settings

Ambulatory, Childcare center

Intended Users

Physician, nurse, nurse practitioner, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D017497 - Hidradenitis Suppurativa

Keywords

clindamycin, retinoids, spironolactone, ertapenem, Hidradenitis suppurativa, carbon dioxide laser, Nd:YAG, oral contraceptive pills, finasteride, laser, microbiome, rifampin, keratolytic agents