Medical Management of Hidradenitis Suppurativa in Special Patient Populations

Publication Date: December 24, 2024
Last Updated: January 14, 2025

Pregnancy

Pregnancy Topical Therapies

  • In pregnant patients with HS who require topical antibiotics, we suggest using these agents with an approach similar to other HS patient populations. (Conditional, Very Low)
  • In pregnant patients with HS who require topical therapy, we suggest avoiding resorcinol as evidence to support its safety is lacking.(Conditional, Very Low)
  • In pregnant patients with HS who require antiseptic washes, we suggest avoiding triclosan as there may be an increased risk of endocrine-disrupting effects. (Conditional, Very Low)
  • In pregnant patients with HS who require antiseptic washes, we suggest using chlorhexidine as it is unlikely to be associated with increased risks in pregnancy based on its mechanism of action. (Conditional, Very Low)
  • In pregnant patients with HS who require antiseptic washes, we suggest using bleach baths as it is unlikely to be associated with increased risks in pregnancy based on its mechanism of action. (Conditional, Very Low)
  • In pregnant patients with HS who require antiseptic washes, we suggest using zinc pyrithione as it is unlikely to be associated with increased risks in pregnancy based on its mechanism of action. (Conditional, Very Low)

Pregnancy Supplements

  • In pregnant patients with HS who are seeking natural therapies, we recommend using zinc supplements as there is evidence it is safe for use in pregnancy. (Strong, Moderate)

Pregnancy Intralesional Steroids

  • In pregnant patients with HS, we suggest using intralesional steroids for acute, localized flares. (Conditional, Very Low)

Pregnancy Systemic Antibiotics

  • In pregnant patients with HS who require systemic antibiotics, we suggest using oral cephalexin as there is evidence it is safe for use in pregnancy. (Conditional, Moderate)
  • In pregnant patients with HS who require systemic antibiotics, we suggest using oral azithromycin as there is evidence it is safe for use in pregnancy. (Conditional, Moderate)
  • In pregnant patients with HS who require systemic antibiotics, we suggest that oral rifampin and clindamycin combination can be used in select patients with severe disease. Oral clindamycin monotherapy may also be considered; however, the data is less robust to support its use as a monotherapy. (Conditional, Very Low)
  • In pregnant patients with HS who require systemic antibiotics, we suggest using oral clindamycin as there is evidence it is safe for use in pregnancy. (Conditional, Moderate)
  • In pregnant patients with HS who require systemic antibiotics, we suggest avoiding oral metronidazole as there may be an increased risk of low birthweight and neuroblastoma. (Conditional, Low)
  • In pregnant patients with HS who require systemic antibiotics, we suggest avoiding oral co-trimoxazole (trimethoprim/sulfamethoxazole) as there may be an increased risk of preterm birth, low birthweight, and kernicterus. (Conditional, Low)
  • In pregnant patients with HS who require systemic antibiotics, we suggest avoiding oral dapsone as there may be an increased risk of preterm birth, low birthweight, and hemolysis. (Conditional, Very Low)
  • In pregnant patients with HS who require systemic antibiotics, we recommend avoiding oral doxycycline as there may be an increased risk of congenital anomalies, potential binding of the medication in fetal bones, and tooth discoloration. (Strong, Low)
  • In pregnant patients with HS who require systemic antibiotics, we recommend avoiding oral erythromycin as there may be an increased risk of adverse outcomes including elevated liver enzymes. (Strong, Low)

Pregnancy Anti-Androgens

  • In pregnant patients with HS who require antiandrogens, we recommend using metformin as there is evidence it is safe for use in pregnancy. (Strong, Moderate)

Pregnancy Systemic Immunomodulators & Biologics

  • In pregnant patients with HS who require systemic immunomodulators, we suggest using prednisone only for acute, widespread flares. (Conditional, Low)
  • In pregnant patients with HS who require systemic immunomodulators, we suggest limiting use of cyclosporine to select treatment-refractory cases. (Conditional, Very Low)
  • In patients with HS who are considering pregnancy while on biologics, we recommend providing counseling regarding the use of biologics during pregnancy. (Strong, Very Low)
  • In patients with HS who are planning pregnancy while well-controlled on biologics, we recommend continuing biologic therapy throughout the pregnancy. (Strong, Very Low)
  • In neonates with in-utero biologic exposure from maternal HS management, we recommend consulting with their pediatrician about the timing of administering live vaccines. (Strong, Very Low)
  • In pregnant patients with HS who require biologics, we recommend using adalimumab. (Strong, Moderate)
  • In pregnant patients with HS who require biologics, we suggest using infliximab with an approach similar to other HS patient populations. (Conditional, Low)
  • In pregnant patients with HS who require biologics, we suggest using secukinumab with an approach similar to other HS patient populations. (Conditional, Very Low)
  • In select patients with HS who are planning pregnancy and require biologics, we suggest using certolizumab as an alternative biologic if they have a compelling reason to be concerned about in-utero biologic exposure. (Conditional, Very Low)

Breastfeeding

Breastfeeding Systemic Antibiotics

  • In breastfeeding patients with HS who require systemic antibiotics, we suggest using oral rifampin with an approach similar to other HS patient populations. (Conditional, Very Low)
  • In breastfeeding patients with HS who require systemic antibiotics, we suggest exercising caution when using oral clindamycin as it may increase the risk of GI side effects in the infant. (Conditional, Very Low)
  • In breastfeeding patients with HS who require systemic antibiotics, we suggest using oral amoxicillin/clavulanic acid. (Conditional, Low)
  • In breastfeeding patients with HS who require systemic antibiotics, we suggest using oral erythromycin. (Conditional, Low)
  • In breastfeeding patients with HS who require systemic antibiotics, we suggest using oral azithromycin. (Conditional, Low)
  • In breastfeeding patients with HS who require systemic antibiotics, we suggest using oral metronidazole. (Conditional, Low)
  • In breastfeeding patients with HS who require systemic antibiotics, we recommend limiting the use of oral doxycycline; if no suitable alternative antibiotic is available, oral doxycycline use should be limited to <3 weeks and without repeating courses. (Strong, Very Low)

Breastfeeding Anti-Androgens

  • In breastfeeding patients with HS who require antiandrogens, we suggest using metformin as there is evidence it is safe for use in breastfeeding. (Conditional, Moderate)
  • In breastfeeding patients with HS who require antiandrogens, we suggest using oral contraceptives especially when contraception is desired. (Conditional, Moderate)

Breastfeeding Systemic Immunomodulators & Biologics

  • In breastfeeding patients with HS who require systemic immunomodulators, we suggest using prednisone <20mg daily only in acute, widespread flares; if a dose of ≥20mg daily is required, patients should wait at least 4 hours prior to breastfeeding. (Conditional, Very Low)
  • In breastfeeding patients with HS who require systemic immunomodulators, we suggest limiting the use of cyclosporine to select treatment-refractory cases. (Conditional, Very Low)
  • In breastfeeding patients with HS who require biologics, we suggest that biologics are likely safe to use during breastfeeding based on pharmacokinetics, as these are large proteins not well-absorbed by the GI tract, with very little medication passing into breast milk. (Conditional, Very Low)
  • In breastfeeding patients with HS who require biologics, we recommend using adalimumab. (Strong, Moderate)
  • In breastfeeding patients with HS who require biologics, we suggest using infliximab with an approach similar to other HS patient populations. (Conditional, Moderate)
  • In breastfeeding patients with HS who benefitted from certolizumab during pregnancy, we suggest continuing certolizumab in select cases only, as efficacy data in HS is limited. (Conditional, Low)
  • In breastfeeding patients with HS who require biologics, we suggest exercising caution when using anti-IL-17s given minimal available data. (Conditional, Very Low)
  • In breastfeeding patients with HS who require biologics, we suggest exercising caution when using ustekinumab given minimal available data. (Conditional, Moderate)

Pediatrics

Pediatrics Topical Therapies

  • In pediatric patients with HS who require topical antibiotics, we suggest using concomitant antiseptic washes to decrease bacterial resistance. (Conditional, Very Low)
  • In pediatric patients with HS who require topical antibiotics, we suggest using these agents with an approach similar to other HS patient populations. (Conditional, Very Low)
  • In pediatric patients with HS who require antiseptic washes, we suggest using these agents with an approach similar to other HS patient populations. (Conditional, Very Low)
  • In pediatric patients with HS who require topical keratolytics, we suggest using topical retinoids in select cases. (Conditional, Very Low)
  • In pediatric patients with HS who require topical keratolytics, we suggest using topical resorcinol in select cases. (Conditional, Very Low)

Pediatrics Intralesional Steroids

  • In pediatric patients with HS, we suggest using intralesional steroids for acute, localized flares, taking into consideration the patient’s age and procedural tolerance. Appropriate pain management and distraction techniques should be used. (Conditional, Very Low)

Pediatrics Systemic Antibiotics

  • In pediatric patients with HS who require systemic antibiotics, we recommend using oral doxycycline for patients 8 years and older. (Strong, Moderate)
  • In pediatric patients with HS who require systemic antibiotics, we suggest using oral minocycline for patients 8 years and older with doxycycline intolerance. (Conditional, Very Low)
  • In pediatric patients with HS who require systemic antibiotics, we suggest using combination therapy with oral rifampin and clindamycin. (Conditional, Low)

Pediatrics Anti-Androgens

  • In adolescent female patients with HS who require anti-androgens, we suggest using spironolactone. (Conditional, Very Low)
  • In adolescent female patients with HS who require anti-androgens, we suggest using combined oral contraceptives. (Conditional, Very Low)
  • In pediatric patients with HS who require antiandrogens, we suggest using finasteride in select cases particularly in male patients. (Conditional, Very Low)
  • In pediatric patients with HS who require antiandrogens, we suggest using metformin especially in cases of insulin resistance. (Conditional, Moderate)

Pediatrics Systemic Immunomodulators & Biologics

  • In pediatric patients with HS who require systemic immunomodulators, we suggest using prednisone for acute, widespread flares. (Conditional, Very Low)
  • In pediatric patients with HS who require systemic immunomodulators, we suggest limiting the use of cyclosporine to select treatment-refractory cases. (Conditional, Very Low)
  • In pediatric patients with HS who require systemic immunomodulators, we suggest using oral isotretinoin only in patients with concomitant moderate-to-severe acne. (Conditional, Low)
  • In pediatric patients with HS who require biologics, we recommend using adalimumab for patients 12 years and older. (Strong, High)
  • In pediatric patients with HS who require biologics, we suggest using adalimumab for patients aged 2-11. (Conditional, Moderate)
  • In pediatric patients with HS who require biologics, we suggest using infliximab for patients 6 years and older. (Conditional, Moderate)
  • In pediatric patients with HS who require biologics, we suggest using secukinumab for patients 6 years and older. (Conditional, Moderate)
  • In pediatric patients with HS who require biologics, we suggest using ustekinumab for patients 6 years and older. (Conditional, Moderate)

Malignancy

Malignancy Intralesional Steroids

  • In patients with HS who have a history of malignancy, we suggest using intralesional steroids for acute, localized flares. (Conditional, Very Low)

Malignancy Systemic Antibiotics

  • In patients with a history of malignancy who require systemic antibiotics for HS, we recommend using oral doxycycline as there is evidence it is safe. (Strong, Moderate)
  • In patients with a history of malignancy who require systemic antibiotics for HS, we suggest using oral tetracycline as there is evidence it is safe. (Conditional, Moderate)
  • In patients with a history of malignancy who require systemic antibiotics for HS, we suggest using oral minocycline as there is evidence it is safe. (Conditional, Low)
  • In patients with a history of malignancy who require systemic antibiotics for HS, we suggest using oral moxifloxacin as there is evidence it is safe, with monitoring for QT prolongation from drug-drug interactions with certain chemotherapy agents. (Conditional, Moderate)
  • In patients with a history of malignancy who require systemic antibiotics for HS, we suggest using oral clindamycin as there is evidence it is safe, with monitoring for severe diarrhea and C. difficile colitis. (Conditional, Low)
  • In patients with a history of malignancy who require systemic antibiotics for HS, we suggest using oral dapsone as it is unlikely to be associated with increased risks in this patient population based on its mechanism of action. (Conditional, Very Low)
  • In patients with a history of malignancy who require systemic antibiotics for HS, we suggest using IV ertapenem for severe, recalcitrant cases as there is evidence it is safe. (Conditional, Moderate)

Malignancy Anti-Androgens

  • In patients with a history of malignancy who require anti-androgens for HS, we recommend using metformin due to evidence of safety and potential survival benefit in certain malignancies. (Strong, Moderate)
  • In patients with a history of malignancy who require anti-androgens for HS, we suggest using spironolactone as there is evidence it is safe. (Conditional, Low)
  • In patients with a history of malignancy who require anti-androgens for HS, we suggest using oral contraceptives as there is evidence they are safe. (Conditional, Low)
  • In patients with a history of malignancy who require anti-androgens for HS, we suggest using finasteride as there is evidence it is safe. (Conditional, Moderate)

Malignancy Systemic Immunomodulators & Biologics

  • When considering immunosuppressive medications or biologics for HS patients in the setting of malignancy, we recommend the physician consult with the patient’s oncologist and take into account activity of HS, patient’s age, characteristics of the previous cancer (organ, stage, histological type and prognosis), the time since completion of cancer treatment, and the individual carcinogenic effects of immunosuppressants. The physician should utilize a shared therapeutic decision-making approach to reach an informed decision, respecting the patient’s preference. (Strong, Very Low)
  • In patients with a history of malignancy who require systemic immunomodulators for HS, we suggest using prednisone for acute, widespread flares. (Conditional, Low)
  • In patients with a history of malignancy who require systemic immunomodulators for HS, we suggest that methotrexate can be used as an adjunct treatment to prevent anti-TNF antibody formation if indicated, as exposure does not increase risk of recurrent malignancy. (Conditional, Moderate)
  • In patients with a history of malignancy who require systemic immunomodulators for HS, we suggest using oral retinoids with an approach similar to other HS patient populations, as exposure does not increase risk of recurrent malignancy. (Conditional, Moderate)
  • In patients with a history of malignancy in remission for over 5 years who require biologics for HS, we suggest considering anti-TNFs especially in non-high risk malignancies. (Conditional, Moderate)
  • In patients with a history of malignancy in the last 5 years who require biologics for HS, we suggest considering secukinumab based on the currently available, albeit limited, evidence. (Conditional, Low)
  • In patients with a history of malignancy in the last 5 years who require biologics for HS, we suggest considering ustekinumab based on the currently available, albeit limited, evidence. (Conditional, Low)

Tuberculosis

Tuberculosis Systemic Antibiotics

  • In patients with HS who require treatment for latent TB, we recommend using a 4-month course of oral rifampin. (Strong, Moderate)

Tuberculosis Anti-Androgens

  • In patients that are high risk for active TB who require anti-androgens for HS, we recommend using metformin as it is associated with a reduced risk of TB infection. (Strong, Moderate)

Tuberculosis Systemic Immunomodulators & Biologics

  • In patients with HS who require glucocorticoids, we recommend annual screening for latent TB if the dose exceeds 15 mg prednisone equivalent daily for at least 4 weeks. (Strong, Low)
  • In patients with HS who require biologics, we recommend screening for TB prior to initiation. Screening can be performed with TST and/or IGRA, but in endemic regions with high percentages of BCG vaccination, IGRA may improve sensitivity and specificity. (Strong, Moderate)
  • In patients at high risk for active TB who require biologics for HS, we suggest considering non-anti-TNF biologic classes and being cautious when using anti-TNFs. (Conditional, Low)
  • In patients with latent TB not at high risk for active TB who require anti-TNFs for HS, we suggest starting prophylactic antibiotics at least 1 month before biologic initiation. (Conditional, Moderate)
  • In patients with latent TB at high risk for active TB and/or are from endemic areas who require anti-TNFs for HS, we suggest completing prophylactic antibiotics prior to biologic initiation. (Conditional, Low)
  • In patients with active TB who require biologics for HS, we suggest completing TB treatment with resolution of symptoms before biologic (re)initiation and considering non-anti-TNF biologic classes. (Conditional, Very Low)
  • In patients with latent TB who require biologics for HS, we suggest treating the latent TB concomitantly with anti-IL-17s or anti-IL-12/23s. (Conditional, Very Low)

Hepatitis B and Hepatitis C

Hepatitis B and Hepatitis C Systemic Antibiotics

  • In patients with chronic hepatitis B or C who require systemic antibiotics for HS, we suggest using oral ciprofloxacin especially if there is evidence of cirrhosis, as it appears to be safe, and may be associated with improved survival and reduced risk of spontaneous bacterial peritonitis. (Conditional, Low)
  • In patients with chronic hepatitis B or C who require systemic antibiotics for HS, we suggest using oral cotrimoxazole (trimethoprim /sulfamethoxazole) especially if there is evidence of cirrhosis, as it appears to be safe, and may be associated with reduced risk of spontaneous bacterial peritonitis. (Conditional, Low)
  • In patients with chronic hepatitis B or C who require systemic antibiotics for HS, we suggest using oral doxycycline with an approach similar to other HS patient populations. (Conditional, Very Low)
  • In patients with chronic hepatitis B or C who require systemic antibiotics for HS, we suggest caution when using oral rifampin due to the potential risk of hepatotoxicity. (Conditional, Very Low)

Hepatitis B and Hepatitis C Anti-Androgens

  • In patients with chronic hepatitis B or C without cirrhosis who require anti-androgens for HS, we suggest using these agents with an approach similar to other HS patient populations regardless of hepatitis B or C exposure status. (Strong, Very Low)
  • In patients with cirrhosis who require anti-androgens for HS, we suggest exercising caution when using metformin as there may be an increased risk of metabolic acidosis and ascites. (Conditional, Moderate)

Hepatitis B and Hepatitis C Systemic Immunomodulators & Biologics

  • In patients with HS who require immunosuppressants or biologics, we recommend screening for hepatitis B and C prior to treatment initiation. (Strong, Very Low)
  • In HBsAg-positive patients who require immunosuppressants or biologics for HS, we recommend coordinating care with a hepatologist. (Strong, Very Low)
  • In HBcAb-positive, HBsAg-negative patients who require immunosuppressants or biologics for HS, we recommend monitoring ALT, HBsAg and HBV DNA every 3-6 months and starting anti-HBV therapy if reactivation occurs. (Strong, Very Low)
  • In hepatitis C infected patients who require immunosuppressants or biologics for HS, we recommend referring to hepatology for consideration of treatment prior to initiating the immunosuppressant or biologic. (Strong, Very Low)
  • In HBsAg-positive patients who require high-dose prednisone (>20mg) for HS, we recommend anti-HBV prophylaxis prior to starting prednisone therapy. (Strong, Moderate)
  • In patients with a history of hepatitis B or C infection who require systemic immunomodulators for HS, we recommend avoiding methotrexate if there is evidence of hepatic impairment regardless of serological status. (Strong, Very Low)

HIV

HIV Systemic Antibiotics

  • In patients with HS and HIV positivity who require systemic antibiotics, we suggest using oral doxycycline due to its added prophylactic benefit against bacterial STIs in this patient population. (Conditional, Moderate)
  • In patients with HS and HIV positivity who require systemic antibiotics, we recommend exercising caution in using oral rifampin due to the potential for drug interactions with certain HIV therapies. (Strong, Moderate)
  • In patients with HS and HIV positivity who require systemic antibiotics, we suggest using oral dapsone ue to its added prophylactic benefit against neumocystis jirovecii pneumonia, a common opportunistic infection in individuals with HIV. (Conditional, Moderate)
  • In patients with HS and HIV positivity who require systemic antibiotics, we suggest using oral cotrimoxazole (trimethoprim /sulfamethoxazole) due to its added benefit of lowering mortality and infection rates in this patient population. (Conditional, Moderate)

HIV Anti-Androgens

  • In patients with HS and HIV positivity who require anti-androgens, we suggest considering non-metformin anti-androgens with an approach similar to other HS patient populations. (Conditional, Very Low)
  • In patients with HS and HIV positivity who require anti-androgens, we suggest using metformin especially in patients that are overweight and/or have metabolic syndrome. (Conditional, Moderate)

HIV Systemic Immunomodulators & Biologics

  • In patients with HS who require immunosuppressives or biologics, we recommend screening for HIV prior to treatment initiation. (Strong, Very Low)
  • In patients with HS and HIV positivity who require systemic immunomodulators or biologics, we recommend coordinating care with an ID specialist and taking into account factors such as HIV control (viral load, CD4 count) and potential for drug interactions. (Strong, Very Low)
  • In patients with HS and HIV positivity who require systemic immunomodulators, we suggest that prednisone can be used cautiously for acute, widespread flares. (Conditional, Moderate)
  • In patients with HS and HIV positivity who require biologics, we suggest that adalimumab can be used cautiously based on currently available, albeit limited evidence. (Conditional, Low)
  • In patients with HS and HIV positivity who require biologics, we suggest that infliximab can be used cautiously based on currently available, albeit limited evidence. (Conditional, Low)
  • In patients with HS and HIV positivity who require biologics, we suggest that anti-IL-17s can be used if the HIV infection is well controlled. (Conditional, Very Low)
  • In patients with HS and HIV positivity who require biologics, we suggest that ustekinumab can be used if the HIV infection is well controlled. (Conditional, Very Low)

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Medical Management of Hidradenitis Suppurativa in Special Patient Populations

Authoring Organization

Consensus and Physician Experts

Publication Month/Year

December 24, 2024

Last Updated Month/Year

January 14, 2025

Document Type

Consensus

Country of Publication

US

Document Objectives

Hidradenitis suppurativa (HS) affects different patient populations that require unique considerations in their management. However, no HS guidelines for these populations exist. The objective of this guideline is to provide evidence-based consensus recommendations for patients with HS in seven special patient populations: i) pregnancy, ii) breastfeeding, iii) pediatrics, iv) malignancy, v) tuberculosis infection, vi) hepatitis B or C infection, and vii) HIV disease.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D017497 - Hidradenitis Suppurativa

Keywords

Hidradenitis suppurativa

Source Citation

Alhusayen R, Dienes S, Lam M, Alavi A, Alikhan A, Aleshin M, Bahashwan E, Daveluy S, Goldfarb N, Garg A, Gulliver W, Jaleel T, Kimball AB, Kirchhof MG, Kirby J, Lenczowski J, Lev-Tov H, Lowes MA, Lara-Corrales I, Micheletti R, Okun M, Orenstein L, Poelman S, Piguet V, Porter M, Resnik B, Sibbald C, Shi V, Sayed C, Wong SM, Zaenglein A, Veillette H, Hsiao JL, Naik HB, North American Clinical Practice Guidelines for the Medical Management of Hidradenitis Suppurativa in Special Patient Populations, Journal of the American Academy of Dermatology (2025), doi: https://doi.org/10.1016/j.jaad.2024.11.071.