Introduction
Long considered an orphan disease until recent years, hidradenitis suppurativa (HS) is rapidly gaining attention in the healthcare field with a growing spotlight on investigating HS pathogenesis, epidemiology, and treatment options. To better navigate the expanding therapeutic options available, a number of HS management guidelines have been published by international expert organizations from North America, South America, and Europe between 2015 and July 2020 ( Fig. 14.1 ). These groups include the British Association of Dermatologists, U.S. and Canadian HS Foundations, HS ALLIANCE, Canadian Dermatology Association, European HS Foundation, European Academy of Dermatology and Venereology, Swiss Consensus Group, and Brazilian Society of Dermatology. These guidelines encompass therapeutic modalities ranging from lifestyle modifications and topical therapies to systemic medications and procedural interventions. While significant overlap exists between the therapeutic ladders proposed by each set of guidelines, there are also abundant variations in recommendations across organizations. International recommendations and practice guidelines have been collated and compared in recent summaries, allowing for review and discussion of practices with the best evidence and efficacy in HS treatment.
The management of HS often requires a comprehensive approach comprised of lifestyle modifications, mental healthcare, and depending on disease severity, topical antimicrobials, systemic antibiotics, hormonal and immune modulators, light-based therapies, and procedural interventions. In this chapter, which is modified from our recent publication, we compare the similarities and differences among the nine published guidelines and highlight knowledge and practice gaps that remain to be addressed. Specific management modalities are discussed in detail in Section 3: Clinician’s Corner, Chapters 13 to 28.
General Guideline Comparison
International guidelines emphasize a multidisciplinary approach to HS management, including primary care providers, dermatologists, surgeons, pain management, and mental health specialists. All nine guidelines propose lifestyle modifications (such as weight loss and smoking cessation) and topical antimicrobials as first-line medical therapy, followed by systemic antibiotics, then systemic immunomodulators (such as adalimumab) for severe widespread disease. All guidelines include procedural modalities, such as intralesional corticosteroids recommended for isolated inflammatory lesions and light-based procedures (including laser hair reduction) as second- or third-line therapeutic considerations. Guideline recommendations vary in the order of use for systemic retinoids and hormonal agents. The North American guideline presents a broader discussion on classification criteria, biomarker and genetic testing, comorbidities screening, and procedural interventions than European and Brazilian groups. Additionally, while other guidelines utilize a therapeutic ladder approach, the North American and HS ALLIANCE guidelines display treatment modalities according to level of evidence. The North American guidelines also incorporate a more in-depth discussion of complementary and alternative medicine treatment modalities.
Detailed Comparison by HS Treatment Modality
Non-Pharmacological Approaches
Several lifestyle modifications are recommended as components of a comprehensive HS treatment plan. Universally supported lifestyle approaches include smoking cessation and weight reduction. While existing data is inconsistent in characterizing the relationship between tobacco use and HS severity, the prevalence of HS is higher among individuals who smoke compared to those who do not, and tobacco cessation should be encouraged for general health benefits. Similarly, there is limited evidence to support an association between higher body mass index and more severe HS, but proposed contributing factors include proinflammatory cytokines from adipose tissue and increased friction and inflammation in intertriginous areas. Tobacco cessation and weight loss counseling should be incorporated in routine HS management where relevant. Additionally, mental health is recognized in all guidelines as a critical factor in treatment of HS due to the psychological impact of chronic pain, skin disfigurement, and variable efficacy of treatment. All expert guidelines support screening for depression and anxiety in routine clinical visits with referral to psychiatric care as appropriate, further emphasizing the importance of a multidisciplinary healthcare team in managing HS.
Pain Management
The pain burden of HS remains a challenging aspect of disease management. Most guidelines recommend assessing pain severity using validated patient-reported outcome tools such as a pain visual analogue scale or numeric rating scale. Guidance regarding selection of analgesic agents is limited, but those guidelines that do address specific agents recommend topical analgesics and nonsteroidal antiinflammatories as first-line treatment, with opioids reserved only for severe pain refractory to first-line agents and to be used under the supervision of pain management specialists.
Topical Analgesics
The North American and Canadian consensus guidelines cite topical lidocaine as a first-line option for HS pain management, with diclofenac gel suggested as an alternative in the Canadian consensus guidelines.
Non-Steroidal Antiinflammatory Drugs (NSAIDs)
North American, Canadian consensus, and European S1 guidelines discuss nonsteroidal antiinflammatory drug (NSAIDs) as first-line systemic pain management in HS. NSAID use should be reviewed regularly during clinical visits with special dosing consideration or use of alternate agents in patients with impaired hepatic or renal function.
Neuropathic Pain Agents
Gabapentin and pregabalin are mentioned in the North American and Canadian consensus guidelines as therapeutic options for neuropathic pain associated with HS.
Tramadol
The opioid-like analgesic tramadol is cited in the North American guidelines as an agent for HS-associated pain that does not respond to topical analgesics or NSAIDs, although specific dosing is not discussed.
Opioids
Opioid use in selected patients (those with severe pain unresponsive to first-line agents) is discussed in the North American, Canadian consensus, and European S1 guidelines. These three guidelines underscore the importance of judicious opioid prescribing and recommend involvement of pain specialists in managing HS patients who are candidates for opioid use. However, the Canadian consensus and European S1 guidelines highlight the lack of evidence for opioid use in treating HS.
Topical Modalities
The nine guidelines recommend topical therapies for use in mild HS, localized disease, or as an adjunct to systemic therapies. Recommendations for these modalities are summarized in Table 14.1 .
| Modality | Recommendations per guideline | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| British Association of Dermatologists | North American (US and Canadian HS Foundations) | HS ALLIANCE | Canadian Dermatology Association | Canadian Consensus Group | European HS Foundation | European S1 | Swiss Consensus Group | Brazilian Society of Dermatology | |
| Topical Therapies (Further discussed in Chapter 15 ) | |||||||||
| Resorcinol 15% cream | — | Recommended (may induce contact dermatitis) | — | 2nd line | Resolve/prevent follicular blockage in mild HS | 2nd line | For recurrent lesions in Hurley stage I/II HS a BID application during flares | — | Can be useful to shorten mean duration of painful nodule or abscess |
| Antiseptics | — | Chlorhexidine, benzoyl peroxide zinc pyrithione supported by expert opinion | — | — | — | — | — | Triclosan, ammonium bituminosulfate for all Hurley stages a | Advise on adequate local hygiene; no need for soaps with high concentrations of chlorhexidine |
| Clindamycin 1% solution | Consider in patients with HS | May reduce pustules; carries risk of bacterial resistance | Recommended BID × ≤ 3 months in Hurley I/II a with localized lesions, especially without deep inflammatory lesions | 1st line tx for mild HS; 1% lotion applied BID × 12 weeks | Use as topical antiinflammatory agent and to prevent secondary infection b | Recommended BID × 3 months as 1st line tx in Hurley stage I/mild stage II, a especially without deep inflammatory lesions b | BID × 3 months in localized Hurley stage I or mild stage II a ; can be prolonged if clinically indicated b | Recommended in Hurley I/II a HS to avoid bacterial superinfection and reduce inflammation | Recommended for Hurley stage I a or in cases of superficial lesions during exacerbation |
Hurley stage I—single or multiple abscesses without scarring
Hurley stage II—limited scarring and/or sinus tracts
Hurley stage III—extensive scarring and/or sinus tracts
b Recommendation based on randomized controlled trial(s) in HS
Topical Keratolytics
Keratolytics aim to reduce follicular plugging thought to exacerbate the cycle of follicular occlusion and inflammation in HS. Resorcinol 15% cream is a keratolytic with antiseptic properties mentioned in six of the nine guidelines, and recommended as second-line therapy in the European HS Foundation and Canadian Dermatology Association guidelines. While more readily available in Europe, resorcinol cream requires compounding by a specialty pharmacy in the United States.
Topical Antiseptics
Topical antiseptics are used to inhibit bacterial colonization and resulting cutaneous inflammation. Recommendations for various antiseptic agents are included in the North American, Swiss, and Brazilian guidelines, although the North American guideline cites a lack of evidence to support specific formulations. Recommended topical antiseptics include chlorhexidine, benzoyl peroxide, zinc pyrithione, triclosan, and ammonium bituminosulfonate (ichthammol). Availability of these agents varies by region, as triclosan was removed from the U.S. market in 2018 due to lack of efficacy and safety data. Ichthammol is available over the counter as a cream or ointment formulation in the United States but is more frequently recommended and used for dermatologic purposes in Europe.
Topical Antibiotics
Clindamycin is a topical antibiotic available as a 1% lotion or solution that decreases cutaneous inflammation and inhibits biofilm formation. There is consensus across all guidelines in recommending topical clindamycin as a first-line therapy in mild HS with predominantly superficial pustules and no deep abscesses. Recommended application as proposed by the European S1, European HS Foundation, and HS ALLIANCE guidelines is twice daily for up to 3 months, with caution against long-term use due to risk of bacterial resistance.
Systemic Therapies
Guideline recommendations regarding systemic therapeutic agents in HS are summarized in Table 14.2 .
| Modality | Recommendations Per Guideline | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| British Association of Dermatologists | North American (US and Canadian HS Foundations) | HS Alliance | Canadian Dermatology Association | Canadian Consensus Group | European HS Foundation | European S1 | Swiss Consensus Group | Brazilian Society of Dermatology | |
| Systemic Antibiotics (Further discussed in Chapter 16 ) | |||||||||
| Tetracyclines | Doxycycline or lymecycline for ≥ 12 weeks. Consider tx breaks to assess efficacy and decrease risk of antimicrobial resistance | In mild to moderate HS × 12 weeks or as long-term maintenance a | Recommended in Hurley I/II b × ≤ 12 weeks a | 500 mg BID × 4 months for mild HS (1st line) a | 500 mg BID a | 500 mg BID as 1st line tx in moderate HS or widespread Hurley I/II b for up to 4 months a | 500 mg BID × 4 months; can be prolonged if clinically indicated a | Doxycycline 50–200 mg daily × 3–6 months in Hurley I/II b HS | 500 mg BID × 10–12 weeks, 1–2 courses |
| Clindamycin + rifampicin | Clindamycin 300 mg BID and rifampicin 300 mg BID × 10–12 weeks for patients unresponsive to oral tetracyclines a | 2nd line for mild-moderate HS, 1st line or adjunct for severe HS a | Clindamycin and rifampicin 300 mg each BID × 10 weeks a | Clindamycin 300 mg BID + rifampicin 600 mg daily × 10 weeks in moderate HS or mild-moderate HS unresponsive to tetracyclines (1st line) a | Clindamycin 300 mg BID + rifampicin 600 mg once daily or 300 mg BID × 10 weeks a | Clindamycin 300 mg BID + rifampicin 600 mg once daily or 300 mg BID × 10 weeks as 1st line tx for moderate PGA a | Clindamycin 300 mg BID + rifampicin 600 mg once daily or 300 mg BID × 10 weeks a | Clindamycin and rifampicin each 300 mg BID × 3 months | Clindamycin 300 mg BID + rifampicin 600 mg daily × 10 weeks |
| Rifampin/ Moxifloxacin/Metronidazole/ | — | 2nd /3rd line in moderate to severe HS | Rifampicin 10 mg/kg once daily + moxifloxacin 400 mg once daily + metronidazole 500 mg TID (× 6 weeks only) may have efficacy in Hurley I/II a patients | — | — | — | Effective in tx-resistant Hurley stage II/III b HS at 12 weeks | — | — |
| Dapsone | Consider in HS unresponsive to antibiotic therapies | May be effective for minority of Hurley I/II a patients as long-term maintenance | Evidence from single study | 3rd line | Efficacy in HS reported in case reports | 3rd line | Reserve for patients with mild to moderate HS when standard 1st and 2nd line agents fail | 50–150 mg daily in refractory Hurley II/III b disease | May be considered after failure of 1st or 2nd line antibiotics |
| Ertapenem | — | For severe disease as one-time rescue, bridge to surgery or maintenance tx | IV ertapenem 1 g/d In selected patients with severe HS × 6 weeks | — | — | — | — | — | — |
| Supplements (Further discussed in Chapter 28 ) | |||||||||
| Zinc | Insufficient evidence | — | Combination tx of oral zinc gluconate 30 mg TID + topical triclosan 2% in Hurley I/II b | Zinc gluconate as 2nd line tx | Zinc sulfate recommended as adjuvant therapy | Zinc gluconate as 2nd line tx | Zinc gluconate initiated at 90 mg/day as maintenance tx in Hurley I/II b | Zinc gluconate 30 mg TID as adjunct to antibiotics in Hurley I/II b HS | 30 mg TID as maintenance tx in Hurley stage I/II b HS Long-term use limited by zinc-induced impairment of iron and copper absorption |
| Retinoids (Further discussed in Chapter 17 ) | |||||||||
| Acitretin | 0.3–0.5 mg/kg daily in men and non-fertile women unresponsive to antibiotics | Consider as 2nd /3rd line tx; contraindicated in women of reproductive potential | 3rd line tx for mild-moderate HS | 2nd line | 0.25–0.88 mg/kg daily can be initiated in early HS stages, may be used in chronic stages with sinus tracts and scarring | 2nd line | Can be initiated in early HS stages, may be used in chronic stages with sinus tracts and scarring Dosing ranges from 0.25–0.88 mg/kg daily × 3–12 months | 0.2–0.5 mg/kg daily in Hurley II/III b HS refractory to antibiotics | Preferred over isotretinoin due to higher response rates, but not appropriate in women of childbearing age |
| Isotretinoin | Do not offer unless concomitant moderate to severe acneiform lesions of face or trunk | Consider only as 2nd/3rd line tx or in patients with severe concomitant acne | — | 3rd line | Not proven effective in HS even with concomitant acne | 3rd line | Not recommended for use in tx of HS | — | Use of isotretinoin over acitretin justified in women of childbearing age |
| Biologics (Further discussed in Chapter 18 ) | |||||||||
| Adalimumab (anti-TNF-α) | 40 mg SC weekly for patients ≥ 12 yo with moderate-severe HS unresponsive to conventional systemic tx a | Recommended at 40 mg SC weekly to improve HS severity and QoL in moderate-severe HS a | First choice biologic in moderate to severe HS after failure of conventional tx a | 160 mg SC week 0, 80 mg week 2, then 40 mg weekly for moderate to severe HS unresponsive to antibiotics (1st line) a | 40 mg SC weekly for patients with moderate to severe HS a | 160 mg SC week 0, 80 mg week 2, then 40 mg weekly as 1st line tx for moderate-severe HS a Consider other tx modalities if HiSCR not achieved by 16 weeks | 40 mg SC weekly for moderate-severe HS a | 160 mg SC week 0, 80 mg week 2, then 40 mg weekly for Hurley II/III b HS refractory to antibiotics | 160 mg SC week 0, 80 mg week 2, then 40 mg weekly a Once inflammation is controlled, consider excision of residual active areas or scarring |
| Infliximab (anti-TNF-α) | Consider at 5 mg/kg q8 weeks in moderate-severe HS unresponsive to adalimumab | Recommended for moderate to severe HS. Dose ranging studies needed to determine optimal dosage | Consider as 2nd line biologic for moderate to severe HS | 2nd line a | No significant difference vs. placebo in HiSCR a | 5 mg/kg IV at weeks 0, 2, 6 and q2 months thereafter x 12 weeks as 2nd line in moderate to severe HS unresponsive to adalimumab | 5 mg/kg IV at weeks 0, 2, 6, then q2 months a | — | 5 mg/kg IV at weeks 0, 2, 6, then q2 months a |
| Anakinra (anti-IL-1) | Insufficient evidence | 100 mg daily may be effective; dose ranging studies needed to determine optimal dosage | Consider as 3rd line biologic for moderate to severe HS | — | Significant improvement in disease severity score and HiSCR a | — | — | — | Not available in Brazil |
| Canakinumab (anti-IL-1β) | — | — | — | — | — | — | — | — | Used successfully in sparse care reports |
| Ustekinumab (anti-IL-12/23) | Insufficient evidence | 45–90 mg q12 weeks may be effective; dose ranging studies needed to determine optimal dosage | Potentially effective tx for moderate-severe HS | — | — | — | Three 45 mg SC injections at 0, 4, and 16 weeks with cumulative 33% response rate in 3-patient case series | — | 45–90 mg SC q12 weeks; higher dose may be needed for HS tx |
| Secukinumab (anti-IL-17A) | — | — | — | — | — | — | — | — | Success in a case of severe tx-refractory HS |
| Etanercept (anti-TNF-α) | Do not offer a | Limited evidence does not support use in HS management a | Not effective a | — | No significant difference vs. placebo a | — | No significant difference vs. placebo a | — | Variable data on efficacy in HS; unable to draw conclusions about its potential utility |
| Immunosuppressive agents (Further discussed in Chapter 17 ) | |||||||||
| Systemic corticosteroids | — | Short-term steroid pulse can be considered for acute flares or bridge to other tx Long-term: taper to lowest possible dose in severe HS | Low-dose prednisolone 10 mg/day (or equivalent) may be effective adjunct tx in recalcitrant HS Use with caution long-term | 2nd line | — | 2nd line | Recommend dose of 0.5–0.7 mg/kg oral prednisolone for short-term use in acute flares, taper over following weeks | Prednisolone 0.5–0.7 mg/kg daily in refractory disease | Short course may be indicated for tx of flares |
| Cyclosporine | Efficacy in HS reported in case reports | 3rd line | Reserved for cases unresponsive to standard 1st, 2nd, or 3rd line tx Reported dosing in HS varies from 2–6 mg/kg for 6 weeks to 7 months | 2–6 mg/kg daily in refractory disease | Data not robust; consider only as 3rd line option for long-term control of inflammation | ||||
| Hormonal agents (Further discussed in Chapter 17 ) | |||||||||
| Metformin | Consider in HS patients with concomitant DM, PCOS, or pregnancy | Consider metformin 500 mg BID-TID in appropriate female patients as monotherapy for mild-moderate or as adjunctive tx in severe HS | — | — | May be beneficial in patients with HS and PCOS | — | — | 500–1500 mg daily in refractory disease | May consider in women of childbearing age who have failed systemic antibiotics |
| Cyproterone acetate + ethinyl estradiol | Insufficient evidence | Consider in appropriate female patients as monotherapy for mild to moderate or as adjunctive tx in severe HS a | — | — | ~ 1/2 of patients exhibited clearance No significant difference in PaGA between cyproterone acetate + ethinyl estradiol vs. ethinyl estradiol + norgestrel at 6 months a | 3rd line | 100 mg cyproterone acetate daily for female patients with menstrual abnormalities, signs of hyperandrogen-ism, or high levels of DHEA, androstenedione, or SHBP | — | May consider in women of childbearing age who have failed systemic antibiotics |
| Finasteride | Insufficient evidence | Consider 1.25–5 mg/d in appropriate female patients as monotherapy for mild to moderate or as adjunctive tx in severe HS | — | — | — | — | — | — | 1–5 mg/d in children < 12 yo with HS refractory to topical/oral antibiotics |
| Spironolactone | Insufficient evidence | Consider spironolactone 100–150 mg daily as monotherapy in women with mild-moderate HS or as adjunctive tx in severe HS | — | — | — | — | — | — | Consider in female HS patients who have failed systemic antibiotics |
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