management

Last reviewed 11/2022

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Management principles are outlined (1):

  • management of acute flare ups (1):
    • a very short course of systemic corticosteroids or intralesional steroids may be beneficial
      • lesions are often sterile so consider an intra-lesional steroid injection or a short course of oral prednisolone 30-40 mg OD for 3-4 days (4)
    • antibiotic treatment
      • short courses of antibiotics are usually ineffective in long standing hidradenitis suppuritiva
      • however for patients with abscesses, but no cicatrization or sinuses (Hurley stage I), antibiotics are a good first-line therapy (2)
          • if the flare is very explosive consider infection, avoid steroid therapy and treat with high dose flucloxacillin (or erythromycin if allergic to penicillin) (4)

  • long term management:
    • treatment options include long-term antibiotics (e.g. systemic tetracyclines or macrolides in doses similar to those used in acne), dianette and acitretin (1,2). Isotretinoin may benefit some patients (2)
      • systemic antibiotics (4)
        • prolonged courses (several months to years) are used to reduce bacterial colonisation and inflammation
          • one of the most useful antibiotics is lymecycline 408 mg, which has a strong anti-inflammatory affect in the skin. While the standard dose of lymecycline is one capsule a day on an empty stomach, some patients, especially if obese and / or have moderate-severe symptoms need to take one capsule twice a day - while such a dose is above that recommended, and should be discussed with the patient, it appears to be safe (4)
          • some patients may require long-term tetracycline treatment
        • other antibiotics used include doxycycline, erythromycin / clarithromycin and metronidazole
        • patients failing to respond adequately to a three month course of lymeycyline, or a suitable alternative, should be considered for the combination treatment of clindamycin 300 mg BD and rifampicin 300 mg BD for three months, which appears to be the most effective antibiotic regime
        • rifampicin can very occasionally affect the liver and so it is recommended that patients should have their LFTs checked prior to treatment and within the first few weeks of starting treatment. Some patients require repeat / more prolonged courses of this treatment
      • if the disease is severe, immunosuppressive therapy may be used but with caution as their benefit has to be weighed against their possible side effects. Such medications include oral corticosteroids, ciclosporin, mycophenolate mofetil and the biologics, eg infliximab (4)
        • NICE have stated that (5):
          • adalimumab is a treatment option for for treating active moderate to severe hidradenitis suppurativa in adults whose disease has not responded to conventional systemic therapy
            • adalimumab is an antibody that inhibits tumour necrosis factor
              • is given by subcutaneous injection
      • botulinum toxin has been shown to be effective for isolated disease
      • spironolactone 100-200 mg per day may benefit some patients (4)

    • surgical treatment is an alternative if there is failure of medical therapy - the appropriate technique is via wide excision with secondary intention healing or split-skin grafting

Reference:

Related pages:

Hurley staging system for hidradenitis suppurativa