Hidradenitis Suppurativa Guidelines

Updated: Oct 19, 2018
  • Author: Marina Jovanovic, MD, PhD; Chief Editor: William D James, MD  more...
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Guideline Summary

In the published guidelines for hidradenitis suppurativa developed by the Guidelines Subcommittee of the European Dermatology Forum, [1] it is recommended that hidradenitis suppurativa be treated based on the subjective impact and objective severity of the disease, as follows:

  • Locally recurring lesions can be treated surgically
  • Medical treatment either as monotherapy or in combination with surgery is more appropriate for widely spread lesions
  • Medical therapy may include antibiotics and immunosuppressants

A Hurley severity grade‒relevant treatment of hidradenitis suppurativa is recommended by the expert group with the following treatment algorithm:

  • Limited surgery such as deroofing and laser ablation techniques are especially suited for recurrent hidradenitis suppurativa lesions at fixed locations in Hurley 1/mild Hurley II stage
  • Wide surgical excision is appropriate for moderate Hurley II/Hurley III stage
  • Topical clindamycin is recommended for localized Hurley I stage

Systemic treatment (clindamycin + rifampin/tetracycline or acitretin) with adjuvant therapy (pain management treatment of superinfections is proposed for Hurley II stage)

  • Systemic biologics (adalimumab/infliximab) are reserved for treatment-resistant, moderate-to-severe hidradenitis suppurativa (moderate Hurley II/Hurley III stage)
  • General measures are offered for all patients and include weight loss and tobacco abstinence [1]

Based on expert opinion it is recommended that adjuvant therapy is offered to all patients in the form of general measures such as weight reduction, cessation of cigarette smoking, and specific help with bandaging lesions in order to improve the patients’ quality of life. Hidradenitis suppurativa‒specific bandages are not currently available. [1] Choice of dressing is based on clinical experience. [54] In addition, adhesive tape should be avoided to minimize trauma to inflamed skin, which can be overcome by using tubular net bandages or superabsorbent pads or materials in the seams of clothing. [2]

Regarding local wound care, superabsorbent dressings are best to treat actively draining lesions or postoperative wounds, but there are no trials or studies to support this recommendation. [1] In order to prevent the primary dressing from sticking to the wound, white petrolatum, zinc oxide paste, or film-forming liquid acrylate should be extensively and generously applied on the marginal skin as the best ways to keep the wound dressings in place. [2]



In 2016, an algorithm with respect to all aspects of hidradenitis suppurativa therapy included in the aforementioned guidelines was developed by using Grading of Recommendations Assessment and Evaluation (GRADE) methodology based on the Category of Evidence and Strength of Recommendation. [1, 54]

The need for surgical intervention should be assessed in all patients depending on the type and extent of scarring. [54]

The proposed dosing regimen as a first-line treatment option in patients with mild hidradenitis suppurativa PGA or localized Hurley I/mild Hurley II stage, especially when there are no deep inflammatory lesions (abscesses), is topical clindamycin 1% solution/gel twice daily for 12 weeks and/or tetracycline 500 mg orally twice daily for 4 months.

If patient fails to exhibit a response to treatment or for a PGA of moderate-to-severe disease with moderate and severe hidradenitis suppurativa PGA or Hurley II stage, considered clindamycin 300 mg orally twice daily with rifampin 600 orally twice daily for 10 weeks.

If the patient is not improved, then adalimumab is recommended as a first-line treatment option in patients with moderate-to-severe hidradenitis suppurativa who were unresponsive to or intolerant of oral antibiotics. Dosing is adalimumab 160 mg at week 0, 80 mg at week 2, and then 40 mg subcutaneously weekly.

If improvement occurs, then therapy should be maintained as long as hidradenitis suppurativa lesions are present. If the patient fails to exhibit response, then consideration of second- or third-line therapy is required.

The second-line therapies include the following:

  • Zinc gluconate
  • Resorcinol
  • Intralesional corticosteroids
  • Infliximab at 5 mg/kg at week 0, 2, and 6, and then every 2 months thereafter for 12 weeks; recommended only after failure of adalimumab, in patients with moderate-to-severe hidradenitis suppurativa
  • Acitretin
  • Etretinate

If clinical response is not achieved after 12 weeks of treatment, other treatment modalities must be considered.

Third line therapies evaluated include the following:

  • Colchicine
  • Botulinum toxin
  • Isotretinoin
  • Dapsone
  • Cyclosporine
  • Hormones

Benefit-to-Risk Ratio

A relevant benefit-to-risk ratio analysis can be performed only for the phase 2 trial of adalimumab, since that is the only randomized controlled trial with an appropriate safety analysis that provides the basis to recommend adalimumab as the first-line treatment option in patients with moderate-to-severe hidradenitis suppurativa who were unresponsive to or intolerant of oral antibiotics. [54, 100]

There is very limited or absent randomized controlled trial data in hidradenitis suppurativa for antibiotic therapy, retinoids, oral immunomodulators, and, in particular, there are no randomized controlled trial data investigating the timing of surgery or type of surgical procedure. Interventions currently under investigation include topical antiseptics, the Nd:YAG and carbon dioxide lasers, anakinra (a newer biological treatment that inhibits IL-1, and the PIONEER I and II studies of adalimumab therapy. [100]