
Managing Hidradenitis Suppurativa (HS) involves a multi-disciplinary approach tailored to disease severity (commonly classified using Hurley staging), patient-specific factors, and comorbidities. The protocol below outlines evidence-based strategies for optimal HS management.
1. Disease Assessment and Classification
- Hurley Stage Classification:
- Stage I: Single or multiple abscesses without sinus tracts or scarring.
- Stage II: Recurrent abscesses with sinus tract formation and scarring.
- Stage III: Widespread disease with interconnected sinus tracts and extensive scarring.
- Conduct thorough history and physical examination to identify:
- Disease triggers (e.g., friction, heat, hormonal factors).
- Comorbidities (e.g., metabolic syndrome, Crohn’s disease, depression).
- Impact on quality of life.
2. Treatment Protocol by Severity
Stage I (Mild Disease)
- Topical Therapies:
- Clindamycin 1% solution or gel, applied twice daily, reduces inflammation and bacterial colonization.
- Adjunctive Measures:
- Use antiseptic washes (e.g., chlorhexidine or benzoyl peroxide) to minimize bacterial load.
- Encourage weight loss, smoking cessation, and wearing loose-fitting clothing.
Stage II (Moderate Disease)
- Systemic Antibiotics:
- Tetracyclines (doxycycline or minocycline, 100 mg daily) for anti-inflammatory effects.
- Combination Therapy (Clindamycin 300 mg + Rifampin 300 mg, both twice daily) for refractory cases or moderate infections.
- Hormonal Therapy:
- Spironolactone (50–100 mg daily) or combined oral contraceptives for hormonal-related HS, particularly in women.
- Lifestyle Modifications:
- Reinforce smoking cessation and weight loss for better disease control.
- Provide guidance on skincare to reduce irritation.
Stage III (Severe Disease)
- Biologic Therapy:
- Adalimumab (Humira): FDA-approved for HS. Administer 160 mg subcutaneously on Day 1, 80 mg on Day 15, then 40 mg weekly starting Day 29.
- Alternatives: Infliximab or emerging biologics targeting IL-17 (e.g., Secukinumab) or IL-1 (e.g., Anakinra).
- Surgical Interventions:
- Wide excision of affected areas for persistent sinus tracts and scarring.
- CO2 laser ablation of affected skin and sinus tracts.
- Adjunctive Pain Management:
- NSAIDs for mild pain; opioids may be considered for severe pain with caution.
3. Supportive Measures
- Dietary Modifications:
- Anti-inflammatory diets (e.g., Mediterranean diet) may help.
- Reduce dairy and high glycemic-index foods, which may exacerbate inflammation.
- Psychosocial Support:
- Address the emotional and psychological impact with counseling or support groups.
- Screen for depression and anxiety, providing appropriate referrals as needed.
- Comorbidity Management:
- Treat associated conditions like obesity, diabetes, and metabolic syndrome.
- Monitor for inflammatory bowel disease in severe cases.
4. Maintenance and Monitoring
- Regular follow-ups to monitor treatment efficacy and side effects.
- Adjust treatment based on response and disease progression.
- Patient education on early recognition of flares and adherence to therapy.
5. Emerging and Future Therapies
- IL-17 and IL-23 Inhibitors: New biologics targeting specific inflammatory pathways offer promise.
- Janus Kinase (JAK) Inhibitors: Small molecules targeting intracellular signaling.
- Gene therapy approaches are under investigation for long-term control.
6. Holistic Approach
Given the chronic and relapsing nature of HS, focus on patient-centered care:
- Empower patients with education on their condition.
- Involve dermatologists, surgeons, dietitians, and mental health professionals as needed.
This protocol aims to reduce disease severity, manage symptoms, prevent complications, and improve the quality of life for patients with HS.