Treatment of hidradenitis suppurativa

Hidradenitis suppurativa is commonly misdiagnosed and can greatly impact quality of life. Refer early to a dermatologist for confirmation of diagnosis, counselling, and long-term management. Treatment can be initiated while waiting for dermatologist assessment.

For mild cases of hidradenitis suppurativa, a topical antiseptic or topical antibiotic may be sufficient therapy. Advise the patient to use a topical antiseptic when bathing (eg benzoyl peroxide 5% wash, antibacterial soap).

If hidradenitis suppurativa is persistent, or in recurrent mild cases, add topical clindamycin. Use:

Prolonged topical antibiotic use is associated with increased antibiotic resistance in skin flora. If there is no response to topical clindamycin therapy, seek dermatologist advice and consider oral therapy.

Oral therapy may include a long-term oral antibiotic for its anti-inflammatory effect (most commonly an oral tetracycline). Adjunct treatments (eg combined oral contraceptive pill, spironolactone, metformin) can be considered, and are sometimes used instead of or in addition to oral antibiotic therapy.

If using an oral antibiotic for hidradenitis suppurativa while waiting dermatologist assessment, consider:

If tetracyclines are not tolerated or are contraindicated (eg in pregnancy), use:

Start treatment with the lower dose of oral antibiotic in smaller patients or to assess tolerability.

Specialist treatments may include intralesional corticosteroids, long-term combinations of oral antibiotics, oral retinoids (eg isotretinoin, acitretin) or biological therapy (eg adalimumab). A combination of treatments is often required.