Management

Seek expert advice. The goal of care should be that patients receive adequate
drug therapy shortly after the first symptoms appear, especially as effectiveness of treatment remains the priority for patients with hidradenitis suppurativa.

Management principles (1):

• management of acute flare ups (1):
  • a very short course of intralesional steroids may be beneficial
    • lesions are often sterile so consider an intra-lesional steroid injection. Triamcinolone acetonide at 10–40 mg per mL concentrations injected into inflammatory lesions reduces pain, redness, and suppuration within 48 hours and can be repeated
      at 2-week intervals.
  • 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. Options used include lymecycline 408 mg od, tetracycline 500 mg bd, doxycycline 100 mg od, or erythromycin 500 mg bd. Where these are not effective after three months, clindamycin 300 mg bd in combination with rifampicin 600 mg od or 300 mg bd may be used. (1)
    • for infective flares with tense and fluctuant abscess formation consider referring for incision and drainage to relieve pain (2)
    • in systemic upset/sepsis, intravenous antibiotics may be required (1)
      
      

Long term management:

• all patients should be prescribed topical antiseptics

• First line therapy for mild hidradenitis suppuritiva:
  • mild disease (1):
    • consider topical clindamycin BD, or oral doxycycline 200 mg OD (or lymecycline 408 mg caps, two caps once a day) both initially for 3 months
      • 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
    • aim for reduction in flares and improved disease control
    • if topical therapy is used and does not control symptoms then swap to doxycycline / lymecycline (do not prescribe oral tetracyclines if less than 12 years of age)
    • has been suggested Isotretinoin may benefit some patients (2)
    • management in pregnancy
      • consider topical clindamycin BD for 3 months and review
      • carefully balance the benefits and risks of oral macrolide antibiotics, if needed (2nd and 3rd trimester only)
    • review at 3 months and if symptoms improved, consider treatment break but restart treatment after two or more flares
      
• second line treatment:
  • refer to dermatology when patients have severe disease or when mild to moderate disease has not responded to first line treatment with tetracyclines in primary care
  • patients failing to respond adequately to a three month course of lymecyline, 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
    • rifampicin prevents oral contraceptives from working effectively so patients either need to use additional barrier methods or changing to a LARC (long-acting reversible contraception) 
    • patients should be advised to stop treatment and seek urgent medical attention should they develop signs of hepatotoxicity (fever, malaise, vomiting, jaundice)
      
• Other specialist therapies for hidradenitis suppurativa:
  • 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
    • NICE state that 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 (3)
      • adalimumab is an antibody that inhibits tumour necrosis factor and is given by subcutaneous injection
    • Secukinumab is recommended as an option for treating active moderate to severe hidradenitis suppurativa (acne inversa) in adults when it has not responded well enough to conventional systemic treatment, only if adalimumab is not suitable, did not work or has stopped working (4)
    • Similarly to adalimumab and secukinumab, bimekizumab is administered subcutaneously. At week 16, approximately 50% of
      patients show a good response, maintained or even increased until week 48. (1)

Note - both secukinumab and bimekizumab are not recommended for those patients with concomitant inflammatory bowel disease. (1)

• surgical treatment is an alternative if there is failure of medical therapy. (1) For acute abscesses, incision and drainage are the treatment of choice for immediate pain reduction. However, this procedure is associated with high recurrence rates.
• tunnels often require complete lesional deroofing, in which the tunnel roof is removed and left for secondary intention healing.
• limited surgical procedures are associated with a lower complication and a higher recurrence rate, while wide excisions have a higher complication and a lower recurrence rate.
• combining surgery with systemic agents (eg, adalimumab) is indicated for patients with more severe disease in the destructive phase

Reference:

1. Sabat R et al. Hidradenitis suppurative. Lancet 2025; 405: 420–38.
2. Hasan S B, Harris C, Collier F. Hidradenitis suppurativa BMJ 2022; 379 :e068383 doi:10.1136/bmj-2021-068383
3. NICE (June 2016). Adalimumab for treating moderate to severe hidradenitis suppurativa
4. NICE (December 2023). Secukinumab for treating moderate to severe hidradenitis suppurativa