Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute abscess

1st line – antibiotic therapy

Back
ACUTE
|
acute abscess
1st line – 

antibiotic therapy

Guidelines recommend a 12-week course of a tetracycline antibiotic.[42][43][44]

In severe HS presenting with a disease flare, rescue therapy in the form of a 6-week course of intravenous ertapenem, followed by a 6-week course of consolidation treatment with moxifloxacin plus metronidazole plus rifampicin, may be considered.[43][44][45][46]

Primary options

tetracycline: 500 mg orally twice daily

OR

doxycycline: 100 mg orally twice daily

OR

minocycline: 100 mg orally twice daily

Secondary options

ertapenem: 1 g intravenously every 24 hours

and

moxifloxacin: 400 mg orally once daily

and

metronidazole: 500 mg orally three times daily

and

rifampicin: 300 mg orally twice daily

Plus – intralesional corticosteroid

Back
ACUTE
|
acute abscess
Plus – 

intralesional corticosteroid

Treatment recommended for ALL patients in selected patient group

If the patient is well, intralesional corticosteroids may provide relief from pain and inflammation, in combination with oral antibiotics if required.[42][43][44][47]

Primary options

triamcinolone acetonide: consult specialist for guidance on dose

Consider – incision and drainage

Back
ACUTE
|
acute abscess
Consider – 

incision and drainage

Additional treatment recommended for SOME patients in selected patient group

If the patient is unwell or disease does not improve with antibiotics and/or intralesional corticosteroids, incision and drainage may be considered.[44] Incision and drainage is a supplemental measure; it should not be considered as the sole treatment because recurrence is very common.

ONGOING

mild (Hurley stage I)

1st line – topical antibacterial or antibiotic

Back
ONGOING
|
mild (Hurley stage I)
1st line – 

topical antibacterial or antibiotic

Stage I is defined as the presence of localised disease with inflammatory papules, pustules, nodules, and abscesses but without sinus tracts or scarring.[4][Figure caption and citation for the preceding image starts]: Hidradenitis suppurativa stage I: discrete inflamed nodules and papules with intervening normal skin and lack of scarringFrom R.A. Lee, MD, PhD [Citation ends].com.bmj.content.model.Caption@8c0c333

It is recommended that patients use an antimicrobial wash, but there is no strong evidence for specific agents; use of chlorhexidine, benzoyl peroxide, and zinc pyrithione is supported by expert opinion. Concomitant use of an antimicrobial wash may be associated with lower rates of antibiotic resistance in HS lesions.[43][48]

Topical antibiotics are useful treatments in mild HS.[41] Topical clindamycin has been shown to be effective in a clinical trial setting.[43][49] Topical metronidazole is another option. Topical therapy should be continued for a minimum of 8 weeks before evaluation of efficacy.

Primary options

clindamycin topical: (1%) apply to the affected area(s) twice daily

OR

metronidazole topical: (0.75%) apply to the affected area(s) twice daily; (1%) apply to the affected area(s) once daily

Consider – antibiotic therapy

Back
ONGOING
|
mild (Hurley stage I)
Consider – 

antibiotic therapy

Additional treatment recommended for SOME patients in selected patient group

Oral tetracyclines are recommended first-line for mild disease. They can attenuate neutrophil activity and reduce pain and inflammation. A treatment course of 12-weeks is recommended before evaluation of efficacy.[42][43][44]

Primary options

tetracycline: 500 mg orally twice daily

OR

doxycycline: 100 mg orally twice daily

OR

minocycline: 100 mg orally twice daily

Consider – analgesia

Back
ONGOING
|
mild (Hurley stage I)
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

The degree of pain usually correlates with the degree of inflammation. Thus, treatments directed at inflammation are often effective at alleviating pain. Non-steroidal anti-inflammatory drugs should be used as required before other pain medications such as paracetamol.

Primary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – lifestyle modifications

Back
ONGOING
|
mild (Hurley stage I)
Consider – 

lifestyle modifications

Additional treatment recommended for SOME patients in selected patient group

A high proportion of patients with hidradentitis suppurativa are active smokers or have a history of smoking, and are obese. Obesity is an independent risk factor for development of the disease and contributes to HS disease severity.[21][24] All patients should be advised to stop smoking, to lose weight if obese, and to be evaluated for cardiovascular disease.[44][50]

moderate (Hurley stage II)

1st line – antibiotic therapy

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ONGOING
|
moderate (Hurley stage II)
1st line – 

antibiotic therapy

Stage II is defined as the presence of inflammatory papules and nodules, ≥1 recurring, widely separated abscesses with sinus tracts and scarring.[4][41][Figure caption and citation for the preceding image starts]: Hidradenitis suppurativa stage II: inflamed nodules and scars with areas of intervening normal skinFrom R.A. Lee, MD, PhD [Citation ends].com.bmj.content.model.Caption@705692b7

Tetracyclines are recommended for 12 weeks.[42][43]

Clindamycin plus rifampicin is an effective combination and should be continued for 10 to 12 weeks.[42][43][44] However, patients often relapse within 4 to 5 months of stopping therapy.[43][44][51]

Diarrhoea may reduce tolerability of clindamycin plus rifampicin in some patients.[42][43][44] Patients who are aged ≥50 years or ever-smokers are less likely to tolerate this combination.[36][52][53]

Rifampicin induces the cytochrome P450 system; check for potential drug interactions with existing medication including the oral contraceptive pill. Clindamycin plus rifampicin may also select for rifampicin-resistant strains of Mycobacterium tuberculosis; tuberculosis screening or avoiding this regimen may be indicated in high-risk populations.[54]

Triple antibiotic therapy with moxifloxacin plus metronidazole plus rifampicin is a second-line option for moderate HS.[43]

Primary options

tetracycline: 500 mg orally twice daily

OR

doxycycline: 100 mg orally twice daily

OR

minocycline: 100 mg orally twice daily

OR

clindamycin: 300 mg orally twice daily

and

rifampicin: 300 mg orally twice daily

Secondary options

moxifloxacin: 400 mg orally once daily

and

metronidazole: 500 mg orally three times daily

and

rifampicin: 300 mg orally twice daily

Plus – topical antibiotic or antibacterial

Back
ONGOING
|
moderate (Hurley stage II)
Plus – 

topical antibiotic or antibacterial

Treatment recommended for ALL patients in selected patient group

It is recommended that patients use an antimicrobial wash, but there is no strong evidence for specific agents; use of chlorhexidine, benzoyl peroxide, and zinc pyrithione is supported by expert opinion. Concomitant use of an antimicrobial wash may be associated with lower rates of antibiotic resistance in HS lesions.[43][48] These products are available over the counter.

Topical antibiotics are useful treatments in mild HS.[41] Topical clindamycin has been shown to be effective in a clinical trial setting.[43][49] Topical metronidazole is another option. Topical therapy should be continued for a minimum of 8 weeks before evaluation of efficacy.

Primary options

clindamycin topical: (1%) apply to the affected area(s) twice daily

OR

metronidazole topical: (0.75%) apply to the affected area(s) twice daily; (1%) apply to the affected area(s) once daily

Consider – analgesia

Back
ONGOING
|
moderate (Hurley stage II)
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

The degree of pain usually correlates with the degree of inflammation. Thus, treatments directed at inflammation are often effective at alleviating pain. Non-steroidal anti-inflammatory drugs should be used as required before other pain medications such as paracetamol.

Primary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – lifestyle modifications

Back
ONGOING
|
moderate (Hurley stage II)
Consider – 

lifestyle modifications

Additional treatment recommended for SOME patients in selected patient group

A high proportion of patients with hidradentitis suppurativa are active smokers or have a history of smoking, and are obese. Obesity is an independent risk factor for development of the disease and contributes to HS disease severity.[21][24] All patients should be advised to stop smoking, to lose weight if obese, and to be evaluated for cardiovascular disease.[44][50]

2nd line – dapsone

Back
ONGOING
|
moderate (Hurley stage II)
2nd line – 

dapsone

Dapsone is reserved for patients with moderate disease who have failed multiple courses of combination antibiotics.[42][43] Evidence is limited; in one published case series, 25% patients experienced clinically significant improvement but with rapid disease recurrence upon cessation.[55]

Primary options

dapsone: 50-200 mg orally once daily

Plus – topical antibiotic or antibacterial

Back
ONGOING
|
moderate (Hurley stage II)
Plus – 

topical antibiotic or antibacterial

Treatment recommended for ALL patients in selected patient group

It is recommended that patients use an antimicrobial wash, but there is no strong evidence for specific agents; use of chlorhexidine, benzoyl peroxide, and zinc pyrithione is supported by expert opinion. Concomitant use of an antimicrobial wash may be associated with lower rates of antibiotic resistance in HS lesions.[43][48] These products are available over the counter.

Topical antibiotics are useful treatments in mild HS.[41] Topical clindamycin has been shown to be effective in a clinical trial setting.[43][49] Topical metronidazole is another option. Topical therapy should be continued for a minimum of 8 weeks before evaluation of efficacy.

Primary options

clindamycin topical: (1%) apply to the affected area(s) twice daily

OR

metronidazole topical: (0.75%) apply to the affected area(s) twice daily; (1%) apply to the affected area(s) once daily

Consider – analgesia

Back
ONGOING
|
moderate (Hurley stage II)
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

The degree of pain usually correlates with the degree of inflammation. Thus, treatments directed at inflammation are often effective at alleviating pain. Non-steroidal anti-inflammatory drugs should be used as required before other pain medications such as paracetamol.

Primary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – lifestyle modifications

Back
ONGOING
|
moderate (Hurley stage II)
Consider – 

lifestyle modifications

Additional treatment recommended for SOME patients in selected patient group

A high proportion of patients with hidradentitis suppurativa are active smokers or have a history of smoking, and are obese. Obesity is an independent risk factor for development of the disease and contributes to HS disease severity.[21][24] All patients should be advised to stop smoking, to lose weight if obese, and to be evaluated for cardiovascular disease.[44][50]

Consider – spironolactone

Back
ONGOING
|
moderate (Hurley stage II)
|
with premenstrual flare
Consider – 

spironolactone

Additional treatment recommended for SOME patients in selected patient group

North American guidelines suggest that hormonal agents, including spironolactone, may be considered in women with clear premenstrual flares (while recognising that recommendations regarding hormonal therapies are based on limited evidence).[43]

Use of spironolactone should be limited to women who are practising adequate birth control.

Treatment should be continued for at least 8 weeks.

UK guidelines conclude that there is insufficient evidence to recommend anti-androgens for the treatment of HS.[42][56]

Primary options

spironolactone: 100-150 mg orally once daily

Consider – oral retinoid

Back
ONGOING
|
moderate (Hurley stage II)
|
with concomitant acne vulgaris
Consider – 

oral retinoid

Additional treatment recommended for SOME patients in selected patient group

Patients with concomitant acne vulgaris may consider using oral isotretinoin.[42][43][57] 

Before treatment, patients require counselling about the potential adverse effects. Severe headaches, decreased night vision, or signs of adverse psychiatric events are indications for prompt discontinuation. Full blood count, lipid panel, and liver function tests are monitored regularly.

Isotretinoin is teratogenic; therefore, women undergo pregnancy testing before starting isotretinoin and monthly while taking the drug. In the UK, isotretinoin is prescribed under the Pregnancy Prevention Programme (PPP), while in the US, it can only be prescribed through the iPledge system.[65] iPledge system (for isotretinoin prescribing) Opens in new window These programmes are aimed at decreasing the number of birth defects associated with this medicine. Oral isotretinoin should be continued for at least 6 months.

Acitretin has demonstrated moderate efficacy in HS.[43][58] Treatment duration in excess of 6 months has been reported.[59] Acitretin is teratogenic and should be avoided in women of child-bearing potential.

Primary options

isotretinoin: 0.5 to 1 mg/kg/day orally given in 2 divided doses

Secondary options

acitretin: 25-50 mg orally once daily

Consider – surgical repair

Back
ONGOING
|
moderate (Hurley stage II)
|
with scarring
Consider – 

surgical repair

Additional treatment recommended for SOME patients in selected patient group

Wide excision with wide and deep margins is the standard of care for surgical therapy. Because of the size of the excision and its corresponding repair, and the availability of specific lasers, referral to plastic surgery and/or a dermatological surgeon is advisable.[60][61][62][63]

Local excision is possible for smaller, quiescent lesions where the clinical margins can be clearly defined.

Destructive methods, such as cryotherapy, are generally not recommended. Selective use of deroofing of individual epithelialised sinus tracts can be effective in treating specific recurrent lesions.

severe (Hurley stage III)

1st line – antibiotic therapy

Back
ONGOING
|
severe (Hurley stage III)
1st line – 

antibiotic therapy

Stage III disease is defined as multiple abscesses and interconnected sinus tracts and scars.[4][Figure caption and citation for the preceding image starts]: Hidradenitis suppurativa stage III: interconnected scars, cysts, comedones, and inflamed nodulesFrom R.A. Lee, MD, PhD [Citation ends].com.bmj.content.model.Caption@37567dc7

In practice, patients in this group will have previously used oral tetracyclines, and they may be used again in between other measures to maintain disease control in stage III disease. However, once disease reaches stage III more aggressive treatment is usually required.

In selected stage III patients with severe HS presenting with a disease flare (usually after failure of a tetracycline [for 12 weeks] or clindamycin plus rifampicin), a 6-week course of intravenous ertapenem, followed by a 6-week course of consolidation treatment with moxifloxacin plus metronidazole plus rifampicin, may be considered.[43][44][45][46]

Primary options

tetracycline: 500 mg orally twice daily

OR

doxycycline: 100 mg orally twice daily

OR

minocycline: 100 mg orally twice daily

OR

clindamycin: 300 mg orally twice daily

and

rifampicin: 300 mg orally twice daily

Secondary options

ertapenem: 1 g intravenously every 24 hours

and

moxifloxacin: 400 mg orally once daily

and

metronidazole: 500 mg orally three times daily

and

rifampicin: 300 mg orally twice daily

Plus – topical antibiotic or antibacterial

Back
ONGOING
|
severe (Hurley stage III)
Plus – 

topical antibiotic or antibacterial

Treatment recommended for ALL patients in selected patient group

It is recommended that all patients use an antimicrobial wash, but there is no strong evidence for specific agents; use of chlorhexidine, benzoyl peroxide, and zinc pyrithione is supported by expert opinion. Concomitant use of an antimicrobial wash may be associated with lower rates of antibiotic resistance in HS lesions.[43][48] These products are available over the counter.

Topical antibiotics are useful treatments in mild HS.[41] Topical clindamycin has been shown to be effective in a clinical trial setting.[43][49] Topical metronidazole is another option. Topical therapy should be continued for a minimum of 8 weeks before evaluation of efficacy.

Primary options

clindamycin topical: (1%) apply to the affected area(s) twice daily

OR

metronidazole topical: (0.75%) apply to the affected area(s) twice daily; (1%) apply to the affected area(s) once daily

Consider – analgesia

Back
ONGOING
|
severe (Hurley stage III)
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

The degree of pain usually correlates with the degree of inflammation. Thus, treatments directed at inflammation are often effective at alleviating pain. Non-steroidal anti-inflammatory drugs should be used as required before other pain medications such as paracetamol.

Primary options

ibuprofen: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – tumour necrosis factor (TNF)-alpha inhibitor

Back
ONGOING
|
severe (Hurley stage III)
Consider – 

tumour necrosis factor (TNF)-alpha inhibitor

Additional treatment recommended for SOME patients in selected patient group

Adalimumab has demonstrated efficacy in phase 3 trials of HS.[64] It is the only approved biologic for HS, and is therefore considered the first-choice biological agent in moderate/severe HS refractory to conventional treatments.[42][43][44]

Infliximab may be considered as a second-line biological agent, and is used off-label for HS.[42][43][44]

Other biological agents may be considered if adalimumab or infliximab fail or are contraindicated, but their use is off-label and should be under specialist guidance.[43]

Therapy with biologics is continued for at least 12 weeks and the efficacy of treatment assessed at this time.

Primary options

adalimumab: 160 mg subcutaneously on day 1, followed by 80 mg on day 15, then 40 mg once weekly or 80 mg every 2 weeks starting on day 29

Secondary options

infliximab: consult specialist for guidance on dose

Consider – lifestyle modifications

Back
ONGOING
|
severe (Hurley stage III)
Consider – 

lifestyle modifications

Additional treatment recommended for SOME patients in selected patient group

A high proportion of patients with hidradentitis suppurativa are active smokers or have a history of smoking, and are obese. Obesity is an independent risk factor for development of the disease and contributes to HS disease severity.[21][24] All patients should be advised to stop smoking, to lose weight if obese, and to be evaluated for cardiovascular disease.[44][50]

Consider – spironolactone

Back
ONGOING
|
severe (Hurley stage III)
|
with premenstrual flare
Consider – 

spironolactone

Additional treatment recommended for SOME patients in selected patient group

North American guidelines suggest that hormonal agents, including spironolactone, may be considered in women with clear premenstrual flares (while recognising that recommendations regarding hormonal therapies are based on limited evidence).[43]

Use of spironolactone should be limited to women who are practising adequate birth control.

Treatment should be continued for at least 8 weeks.

UK guidelines conclude that there is insufficient evidence to recommend anti-androgens for the treatment of HS.[42][56]

Primary options

spironolactone: 100-150 mg orally once daily

Consider – oral retinoid

Back
ONGOING
|
severe (Hurley stage III)
|
with concomitant acne vulgaris
Consider – 

oral retinoid

Additional treatment recommended for SOME patients in selected patient group

Patients with concomitant acne vulgaris may consider using oral isotretinoin.[42][43][57] 

Before treatment, patients require counselling about the potential adverse effects. Severe headaches, decreased night vision, or signs of adverse psychiatric events are indications for prompt discontinuation. Full blood count, lipid panel, and liver function tests are monitored regularly.

Isotretinoin is teratogenic; therefore, women undergo pregnancy testing before starting isotretinoin and monthly while taking the drug. In the UK, isotretinoin is prescribed under the Pregnancy Prevention Programme (PPP), while in the US, it can only be prescribed through the iPledge system.[65] iPledge system (for isotretinoin prescribing) Opens in new window These programmes are aimed at decreasing the number of birth defects associated with this medicine. Oral isotretinoin should be continued for at least 6 months.

Acitretin has demonstrated moderate efficacy in HS.[43][58] Treatment duration in excess of 6 months has been reported.[59] Acitretin is teratogenic and should be avoided in women of child-bearing potential.

Primary options

isotretinoin: 0.5 to 1 mg/kg/day orally given in 2 divided doses

Secondary options

acitretin: 25-50 mg orally once daily

Consider – surgical repair

Back
ONGOING
|
severe (Hurley stage III)
|
with scarring
Consider – 

surgical repair

Additional treatment recommended for SOME patients in selected patient group

Wide excision with wide and deep margins is the standard of care for surgical therapy. Because of the size of the excision and its corresponding repair, and the availability of specific lasers, referral to plastic surgery and/or a dermatological surgeon is advisable.[60][61][62][63]

Local excision is possible for smaller, quiescent lesions where the clinical margins can be clearly defined.

Destructive methods, such as cryotherapy, are generally not recommended. Selective use of deroofing of individual epithelialised sinus tracts can be effective in treating specific recurrent lesions.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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