Hurley’s Clinical Staging1 for Hidradenitis Suppurativa (essential for treatment decisions)
| Stage I | Abscess formation, single or multiple, without sinus tracts and cicatrization. |
| Stage II | Recurrent abscesses with tract formation and cicatrization. Single or multiple, widely separated lesions |
| Stage III | Diffuse or near-diffuse involvement, or multiple interconnected tracts and abscesses across entire area. Delay in diagnosis is an average of seven years, and can be decades. Multiple clinicians incise and drain the “boils” and no one recognizes the pathology occurring. Misdiagnosis leads to inability to sit or walk without pain from large, draining sinuses with significant odor, need to wear diapers for the drainage. There may be difficulties with employment, social isolation, and depression, dysfunction, suicide. All of this is preventable. |
| Treatment action | Topical/behavioral | Oral meds | Intralesional meds | IM/SC/IV meds | Surgery | Testing/Notes |
|---|---|---|---|---|---|---|
| Comfort measures, general care | Reduce heat, sweating, friction (weight loss, loose clothing, tampons, antiperspirants, avoidance of hot environments all can help). Avoid any pressure and friction from panty hose, girdles, or other garments rubbing in the area. The use of ventilated cotton clothing (that is, cotton boxer shorts) is essential.
Cleanse gently with triclosan solution once or twice a day. Topical 2% clindamycin in a mixture of isopropyl alcohol and propylene glycol twice a day is prescribed to avoid minor folliculitis. Bleach baths are helpful for large, draining, foul-smelling areas. (LINK, bleach bath handout). Stop smoking; nicotine avoidance is imperative. Stop all dairy foods (casein, whey, milk solids); change to low glycemic-load diet. The diet is helpful to prevent new lesions and for efficacy of therapy for existing nodules. Dairy products contain multiple hormones and androgens that exacerbate HS. |
Biopsies may or may not be helpful. Consult a dermatologist if not comfortable treating this condition.
Surgical intervention is advised for Stage III and may be necessary for Stage II. HS is not contagious, not caused by poor hygiene. Diet may be more valuable than surgery. Hormone control is more valuable than antibiotics. Surgery undertaken early in the disease need not be mutilating, expensive, or painful. Primary closure of any unroofed or excised hidradenitis lesion leads to recurrence. Link to Hidradenitis Suppurativa in the Atlas. |
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| Treatment: Hurley Stage I (Only a few flares yearly, single or multiple abscess formation without tracts or cicatrization) | Antibiotics are used for 7–10 days or longer for their anti-inflammatory effect: Tetracycline 250-500 mg orally 4 x a day OR Doxycycline 50 mg/d to 100 mg/d orally 2 x a day OR Minocycline 100 mg orally 2 x a day OR Erythromycin 1 gm orally, 1 x a day OR Amoxicillin + Clavulinic acid 500 mg to1 gm orally every eight hours OR Clindamycin 150-300 mg orally 2 x a day OR Dicloxacillin 1-2 gm orally 2 x a day OR Trimethaprim-sulfamethoxazole DS 1 tab orally 2 x a day AND Zinc Gluconate 30-60 mg/d orally (anti-inflammatory, anti- androgenic) AND Oral contraceptives with ethinyl estradiol and low androgen-potential progestins such as ethynodiol diacetate or norethindrone + spironolactone 25-100 mg/day. |
For acute painful nodules: Triamcinolone 10 mg/ml injection brings immediate relief. Shake vial well and withdraw 10 mg (one ml), then dilute with two ml saline or 0.25% Marcaine. Shake well before injection. Inject 0.5 ml into center of painful lesions with 27-gauge needle. |
For injectable steroids, you must shake the bottle prior to dispensing and also shake the syringe prior to injecting. | |||
| Treatment: Hurley Stage II (>1 flare/month or severe flares; sinus tracts or cicatrization present, single or multiple lesions still widely spaced) | Antibiotics are used for 7–10 days or longer for their anti-inflammatory effect: Clindamycin 300 mg orally 2 x a day + Rifampin 300 mg orally 2 x a day x 3 months AND Prednisone 40-60 mg orally x 3-4 days, then taper over 7-10 days AND Zinc Gluconate 30-60 mg/day (anti-inflammatory and anti-androgenic) AND Avlosulfone (Dapsone) 50-100 mg/day (Use only if you are comfortable prescribing this medication) AND Anti-androgen treatment may be necessary. Newer oral contraceptives with desogestrel or norgestimate provide less androgenic effects. Spironolactone 100 to 150 mg a day can be added to these or to regular birth control pills for additional or long-term control. In Europe a truly androgen-blocking combination of ethinyl estradiol 35 μg and cyproterone acetate 2 mg (Diane 35) is available and is very effective. Finasteride 5 mg daily, a 5-alpha-reductase inhibitor which transforms testosterone into dihydrotestosterone is reported helpful. Due to possible feminization of a male fetus is case of pregnancy the drug must be prescribed with caution. Avoid Depot-MPA and LNG IUD |
Triamcinolone 5-10 mg/ml (0.1-0.5 ml) once monthly for 1 to 3 injections | Early, local unroofing may help; I&D only to relieve painful pressure.Follow with Antibiotics: (Amox, then doxy). |
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| Treatment: Hurley Stage III (diffuse or near-diffuse involvement or multiple, interconnected tracts and abscesses across entire area) | Treatment is palliative, used in preparation for surgery. | Anti-inflammatory/antibiotics: Clindamycin 30 mg orally 2 x a day+ rifampin 300 mg orally 2 x a day AND Prednisone 40-60 mg/day orally x 3-4 days, then taper over 7-10 d OR Triamcinolone IM 1 mg/kg up to 60-80 mg intralesionally x 1 OR Cyclosporine 4-5 mg/kg/day orally for 5 to 30 wks |
Tumor Necrosis Factor Alpha Inhibitors: Infliximab (Remicade) IV infusion 5 mg/kg (available if patient has Crohn disease plus HS) Adalimumab (Humira):Autoinjection 40 mg every other week Etanercept (Enbrel): self-SQ injections 25-50 mg 1-2X/wk |
Surgery is extensive, with special wound care and avoidance of primary closure. Deroofing the sinus tracts, removal of all granulation tissue, and slow healing by secondary intention is effective |
Updated 8/31/14 Link to Hidradenitis Suppurativa in the Atlas