Therapeutic Options for Hidradenitis Suppurativa: An Update submitted: Mar 20, 2020; Accepted: May 18, 2020; Published online: Jun 3, 2020


Hasan Alghamdi


Hidradenitis suppurativa (HS) is a chronic skin condition with severe, deep inflammatory lesions, also referred to as acne inversa. Intertriginous regions, such as the axillae, groins (genital, anal, and perianal areas), infra- and intermammary skin, and buttocks are typically affected, although other areas (e.g., neck nape and lower abdominal fold) might also be affected. Painful nodules and leaking sinuses often affect patients with serious conditions, exuding fluid that sometimes smells, and many patients fear that these new lesions might burst at any moment, requiring incision and drainage, corticosteroid, or surgical injection. Topical lotion of clindamycin or cream of resorcinol can be useful long-term treatments in mild disease, while tetracycline is a first-line systemic option. While antibiotics can help reduce inflamed lesions, recurrence is common after discontinuation.

If patients do not respond well to these standard medical procedures, then using biologics such as adalimumab or infliximab would be the next step. Anti-inflammatory drugs, such as fumarate, dapsone, and cyclosporine, are also prescribed for HS. Surgical procedures are also necessary for healing, particularly when the sinuses or scars are present.

The clinical staging system of HS and the desires of patients should be used as the basis for every therapy.


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Hidradenitis suppurativa, Acne inversa, Clindamycin, Rifampicin, Infliximab

How to Cite
Alghamdi, H. (2020). Therapeutic Options for Hidradenitis Suppurativa: An Update: submitted: Mar 20, 2020; Accepted: May 18, 2020; Published online: Jun 3, 2020. Advances in Medicine and Medical Research, 3(1), 109–118.
Original Articles


1. Jemec GBE. Clinical practice. Hidradenitis suppurativa. N Engl
J Med. 2012; 366:158–64.
2. Revuz JE. Hidradenitis suppurativa. J Eur Acad Dermatol
Venereol. 2009; 23:985–98.
3. Zouboulis CC, Desai N, Emtestam L, Hunger RE, Ioannides
D, Juha´sz I. European S1 guideline for the treatment of
hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol
Venereol. 2015; 29:619–44.
4. Deckers IE, van der Zee HH, Boer J, Prens EP. Correlation
of early-onset hidradenitis suppurativa with stronger genetic
susceptibility and more widespread involvement. J Am Acad
Dermatol. 2015; 72:485–8.
5. Bettoli V, Ricci M, Zauli S, Virgili A. Hidradenitis suppurativa–
acne inversa: a relevant dermatosis in pediatric age. Br J
Dermatol. 2015; 173(5):1328-30.
6. Cosmatos I, Matcho A, Weinstein R, Montgomery MO, Stang
P. Analysis of patient claims data to determine the prevalence
of hidradenitis suppurativa in the United States. J Am Acad
Dermatol. 2013; 68:412–9.
7. Jemec GBE, Heidenheim M, Nielsen NH. The prevalence of
hidradenitis suppurativa and its potential precursor lesions. J
Am Acad Dermatol. 1996; 35:191–4.
8. Revuz JE, Canoui-Poitrine F, Wolkenstein P, Viallette C,
Gabison G, Pouget F. Prevalence and factors associated with
hidradenitis suppurativa: results from two case–control
studies. J Am Acad Dermatol. 2008; 59:596–601.
9. Hurley HJ. Axillary hyperhidrosis, apocrine bromhidrosis,
hidradenitis suppurativa, and familial benign pemphigus:
surgical approaches. In: Roenigh R, Roenigh H (eds.).
Dermatogic surgery. Marcel Dekker, New York, pp 729–39,
10. Sartorius K, Lapins J, Emtestam L. Jemec GBE. Suggestions for
uniform outcome variables when reporting treatment effects in
hidradenitis suppurativa. Br J Dermatol. 2003; 149:211–3.
11. Canoui-Poitrine F, Revuz JE, Wolkenstein P, Viallette C,
Gabison G, Pouget F. Clinical characteristics of a series of
302 French patients with hidradenitis suppurativa, with an
analysis of factors associated with disease severity. J Am Acad
Dermatol. 2009; 61:51–7.
12. Kimball AB, Kerdel F, Adams D, Mrowietz U, Gelfand JM,
Gniadecki R. Adalimumab for the treatment of moderate to

severe hidradenitis suppurativa: a parallel randomized trial.
Ann Intern Med Am Coll Phys. 2012; 157:846–55.
13. Yu C-W, Cook MG. Hidradenitis suppurativa: a disease
of follicular epithelium, rather than apocrine glands. Br J
Dermatol. 1990; 122:763–9.
14. Boer J, Weltevreden EF. Hidradenitis suppurativa or acne
inversa. A clinicopathological study of early lesions. Br J
Dermatol. 1996; 135:721–5.
15. von Laffert M, Helmbold P, Wohlrab J, Fiedler E, Stadie V,
Marsch WC. Hidradenitis suppurativa (acne inversa): early
inflammatory events at terminal follicles and at interfollicular
epidermis. Exp Dermatol. 2010; 19:533–7.
16. Von Laffert M, Stadie V, Wohlrab J, Marsch WC. Hidradenitis
suppurativa/acne inversa: bilocated epithelial hyperplasia with
very different sequelae. Br J Dermatol. 2011; 164:367–71.
17. van der Zee HH, de Ruiter L, van den Broecke DG, Dik WA,
Laman JD, Prens EP. Elevated levels of tumour necrosis
factor (TNF)-a, interleukin (IL)-1b and IL-10 in hidradenitis
suppurativa skin: a rationale for targeting TNF-a and IL-1b. Br
J Dermatol. 2011; 164:1292–8.
18. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ,
Gavaghan DJ. Assessing the quality of reports of randomized
clinical trials: Is blinding necessary? Control Clin Trials 1996;
19. Rambhatla PV, Lim HW, Hamzavi I. A systematic review of
treatments for hidradenitis suppurativa. Arch Dermatol. 2012;
20. Ingram JR, McPhee M. Management of hidradenitis
suppurativa: a UK survey of current practice. Br J Dermatol.
2015; 173:1070–2.
21. Clemmensen OJ. Topical treatment of hidradenitis suppurativa
with clindamycin. Int J Dermatol. 1983; 22:325–8.
22. Yu C-W, Cook MG. Hidradenitis suppurativa: a disease
of follicular epithelium, rather than apocrine glands. Br J
Dermatol. 1990; 122:763–9.
23. Boer J, Weltevreden EF. Hidradenitis suppurativa or acne
inversa. A clinicopathological study of early lesions. Br J
Dermatol. 1996; 135:721–5.
24. Sartorius K, Boer J, Jemec GBE. Topical treatment. Hidradenitis
suppurativa. Springer, Berlin, Germany, pp 150–60, 2006.
25. 25. Boer J, Jemec GBE. Resorcinol peels as a possible self-
treatment of painful nodules in hidradenitis suppurativa. Clin
Exp Dermatol. 2010; 35:36–40.
26. Detmar M, Mayer-da-Silva A, Stadler R, Orfanos CE. Effects
of azelaic acid on proliferation and ultrastructure of mouse
keratinocytes in vitro. J Invest Dermatol. 1989; 93:70–4.
27. Zouboulis CC, Desai N, Emtestam L, Hunger RE, Ioannides
D, Juha´sz I. European S1 guideline for the treatment of
hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol
Venereol. 2015; 29:619–44.
28. Deckers IE, van der Zee HH, Prens EP. Epidemiology ofhidradenitis suppurativa: prevalence, pathogenesis, and factors
associated with the development of HS. Curr Dermatol Rep.
2014; 3:54–60.
29. Jemec GBE, Faber M, Gutschik E, Wendelboe P. The
bacteriology of Hidradenitis suppurativa. Dermatology 1996;
30. Lapins J, Jarstrand C, Emtestam L. Coagulase-negative
staphylococci are the most common bacteria found in cultures
from the deep portions of hidradentis suppurativa lesions, as
obtained by carbon dioxide laser surgery. Br J Dermatol. 1999;
31. Sartorius K, Killasli H, Oprica C, Sullivan A, Lapins J.
Bacteriology of Hidradenitis suppurativa exacerbations and
deep tissue cultures obtained during carbon dioxide laser
treatment. Br J Dermatol. 2012; 166:879–83.
32. Matusiak Ł, Bieniek A, Szepietowski JC. Bacteriology of
hidradenitis suppurativa—which antibiotics are the treatment
of choice? Acta Derm Venereol. 2014; 94:699–702.
33. Nikolakis G, Join-Lambert O, Karagiannidis I, Guet-Revillet
H, Zouboulis CC, Nassif A. Bacteriology of hidradenitis
suppurativa/ acne inversa: a review. J Am Acad Dermatol.
2015; 73:S12–8.
34. Ring HC, Riis Mikkelsen P, Miller IM, Jenssen H, Fuursted K,
Saunte DM. The bacteriology of hidradenitis suppurativa: a
systematic review. Exp Dermatol. 2015; 24:727–31.
35. Guet-Revillet H, Coignard-Biehler H, Jais J-P, Quesne G, Frapy
E, Poirée S. Bacterial pathogens associated with Hidradenitis
suppurativa, France. Emerg Infect Dis. 2014; 20:1990–8.
36. Collier F, Smith RC, Morton CA. Diagnosis and management of
hidradenitis suppurativa. BMJ 2013; 346:f2121.
37. Pasquale TR, Tan JS. Nonantimicrobial effects of antibacterial
agents. Clin Infect Dis. 2005; 40:127–35.
38. Sapadin AN, Fleischmajer R. Tetracyclines: nonantibiotic
properties and their clinical implications. J Am Acad Dermatol.
2006; 54:258–65.
39. Monk E, Shalita A, Siegel DM. Clinical applications of
nonantimicrobial tetracyclines in Dermatology. Pharmacol
Res. 2011; 63:130–45.
40. Jemec GBE, Wendelboe P. Topical clindamycin versus systemic
tetracycline in the treatment of hidradenitis suppurativa. J Am
Acad Dermatol. 1998; 39:971–4.
41. Simonart T, Dramaix M, De Maertelaer V. Efficacy of
tetracyclines in the treatment of acne vulgaris: a review. Br J
Dermatol. 2008; 158:208–16.
42. Nahum GG, Uhl K, Kennedy DL. Antibiotic use in pregnancy
and lactation: what is and is not known about teratogenic and
toxic risks. Obstet Gynecol. 2006; 107:1120–38.
43. Leigh DA. Antibacterial activity and pharmacokinetics of
clindamycin. J Antimicrob Chemother. 1981; 7:3–9.
44. Sensi P. History of the development of rifampin. Rev Infect Dis.
1983; 5:S402–6.

45. Tsankov N, Angelova I. Rifampin in Dermatology. Clin
Dermatol. 2003; 21:50–5.
46. Ziglam HM, Daniels I, Finch RG. Immunomodulating activity
of rifampicin. J Chemother. 2004; 16:357–61.
47. Mendonc¸a CO. Griffiths CEM. Clindamycin and rifampicin
combination therapy for hidradenitis suppurativa. Br J
Dermatol. 2006; 154:977–8.
48. Gener G, Canoui-Poitrine F, Revuz JE, Faye O, Poli F, Gabison
G. Combination therapy with clindamycin and rifampicin for
hidradenitis suppurativa: a series of 116 consecutive patients.
Dermatology 2009; 219:148–54.
49. Van der Zee HH, Boer J, Prens EP, Jemec GBE. The effect of
combined treatment with oral clindamycin and oral rifampicin
in patients with hidradenitis suppurativa. Dermatology 2009;
50. Bettoli V, Zauli S, Borghi A, Toni G, Minghetti S, Ricci M. Oral
clindamycin and rifampicin in the treatment of hidradenitis
suppurativa–acne inversa: a prospective study on 23 patients.
J Eur Acad Dermatol Venereol. 2014; 28:125–6.
51. Renneberg J, Karlsson E, Nilsson B, Walder M. Interactions
of drugs acting against Staphylococcus aureus in vitro and in a
mouse model. J Infect. 1993; 26:265–77.
52. Join-Lambert O, Ribadeau-Dumas F, Jullien V, Kitzis M-D, Jais
J-P, Coignard-Biehler H. Dramatic reduction of clindamycin
plasma concentration in hidradenitis suppurativa patients
treated with the rifampin–clindamycin combination. Eur J
Dermatol. 2014; 24:94–5.
53. Bernard A, Kermarrec G, Parize P, Caruba T, Bouvet A, Mainardi
J-L. Dramatic reduction of clindamycin serum concentration
in staphylococcal osteoarticular infection patients treated with
the oral clindamycin–rifampicin combination. J Infect. 2015;
54. Curis E, Pestre V, Jullien V, Eyrolle L, Archambeau D, Morand
P. Pharmacokinetic variability of clindamycin and influence of
rifampicin on clindamycin concentration in patients with bone
and joint infections. Infection 2015; 43:473–81.
55. Join-Lambert O, Coignard H, Jais J, Guet-Revillet H, Poiree S,
Fraitag S. Efficacy of rifampin–moxifloxacin–metronidazole
combination therapy in hidradenitis suppurativa. Dermatology
2011; 222:49–58.
56. Lamp KC, Freeman CD, Klutman NE, Lacy MK.
Pharmacokinetics and pharmacodynamics of the nitroimidazole
antimicrobials. Clin Pharmacokinet. 1999; 36:353–73.
57. Shakir L, Javeed A, Ashraf M, Riaz A. Metronidazole and the
immune system. Pharmazie 2011; 66:393–8.
58. Muijsers RBR, Jarvis B. Moxifloxacin. Drugs 2002; 62:967–73.
59. Dalhoff A. Immunomodulatory activities of fluoroquinolones.
Infection 2005; 33:55–70.
60. Cação G, Fontes S, Salgado M, Rodrigues T, Dama´sio J.
Metronidazole-induced central and peripheral nervous system
toxicity. Neurol Sci. 2015; 36:1737–9.
61. Kuriyama A, Jackson JL, Doi A, Kamiya T. Metronidazoleinduced
central nervous system toxicity: a systematic review. Clin
Neuropharmacol. 2011; 34:241–7.
62. Shanmugam VK, Zaman NM, McNish S, Hant FN. Review of the
current immunologic therapies for Hidradenitis suppurativa.
Int J Rheumatol. 2017; 2017:8018192.
63. Martínez F, Nos P, Benlloch S, Ponce J. Hidradenitis
suppurativa and Crohn’s disease: response to treatment with
infliximab. Inflamm Bowel Dis. 2001; 7:323–6.
64. Gill L, Williams M, Hamzavi I. Update on hidradenitis
suppurativa: connecting the tracts. F1000Prime Rep. 2014;
65. Kelly G, Prens EP. Inflammatory Mechanisms in hidradenitis
Suppurativa. Dermatol Clin. 2016; 34:51–8.
66. Prens E, Deckers I. Pathophysiology of hidradenitis suppurativa:
an update. J Am Acad Dermatol. 2015; 73(5 Suppl 1):S8–11.
67. Hoffman LK, Tomalin LE, Schultz G, Howell MD,
Anandasabapathy N, Alavi A. Integrating the skin and
blood transcriptomes and serum proteome in Hidradenitis
suppurativa reveals complement dysregulation and a plasma
cell signature. PLoS One 2018; 13:e0203672.
68. Bechara FG, Sand M, Skrygan M, Kreuter A, Altmeyer P,
Gambichler T. Acne inversa: evaluating antimicrobial peptides
and proteins. Ann Dermatol. 2012; 24:393–7.
69. Xu H, Xiao X, He Y, Zhang X, Li C, Mao Q. Increased serum
interleukin-6 levels in patients with hidradenitis suppurativa.
Postepy Dermatol Alergol. 2017; 34:82–4.
70. Napolitano M, Megna M, Timoshchuk EA, Patruno C, Balato N,
Fabbrocini G. Hidradenitis suppurativa: from pathogenesis to
diagnosis and treatment. Clin Cosmet Investig Dermatol. 2017;
71. Zouboulis CC, Bechara FG, Dickinson-Blok JL, Gulliver W,
Horváth B, Hughes R. Hidradenitis suppurativa/acne inversa:
a practical framework for treatment optimization systematic
review and recommendations from the HS ALLIANCE working
group. J Eur Acad Dermatol Venereol. 2019;33(1):19-31.
72. Megna M, Bettoli V, Chimenti S, Chiricozzi A, Naldi L, Virgili
A. Hidradenitis suppurativa: guidelines of the Italian Society of
Dermatology and Venereology (SIDeMaST) for the use of anti-
TNF-α agents. G Ital Dermatol Venereol. 2015; 150:731–9.
73. Lee RA, Eisen DB. Treatment of hidradenitis suppurativa with
biologic medications. J Am Acad Dermatol. 2015; 73 (Suppl
74. Hunger RE, Laffitte E, Läuchli S, Mainetti C, Mühlstädt
M, Schiller P. Swiss Practice Recommendations for the
Management of Hidradenitis Suppurativa/Acne Inversa.
Dermatology 2017;233:113–9.
75. Alavi A, Lynde C, Alhusayen R, Bourcier M, Delorme I, George
R. Approach to the management of patients with hidradenitis
suppurativa: a consensus document. J Cutan Med Surg. 2017;
76. Vekic DA, Cains GD. Hidradenitis suppurativa—management,

comorbidities and monitoring. Aust Fam Phys. 2017; 46:584–
77. Arenbergerová M, Dahmen RA, Arenberger P. Hidradenitis
suppurativa—symptoms, diagnostics, and therapy. Cas Lek
Cesk. 2017; 156:127–32.
78. Ingram JR. Interventions for hidradenitis suppurativa: updated
summary of an original cochrane review. JAMA Dermatol.
2017; 153:458–9.
79. Kyriakou A, Trigoni A, Galanis N, Sotiriadis D, Patsatsi A. Efficacy
of adalimumab in moderate to severe hidradenitis suppurativa:
Real life data. Dermatol Reports. 2018;1;10(2):7859.
80. Kimball AB, Kerdel F, Adams D, Mrowietz U, Gelfand JM,
Gniadecki R. Adalimumab for the treatment of moderate to
severe Hidradenitis suppurativa: a parallel randomized trial.
Ann Intern Med. 2012; 157:846–55.
81. Kimball AB, Okun MM, Williams DA, Gottlieb AB, Papp
KA, Zouboulis CC. Two Phase 3 Trials of Adalimumab for
Hidradenitis Suppurativa. N Engl J Med. 2016; 375:422–34.
82. Giamarellos-Bourboulis EJ, Sobell J, Ryan C, Wolkenstein PJ,
Geng Z, Mulder GD. Infection-free clinical response among
patients with hidradenitis suppurativa who were treated with
adalimumab: results from two phase 3 studies. Wounds 2017;
83. DeFazio MV, Economides JM, King KS, Han KD, Shanmugam
VK, Attinger CE. Outcomes after combined radical resection and
targeted biologic therapy for the management of recalcitrant
hidradenitis suppurativa. Ann Plast Surg. 2016; 77:217–22.
84. Grant A, Gonzalez T, Montgomery MO, Cardenas V, Kerdel
FA. Infliximab therapy for patients with moderate to severe
hidradenitis suppurativa: a randomized, doubleblind, placebo-
controlled crossover trial. J Am Acad Dermatol. 2010; 62:205–
85. Moriarty B, Jiyad Z, Creamer D. Four-weekly infliximab in the
treatment of severe hidradenitis suppurativa. Br J Dermatol.
2014; 170:986–7.
86. Cusack C, Buckley C. Etanercept: effective in the management
of Hidradenitis suppurativa. Br J Dermatol. 2006; 154:726–9.
87. Giamarellos-Bourboulis EJ, Pelekanou E, Antonopoulou A,
Petropoulou H, Baziaka F, Karagianni V. An open-label phase
II study of the safety and efficacy of etanercept for the therapy
of hidradenitis suppurativa. Br J Dermatol. 2008; 158:567–72.
88. Sotiriou E, Apalla Z, Ioannidos D. Etanercept for the treatment
of hidradenitis suppurativa. Acta Derm Venereol. 2009;
89. Gulliver WP, Jemec GB, Baker KA. Experience with
ustekinumab for the treatment of moderate to severe
hidradenitis suppurativa. J Eur Acad Dermatol Venereol.
2012; 26:911–4.
90. Sharon VR, Garcia MS, Bagheri S, Goodarzi H, Yang C, Ono
Y. Management of recalcitrant hidradenitis suppurativa with
ustekinumab. Acta Derm Venereol. 2012; 92:320–1.
91. Baerveldt EM, Kappen JH, Thio HB, van Laar JA, van HagenPM, Prens EP. Successful long-term triple disease control by
ustekinumab in a patient with Behcet’s disease, psoriasis and
hidradenitis suppurativa. Ann Rheum Dis. 2013; 72:626–7.
92. Santos-Pérez MI, García-Rodicio S, Del Olmo-Revuelto MA,
Pozo-Román T. Ustekinumab for hidradenitis suppurativa: a
case report. Actas Dermosifiliogr. 2014; 105:720–2.
93. Blok JL, Li K, Brodmerkel C, Horvátovich P, Jonkman MF,
Horváth B. Ustekinumab in hidradenitis suppurativa: clinical
results and a search for potential biomarkers in serum. Br J
Dermatol. 2016; 174:839–46.
94. Jaeger T, Andres C, Grosber M, Zirbs M, Hein R, Ring J.
Pyoderma gangrenosum and concomitant hidradenitis
suppurativa--rapid response to canakinumab (anti-IL-1β). Eur
J Dermatol. 2013; 23:408–10.
95. Galimberti RL, Vacas AS, Bollea Garlatti ML, Torre AC. The
role of interleukin-1β in pyoderma gangrenosum. JAAD Case
Rep. 2016; 2:366–8.
96. Houriet C, Seyed Jafari SM, Thomi R, Schlapbach C, Borradori L,
Yawalkar N. Canakinumab for severe hidradenitis suppurativa:
preliminary experience in 2 cases. JAMA Dermatol. 2017;
97. Matusiak Ł, Szczęch J, Bieniek A, Nowicka-Suszko D,
Szepietowski JC. Increased interleukin (IL)-17 serum levels
in patients with hidradenitis suppurativa: implications for
treatment with anti-IL-17 agents. J Am Acad Dermatol. 2017;

98. Thorlacius L, Theut Riis P, Jemec GBE. Severe hidradenitis
suppurativa responding to treatment with secukinumab: a case
report. Br J Dermatol. 2018; 179:182–5.
99. Blok JL, Spoo JR, Leeman, FWJ, Jonkman MF, Horváth B.
Skin-Tissuesparing Excision with Electrosurgical Peeling
(STEEP): a surgical treatment option for severe hidradenitis
suppurativa Hurley stage II/III. J Eur Acad Dermatol Venereol.
2015; 29(2):379–82.
100. Wortsman X, Moreno C, Soto R, Arellano J, Pezo C, Wortsman
J. Ultrasound in-depth characterization and staging of
Hidradenitis suppurativa. Dermatol Surg. 2013; 39:1835–42.
101. Pagliarello C, Fabrizi G, Feliciani C, Di Nuzzo S. Cryoinsufflation
for Hurley Stage II Hidradenitis Suppurativa: a useful
treatment option when systemic therapies should be avoided.
JAMA Dermatol. 2014; 150:765–6.
102. Hazen PG, Hazen BP. Hidradenitis suppurativa: Successful
treatment using carbon dioxide laser excision and
marsupialization. Dermatol Surg. 2010; 36:208–13.
103. Saunte DM, Lapins J. Lasers and Intense Pulsed Light
hidradenitis supurativa. Dermatol Clin. 2016; 34:111–9.