Hidradenitis Suppurativa Clinical Practice Guidelines (2019)

US Hidradenitis Suppurativa Foundation and the Canadian Hidradenitis Suppurativa Foundation

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

September 04, 2019

Guidelines on the diagnosis and evaluation; complementary and procedural management; and topical, intralesional, and systemic medical management of hidradenitis suppurativa were released in July 2019 by the US Hidradenitis Suppurativa Foundation and the Canadian Hidradenitis Suppurativa Foundation.[1,2]

Grading and Classification

Recommended grading tools are clinical performance, Hurley staging, and abscess and inflammatory lesion counts. The Visual Analogue Scale (VAS) and the Dermatology Life Quality Index (DLQI) also can be considered. For research studies, the recommended grading systems are the Hidradenitis Suppurativa Clinical Response (HiSCR) score, Hidradenitis Suppurativa Physician Global Assessment (HS-PGA), Sartorius score, DLQI, and pain VAS. Others to consider are the Hidradenitis Suppurativa Impact Assessment (HSIA) and the Hidradenitis Suppurativa Symptom Assessment (HSSA).

Screening for Comorbidities

The patient should undergo a physical examination and a review of systems, with screening for metabolic syndrome, diabetes, depression, anxiety, polycystic ovarian syndrome, and tobacco abuse. If patients have additional risk factors for diabetes (eg, obesity, hyperlipidemia, hypertension, acanthosis nigricans), refer them for HbA1c and/or fasting glucose testing. Based on the review of systems, other screening considerations are depression, inflammatory bowel disease, autoinflammatory syndromes, and inflammatory arthropathy.

Lifestyle Modifications and Alternative Treatments

Patients should be counseled to quit smoking. If the patient is obese, weight loss should be recommended. As far as alternative treatments, zinc supplementation may be recommended but the evidence is weak. Vitamin D supplementation lacks sufficient evidence, as does avoidance of dairy or brewer's yeast, friction, deodorant, and shaving/depilation.

Surgical Modalities

Deroofing or excision is recommended for recurrent nodules and tunnels. Incision and drainage should only be used for pain relief from acute abscesses. For extensive chronic lesions, use wide local scalpel, carbon dioxide, or electrosurgical excision (with or without reconstruction). Secondary intention healing, primary closure, delayed primary closure, flaps, grafts, or skin substitutes are all appropriate for wound healing. It is likely beneficial to continue medical treatment during the perioperative period; this poses minimal risk for increased postoperative complications.

Pain Management

Disease control is paramount for pain management. Pain management involves considering the multidimensional aspects of pain. Short-acting opioids may be needed in select cases; dosing should be individualized and drugs carefully prescribed. Use of the World Health Organization pain ladder is recommended for chronic pain management.

Wound Care

Follow the principals of best-practice individualized wound care for local wound care in surgical and nonsurgical wounds. Consider periwound skin condition, location, amount of drainage, cost, and patient preference when choosing the type of dressing. While it carries a low risk of contact dermatitis, use of antiseptic washes is generally supported by expert opinion. Negative-pressure therapy may be beneficial for selected large open wounds (for 1-4 wk), followed by delayed reconstruction.

Light, Laser, and Energy Sources

Nd:YAG laser is recommended in those with Hurley stage I disease based on expert consensus. It is also recommended in those with Hurley stage II or III disease based on randomized controlled trial and case series data. Lower quality evidence suggests other wavelengths that are used for follicular destruction may be helpful. In patients with Hurley stage II or III disease with fibrotic sinus tracts, carbon dioxide laser is recommended. Photodynamic therapy and external beam radiation have limited roles.

Topical and Intralesional Therapies

Topical clindamycin can be used to reduce pustules; however, it carries a high risk of bacterial resistance. Resorcinol 15% cream is recommended; however, it may induce contact dermatitis. Expert opinion supports using antibacterial washes such as chlorhexidine, zinc pyrithione, or others. Intralesional corticosteroid injections can be considered for short-term control of inflamed lesions, but the evidence for this recommendation is weak.

Systemic Antibiotics

For mild-to-moderate disease, tetracyclines are recommended for a 12-week course or for long-term maintenance when appropriate. For mild-to-moderate disease or for a first-line or adjunctive treatment in severe disease, combination therapy with clindamycin and rifampin is an effective second-line treatment. For moderate-to-severe disease, combination therapy with metronidazole, moxifloxacin, and rifampin is recommended as second- or third-line treatment. A minority of patients with Hurley stage I or II disease may benefit from dapsone as long-term maintenance therapy. For severe disease as a one-time rescue treatment or a bridge to surgery or other long-term maintenance, intravenous ertapenem is recommended. Balance the benefit achieved for each patient against the antibiotic resistance risk when determining the frequency and duration of antibiotic use. Disease recurrence is common following cessation of antibiotic therapy.

Hormonal Agents

All described evidence for hormonal therapies has major limitations, based on variable outcome measures and methods, small samples sizes, and reporting bias. Estrogen-containing combined oral contraceptives, cyproterone acetate, spironolactone, finasteride, and metformin can be considered in appropriate female patients. These can be used as monotherapy for mild-to-moderate disease or in combination with other agents for more severe disease. Progestogen-only contraceptives should likely be avoided, as anecdotal data suggest they may worsen hidradenitis suppurativa.


Owing to mixed results from isotretinoin studies, it should be considered only as a second- or third-line treatment or in patients with severe concomitant acne. Acitretin should also be considered a second- or third-line treatment; it may be superior to isotretinoin, but significantly robust comparative studies are lacking. While not available in the United States, alitretinoin is supported by a single study in women. It is available in Canada and other countries.


Based on the available limited evidence, methotrexate or azathioprine is not recommended. While the evidence is weak, combination colchicine/minocycline can be considered for refractory mild-to-moderate disease; avoid colchicine monotherapy. In patients with recalcitrant moderate-to-severe disease in whom standard therapies have failed or who are not candidates for standard therapy, consider cyclosporine. In acute flares or as a bridge to other treatments, short-term pulse steroid therapy can be considered. In cases of severe disease, consider using long-term corticosteroids, tapered to the lowest dose, as adjunctive therapy when the response to standard therapy has been suboptimal.


Adalimumab and infliximab are recommended for moderate-to-severe disease. Adalimumab should be administered at the dosage approved for hidradenitis suppurativa. Dose-ranging studies are needed to determine the optimal dosage for infliximab. Agents that may be effective include anakinra (100 mg daily) and ustekinumab (45-90 mg q12wk). Dose-ranging studies are needed for anakinra, and placebo-controlled dose-ranging studies are needed for ustekinumab. Etanercept use is not supported by the limited available evidence.

Pediatric and Pregnant Patients

For pediatric patients with hidradenitis suppurativa, a laboratory evaluation for precocious puberty should be performed in those aged 11 years or younger when other suggestive physical examination findings are present. Additionally, avoid tetracyclines in children younger than 9 years. Avoid administration of acitretin to female patients during childbearing years. Agents to be avoided by pregnant patients with hidradenitis suppurativa include hormonal agents, retinoids, most immunosuppressive medications, and most systemic antibiotics. Topical treatments, procedures, and safe systemic agents are acceptable for use in pregnant patients.

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