Joint AAD & HS Foundation clinical guidelines
Guidelines of Care for the Management of Hidradenitis Suppurativa
Every recommendation with its strength, certainty of evidence, dosing, and monitoring.
View and download the guidelines
4strong recommendations
2good practice statements, treated as strong
37recommendations in total
40therapies where evidence generation is needed
Dosing and monitoring
The therapies for which the guidelines tabulate dosing, monitoring, boxed warnings, and adverse effects. Select one for the full record.
Not a substitute for prescribing information. The guidelines direct clinicians to the full prescribing information for the laboratory monitoring each medication requires.
Topical clindamycin 1%
Topical antibiotic
1% lotion, gel or solution twice daily to affected skin.
Topical resorcinol 10-15%
Topical keratolytic
Over the counter; requires compounding. 10-15% cream once to twice daily to affected skin.
Topical ruxolitinib 1.5% cream
Topical JAK1/JAK2 inhibitor
1.5% cream twice daily to affected skin. Do not exceed 60 g/week or 100 g per 2 weeks.
Boxed warning
Doxycycline
Tetracycline antibiotic
100 mg by mouth twice daily for 12 weeks.
Tetracycline
Tetracycline antibiotic
500 mg by mouth twice daily for 12 weeks.
Clindamycin with rifampin
Combination systemic antibiotics
Clindamycin 300 mg and rifampin 300 mg, both by mouth twice daily for 12 weeks.
Ertapenem
Carbapenem antibiotic
1 g intravenously daily for six or more weeks via PICC.
Spironolactone
Anti-androgen
50-200 mg by mouth daily.
Boxed warning
Adalimumab
TNF inhibitor
Adults and adolescents 12 years and older, 60 kg or more: 160 mg subcutaneously day 1 (or 80 mg on days 1 and 2), then 80 mg on day 15, then 40 mg weekly or 80 mg every 2 weeks from day 29. Adolescents 12 years and older, 30 to under 60 kg: 80 mg day 1, then 40 mg every 2 weeks from day 8.
Boxed warning
Bimekizumab
IL-17A/F inhibitor
Loading: 320 mg subcutaneously every 2 weeks from week 0 through 16. Maintenance: 320 mg every 4 weeks thereafter.
Infliximab
TNF inhibitor
Loading: 5-10 mg/kg intravenously at weeks 0, 2 and 6. Maintenance: every 4 to 8 weeks thereafter.
Boxed warning
Secukinumab
IL-17A inhibitor
Adults, loading: 300 mg subcutaneously weekly at weeks 0, 1, 2, 3 and 4. Maintenance: 300 mg every 4 weeks, may escalate to every 2 weeks for adequate response. Adolescents 12 years and older: 150 mg (30 to under 90 kg) or 300 mg (90 kg or more) on the same schedule.
Upadacitinib
JAK1 inhibitor
Adults and adolescents 12 to 64 years: 30 mg by mouth daily. Adults 65 and older: 15 mg by mouth daily.
Boxed warning
Short-term systemic corticosteroids
Systemic corticosteroid
Prednisone 40-60 mg by mouth daily with a taper over 1 to 2 weeks.
Conditional Low certainty
For patients with HS, we conditionally recommend topical clindamycin.
Population
All HS
Evidence summary
Five RCTs in 204 participants with mild to moderate disease. Reduced mean abscesses, inflammatory nodules and pustules from baseline at week 12 versus placebo. Fewer adverse events than placebo; discontinuation uncommon.
Drug class
Topical antibiotic
Dosing
1% lotion, gel or solution twice daily to affected skin.
Monitoring
No routine monitoring recommended per FDA label.
Adverse effects
Skin burning, itching, dryness, erythema, peeling. C. difficile colitis (rare, systemic absorption).
Evidence trail
References 14-18
Supplemental Tables 1-5
Conditional Low certainty
For patients with HS, we conditionally recommend topical resorcinol.
Population
All HS
Evidence summary
One RCT (40 participants) plus five case series (229 patients), mild to moderate disease. IHS4 fell from 5.65 to 2.5 and DLQI from 9.6 to 4.8 at 24 weeks. No discontinuations for adverse events reported.
Drug class
Topical keratolytic
Dosing
Over the counter; requires compounding. 10-15% cream once to twice daily to affected skin.
Monitoring
No routine monitoring recommended.
Adverse effects
Desquamation (64-100%), discoloration (33-41%), mild irritation (34%).
Evidence trail
References 15, 19-23
Supplemental Tables 6-7
Conditional Low certainty
For patients with HS, we conditionally recommend topical ruxolitinib.
Population
All HS
Evidence summary
One phase 2 RCT (69 participants) and a 6-patient open-label trial, mild to moderate disease. HiSCR-50 reached in 79% versus 50% with vehicle at 16 weeks. No difference in pain or IHS4.
Drug class
Topical JAK1/JAK2 inhibitor
Dosing
1.5% cream twice daily to affected skin. Do not exceed 60 g/week or 100 g per 2 weeks.
Monitoring
No routine laboratory monitoring required per FDA label for topical use. CBC as clinically indicated. Periodic skin exams for non-melanoma skin cancer during and after treatment.
Boxed warning
Class boxed warning for JAK inhibitors: serious infections, all-cause mortality, malignancy, major adverse cardiovascular events, thrombosis. Carried on the topical label as a class warning; systemic exposure from topical use is low.
Adverse effects
Upper respiratory infection, nasopharyngitis, application site reactions, acne, folliculitis, fever, cytopenias.
Evidence trail
References 24-26
Supplemental Tables 8-9
Conditional Very Low certainty
For patients with HS, we conditionally recommend doxycycline.
Population
All HS
Evidence summary
Despite extensive use in HS, only two RCTs were identified. HiSCR reached in 64% and 60% with modified- and regular-release formulations, with no difference between them. HiSCR-50 in 41% on monotherapy.
Drug class
Tetracycline antibiotic
Dosing
100 mg by mouth twice daily for 12 weeks.
Monitoring
No routine monitoring recommended per FDA label.
Adverse effects
Gastrointestinal symptoms, photosensitivity, transaminitis (rare).
Evidence trail
References 27, 28
Supplemental Tables 10-11
Conditional Very Low certainty
For patients with HS, we conditionally recommend tetracycline.
Population
All HS
Evidence summary
One RCT (46 participants) against topical clindamycin showed no significant difference in physician global assessment or pain at 16 weeks. A 108-patient prospective cohort showed the highest numerical improvement in Sartorius score with tetracycline, without statistical significance.
Drug class
Tetracycline antibiotic
Dosing
500 mg by mouth twice daily for 12 weeks.
Monitoring
No routine monitoring recommended per FDA label.
Adverse effects
Gastrointestinal symptoms, skin irritation, photosensitivity.
Evidence trail
References 16, 29, 342
Supplemental Tables 12-13
Conditional Very Low certainty
For patients with HS, we conditionally recommend clindamycin in combination with rifampin.
Population
All HS
Evidence summary
Eight cohort studies and case series in 392 patients plus one active comparator RCT. Mean Sartorius scores fell 46-53% at 10 weeks; HiSCR-50 in 48% at 12 weeks. Between 4% and 26% discontinued for adverse events.
Drug class
Combination systemic antibiotics
Dosing
Clindamycin 300 mg and rifampin 300 mg, both by mouth twice daily for 12 weeks.
Monitoring
No routine laboratory monitoring recommended per FDA label for a typical 12-week course. Rifampin is a potent CYP3A4 inducer: review all concomitant medications for interactions before starting.
Adverse effects
Gastrointestinal symptoms, C. difficile colitis, hepatotoxicity, orange discoloration of body fluids, significant CYP450 drug interactions.
Evidence trail
References 30-38
Supplemental Tables 14-15
Conditional Very Low certainty
For patients with moderate to severe HS, we conditionally recommend ertapenem.
Population
Moderate to severe HS
Evidence summary
Four cohort studies and case series in 179 patients. Median Sartorius score fell from 49.5 to 19.0 and pain VAS from 9 to 2 at six weeks. Should be reserved for moderate to severe disease refractory to other treatment and used as a bridge to longer-term therapy to steward antibiotic use.
Drug class
Carbapenem antibiotic
Dosing
1 g intravenously daily for six or more weeks via PICC.
Monitoring
Baseline: renal function, CBC, LFTs. On treatment: periodic renal function with dose adjustment if CrCl 30 mL/min or less; PICC site monitoring for infection, thrombosis and local reaction.
Adverse effects
PICC line infection and thrombosis, adhesive dermatitis, vaginal candidiasis, transaminitis, infusion reactions, C. difficile colitis.
Evidence trail
References 40-43
Supplemental Table 16
Conditional Very Low certainty
For patients with HS, we conditionally recommend spironolactone.
Population
All HS
Evidence summary
Five case series in 323 female patients, most on concomitant therapy. Median dose 100 mg daily. Mean HS-PGA fell 0.6 after a mean seven months of follow-up.
Drug class
Anti-androgen
Dosing
50-200 mg by mouth daily.
Monitoring
Baseline: serum potassium and creatinine; eGFR in renally impaired patients or those on an ACE inhibitor or ARB. On treatment: potassium is not needed in healthy patients; check within one week of starting or a dose change, then periodically, for renally impaired patients or those on an ACE inhibitor or ARB.
Boxed warning
Tumorigenicity: spironolactone was tumorigenic in chronic toxicity studies in rats. Unnecessary use should be avoided.
Adverse effects
Irregular menses, gastrointestinal symptoms, breast tenderness, changes in urination, gynecomastia, hyperkalemia, teratogenicity.
Evidence trail
References 54-58
Supplemental Table 25
Strong Moderate certainty
For patients with moderate to severe HS, we recommend adalimumab.
Population
Moderate to severe HS
Evidence summary
Seven RCTs in 733 patients. At week 12, HiSCR-50 favored adalimumab 40 mg weekly over placebo (RR 1.92; 95% CI 1.57-2.36). In open-label extension, 52% maintained HiSCR-50 at three years. Every-other-week 40 mg dosing did not meet efficacy endpoints; 80 mg every two weeks is an approved maintenance alternative that may improve adherence.
Drug class
TNF inhibitor
Dosing
Adults and adolescents 12 years and older, 60 kg or more: 160 mg subcutaneously day 1 (or 80 mg on days 1 and 2), then 80 mg on day 15, then 40 mg weekly or 80 mg every 2 weeks from day 29. Adolescents 12 years and older, 30 to under 60 kg: 80 mg day 1, then 40 mg every 2 weeks from day 8.
Monitoring
Baseline: TB screening (TST or IGRA), hepatitis B panel, hepatitis C antibody, HIV screen, CBC, hepatic profile. On treatment: annual TB screening, monitoring for active TB and serious infection, and HBV carrier monitoring for reactivation during therapy and for several months after stopping.
Boxed warning
Serious infections: fatal and serious infections including TB, bacterial sepsis, invasive fungal and opportunistic infections. Malignancy: lymphoma and other malignancies, some fatal; hepatosplenic T-cell lymphoma reported in adolescent and young adult patients with IBD on TNF blockers plus immunosuppressants.
Adverse effects
Serious infections, malignancy, injection site reactions, hypersensitivity, lupus-like syndrome, worsening heart failure.
Evidence trail
References 69-75
Supplemental Tables 29-31
Strong Moderate certainty
For patients with moderate to severe HS, we recommend bimekizumab.
Population
Moderate to severe HS
Evidence summary
Three RCTs in 784 participants. At week 16, HiSCR-50 (RR 1.67; 95% CI 1.31-2.13) and HiSCR-75 (RR 2.14; 1.49-3.06) favored bimekizumab 320 mg every two weeks over placebo. At week 48, 77-82% maintained HiSCR-50 on every-four-week dosing.
Drug class
IL-17A/F inhibitor
Dosing
Loading: 320 mg subcutaneously every 2 weeks from week 0 through 16. Maintenance: 320 mg every 4 weeks thereafter.
Monitoring
Baseline: TB screening (TST or IGRA), LFTs including AST, ALT, alkaline phosphatase and bilirubin. On treatment: periodic LFTs, since transaminase elevations were observed in trials.
Adverse effects
Upper respiratory infection, oral candidiasis, headache, eczema, tinea, serious infections, suicidal ideation and behavior (observed in trials, monitor), new or worsening IBD, transaminitis.
Evidence trail
References 70, 79
Supplemental Tables 33-34
Strong Low certainty
For patients with moderate to severe HS, we recommend infliximab.
Population
Moderate to severe HS
Evidence summary
One RCT in 33 participants plus seven cohort studies in 132 patients. Infliximab was more likely to achieve an excellent physician global assessment outcome at week 8 (RR 4.80; 95% CI 1.66-13.90) and reduced mean pain VAS substantially more than placebo.
Drug class
TNF inhibitor
Dosing
Loading: 5-10 mg/kg intravenously at weeks 0, 2 and 6. Maintenance: every 4 to 8 weeks thereafter.
Monitoring
Baseline: TB screening, hepatitis B panel, hepatitis C antibody, HIV screen, CBC, hepatic profile. On treatment: annual TB screening, monitoring for active TB and serious infection, HBV reactivation monitoring, and evaluation for hepatic injury with discontinuation if jaundice or LFTs reach five times the upper limit of normal.
Boxed warning
Serious infections: fatal and serious infections including TB, bacterial sepsis, invasive fungal and opportunistic infections. Malignancy: lymphoma and other malignancies, some fatal; hepatosplenic T-cell lymphoma reported in pediatric and young adult patients with IBD on TNF blockers plus immunosuppressants.
Adverse effects
Serious infections, malignancy, acute and delayed infusion reactions, hepatotoxicity, lupus-like syndrome, worsening heart failure.
Evidence trail
References 80-89
Supplemental Tables 35-36
Strong Moderate certainty
For patients with moderate to severe HS, we recommend secukinumab.
Population
Moderate to severe HS
Evidence summary
Two RCTs in 724 participants. At week 16, HiSCR-50 favored secukinumab on both dosing schedules (RR 1.35). Pain reduction of 30% or more and DLQI improvement of five points or more were both more common than placebo. HiSCR-50 was maintained at week 52 in 76-81% of week-16 responders.
Drug class
IL-17A inhibitor
Dosing
Adults, loading: 300 mg subcutaneously weekly at weeks 0, 1, 2, 3 and 4. Maintenance: 300 mg every 4 weeks, may escalate to every 2 weeks for adequate response. Adolescents 12 years and older: 150 mg (30 to under 90 kg) or 300 mg (90 kg or more) on the same schedule.
Monitoring
Baseline: TB screening (TST or IGRA) with chest radiograph, CBC, hepatic profile. On treatment: annual TB screening and monitoring for active TB and serious infection.
Adverse effects
Upper respiratory infection, nasopharyngitis, oral and esophageal candidiasis, headache, fungal infections, hypersensitivity, serious infections, new or worsening IBD, new or worsening severe eczema.
Evidence trail
References 90
Supplemental Tables 37-39
Conditional Low certainty
For patients with moderate to severe HS, we conditionally recommend upadacitinib.
Population
Moderate to severe HS
Evidence summary
One RCT in 68 patients. HiSCR-50 and 30% pain reduction were reached in more patients than historical controls but did not differ from the in-trial placebo group. An ongoing phase 3 trial will inform efficacy, safety and potential on-label access.
Drug class
JAK1 inhibitor
Dosing
Adults and adolescents 12 to 64 years: 30 mg by mouth daily. Adults 65 and older: 15 mg by mouth daily.
Monitoring
Baseline: TB screening with chest radiograph, CBC (do not start if ANC under 1,000, ALC under 500, or hemoglobin under 8), hepatic profile, fasting lipids, viral hepatitis screening. On treatment: fasting lipids at 12 weeks then per hyperlipidemia guidelines; CBC and hepatic function as clinically indicated.
Boxed warning
Serious infections, higher all-cause mortality including sudden cardiovascular death versus TNF inhibitors, malignancy, major adverse cardiovascular events, thrombosis.
Adverse effects
Headache, dizziness, urinary tract infection, serious infections, malignancy, MACE, thrombosis.
Evidence trail
References 115
Supplemental Table 50
Conditional Very Low certainty
For patients with moderate to severe HS, we conditionally recommend short-term systemic corticosteroids.
Population
Moderate to severe HS
Evidence summary
Three case series in 73 patients. A prednisone taper combined with amoxicillin-clavulanate improved patient impression of severity, pain and DLQI by day 14. Duration should be limited to minimize the risks of long-term corticosteroid use.
Drug class
Systemic corticosteroid
Dosing
Prednisone 40-60 mg by mouth daily with a taper over 1 to 2 weeks.
Monitoring
Blood glucose monitoring, especially in patients with diabetes or prediabetes. No additional routine laboratory monitoring required per FDA label for a short-term taper.
Adverse effects
Hyperglycemia and new-onset diabetes, hypertension, cataracts and glaucoma, osteoporosis with long-term use, serious infections, adrenal suppression.
Evidence trail
References 116-118
Supplemental Table 51