General skin care Adequate bathing and hygiene is important with, for example, twice daily use of an antibacterial wash containing triclosan. Ideally, this occurs before starting disease-specific treatment.

First-line treatment options Topical antibiotics First-line medical management is clindamycin 1 % lotion topically, twice daily until active disease resolves, or for up to three months in recurrent disease.

Oral antibiotics First-line therapy doxycycline 50-100mg orally, once daily for six weeks. If this is not tolerated, minocycline 50-100mg once daily is suggested. Tetracyclines are used predominantly for their antiinflammatory effect. 12

Patients should be referred to a dermatologist if a threemonth trial of tetracyclines initiated by the GP is ineffective.

For more severe disease, oral clindamycin 300mg twice daily and rifampicin 600mg daily for 10 weeks is recommended.

However, the use of these antibiotics is limited by adverse effects, for example Clostridium difficile.

Biologic therapies Biologic medications are proteins derived from human genes.

Adalimumab is recommended following the failure

of antibiotics, based on recent studies. 3

The regimen recommended by the European Dermatology Forum, which is currently used at the Liverpool Hospital HS clinic in Sydney, is Adalimumab 160mg at

week 0, 80mg at week 2, then 40mg weekly thereafter.

Adjuncts Hormone therapy Hormone therapies are of the greatest benefit in women with PCOS. Cyproteronecontaining combined oral contraceptive pills are most

likely to be of benefit for a woman with HS. The firstline recommendation is ethinyloestradiol and cyproterone 35 µ g and 2mg orally, once daily on days 1-21 of a 28-day cycle.

INTRALESIONAL STEROIDS ARE EFFECTIVE IN TARGETING LOCALISED DISEASE, AND LIMITING PAIN IN ACUTELY INFLAMED LESIONS.

Spironolactone For women with PCOS, spironolactone is recommended at a dose of 25-50mg once daily, increasing gradually to 50-100mg once daily as tolerated.

Metformin In patients who are obese

and / or insulin-resistant, metformin is now routinely started at 500mg daily, and up-titrated to 1g. Recommendations regarding diet are also emphasised.

Corticosteroids Intralesional steroids, such as triamcinolone, are effective in targeting localised disease, and limiting pain in acutely inflamed lesions.

High-dose oral corticosteroids are an effective, but indiscriminate and outdated therapy, with a specific role only in painful flares. They should be initiated by a specialist, and weaned over 2-3 weeks. 4

Although effective in pain management, the response is short-lived, and the patient may be subject to the side effects of systemic steroid use. 5-6 Oral steroids also may have a place in the pre-operative setting, to shrink the size of lesions.

Intense pulsed light( IPL) and laser Laser and light-based therapies have been reported to be effective at reducing the amount of hair, number of sebaceous glands and bacterial load in patients with HS. Laser hair reduction induces selective photothermolysis of hair follicles, by exploiting an understanding of melanin absorption range and thermal relaxation time of follicles. 7 Laser may be particularly useful in Hurley Stage I disease, to limit the progression of lesions.

Surgery There is minimal evidence in support of appropriate timing of surgery, and how it may be used in tandem with medical treatment. Furthermore, surgical approaches vary widely between Europe, the US and Australia.

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