I. Introduction

Why is it that the same HS treatment can be very helpful for some people while only slightly helpful or not helpful at all for others? This is because HS is a heterogeneous disease, which means it may have different causes and triggers in different people. Given this, it can be helpful for both healthcare providers and people with HS to view the options for HS treatment as a “toolbox”.

The tools used by different people with HS may differ since their HS may be triggered by different things. For example, for some people, hormones may be a strong driving force for disease activity, in which case, starting a medication that targets hormones would be beneficial.

Having a variety of tools in the HS toolbox is valuable because different tools are appropriate for different situations. Sometimes the situation for a person with HS changes, so the tools used to treat their HS also needs to change. This chapter discusses how to think about the tools available in the HS toolbox.

II. Your HS Toolbox and Your Doctor

If your HS is triggered by a combination of causes, you may need a combination of different types of medicine to get the best results. Currently, choosing the best therapy or combination of therapies to treat HS typically involves some trial and error.

You may need to try different treatments to find what works best to control your HS. Because of this, working with a healthcare provider who is knowledgeable about HS can be really helpful because they are familiar with the HS toolbox. They can help choose tools that are best for you, taking into consideration the specifics of your case (for example, your HS disease severity and any treatment preferences).

III. HS Toolbox Medicines

The HS toolbox is made up of a wide variety of treatment options listed by medical experts in guidelines and reviews based on clinical studies and expert opinion. These treatment guidelines and reviews are accessible through the Hidradenitis Suppurativa Foundation’s website (www.hs-foundation.org).

It is important to keep in mind that different treatment options are appropriate for different disease severities. Some treatments, such as oral antibiotics like doxycycline, do not seem to work as well for people who have severe HS (such as Hurley Stage 3) as they do for people with mild HS (Hurley Stage 1). On the other hand, adalimumab is only approved for people with moderate to severe HS.

When it comes to combining therapies from the HS toolbox, sometimes it is helpful to combine medicines of the same type while other times it is helpful to combine different types of medicines. For example, sometimes combining two or three antibiotics together may be more helpful than just treating HS with one antibiotic. For women with menstrual HS flares, taking an oral contraceptive pill (also known as a birth control pill) and spironolactone together may work well. Both of these medications work to target the hormonal component of HS.

There are also successful examples of combining two different medicine types from the HS toolbox. One example of this is the combination of oral antibiotics with a biologic, such adalimumab (Humira®). For some people, taking doxycycline may be enough to control their disease. However, for those who find that doxycycline helps them but not enough, their healthcare provider may suggest combining it with adalimumab, and then continuing adalimumab long-term since oral antibiotics are not a long-term treatment.

There are no firm rules about how long a medicine should be tried before giving up on it, or before adding on another medicine to try to get better results. Please see Chapter 12 for more information on HS treatment goals and how to manage your treatment expectations.

IV. Non-Medicines in Your HS Toolbox

In addition to medicines, the HS toolbox also has other tools that can help with HS. Depending on your situation, surgery and/or laser treatment may be tools from the toolbox that are helpful, likely in combination with medicines (please see Chapter 21 for further information about HS surgeries). Additionally, lifestyle modifications, such as not smoking, weight management, and diet adjustments may be good for your general health and may help with HS. It can be challenging to stop smoking or make diet changes, so it is important not to feel guilty or blame yourself if you struggle to make lifestyle modifications. Some people with HS report finding it easier to make lifestyle changes after they have started medicines that get their HS under control to the point where they have more energy to work on lifestyle changes.