›Acetaminophen as the analgesic base
›Acetaminophen 1000 mg PO every 6 hours, maximum 4000 mg in 24 hours
›Cap at 3000 mg in 24 hours with hepatic impairment, chronic use, malnutrition, or regular alcohol use
›Nonsteroidal anti-inflammatory drugs, which also address the inflammatory component
›Ibuprofen 400 to 600 mg PO every 6 to 8 hours with food, maximum 2400 mg in 24 hours
›Naproxen 500 mg PO every 12 hours, maximum 1000 mg in 24 hours
›Avoid in chronic kidney disease, active peptic ulcer disease, and uncontrolled hypertension
›Use with caution alongside methotrexate, and avoid in pregnancy from 20 weeks onward
›Short opioid course for severe or post-procedural pain only
›Oxycodone 5 mg PO every 6 hours as needed for 2 to 3 days, then stop
›Avoid longer courses; dependence risk is high in this young chronic-pain population
›Co-prescribe a stimulant laxative and counsel against driving
›Chronic or neuropathic pain component, initiated as an outpatient
›Gabapentin 300 mg PO at night, titrated over weeks toward 900 to 1800 mg per day in divided doses, renally adjusted
›Duloxetine 30 mg PO daily for 1 week then 60 mg PO daily
›Non-pharmacologic measures
›Warm compresses 10 to 15 minutes three to four times daily
›Loose breathable clothing and reduction of friction and shear over affected sites
›Framing: in HS, antibiotics act largely as anti-inflammatories, courses are time-limited, and most flares without cellulitis do not need them
›Adjunct to drainage when surrounding cellulitis or systemic signs are present, covering S. aureus including MRSA, streptococci, and anaerobes
›Doxycycline 100 mg PO twice daily for 7 to 14 days
›Take upright with a full glass of water to prevent pill esophagitis; counsel on photosensitivity and use of SPF 30 or higher
›Avoid in pregnancy and in children under 8 years for prolonged courses
›Trimethoprim-sulfamethoxazole 160/800 mg, 1 to 2 tablets PO twice daily for 7 to 10 days, for MRSA coverage
›Avoid in the first trimester and near term; check potassium and renal function, especially with an ACE inhibitor or ARB
›Cephalexin 500 mg PO four times daily for 7 to 10 days when MRSA risk is low
›Clindamycin 300 mg PO four times daily for MRSA plus anaerobe coverage
›Counsel on Clostridioides difficile risk and to stop and seek care for significant diarrhea
›Amoxicillin-clavulanate 875/125 mg PO twice daily for mixed anaerobic groin or perianal infection
›Topical therapy for mild localized Hurley I disease
›Clindamycin 1% solution or lotion applied twice daily
›Benzoyl peroxide 5 to 10% wash or chlorhexidine 4% wash several times weekly to reduce secondary colonization
›Disease-modifying oral antibiotic regimens for moderate disease, usually started by dermatology and often continued when a patient presents
›Tetracycline-class monotherapy: doxycycline 100 mg PO twice daily for up to 12 weeks
›Clindamycin 300 mg PO twice daily plus rifampin 300 mg PO twice daily for 10 to 12 weeks
›Rifampin is a potent CYP3A4 inducer: it defeats hormonal contraception, so advise a barrier or non-hormonal method
›It reduces levels of warfarin, direct oral anticoagulants, statins, and many antiarrhythmics; review the full medication list
›Warn about orange discolouration of urine, sweat, and tears, and monitor liver enzymes
›Rifampin plus moxifloxacin plus metronidazole for severe refractory disease, specialist-directed
›Moxifloxacin 400 mg PO daily: QT prolongation, tendinopathy, and aortic aneurysm and dissection cautions
›Baseline ECG and avoidance of other QT-prolonging drugs and of hypokalemia and hypomagnesemia
›Metronidazole 500 mg PO three times daily: avoid alcohol, and limit duration because of peripheral neuropathy
›Ertapenem 1 g IV daily for up to 6 weeks as a rescue bridge to surgery in severe disease, specialist-directed
›Parenteral therapy for admitted extensive infection
›Vancomycin 15 to 20 mg per kg IV every 8 to 12 hours, target AUC-to-MIC 400 to 600, or trough 15 to 20 mg/l
›Piperacillin-tazobactam 3.375 g IV every 6 hours, or 4.5 g every 6 to 8 hours, for polymicrobial groin or perianal infection
›Add clindamycin 900 mg IV every 8 hours for toxin suppression if necrotizing infection is being considered, pending surgical exploration
›Interpret cultures against the clinical picture; do not chase every colonizer, since over-treatment drives resistance and C. difficile
Systemic disease-modifying therapy
›Biologic therapy is the standard for moderate-to-severe disease; screen for latent TB and hepatitis B first, and hold doses during an active undrained infection
›Adalimumab, a TNF-alpha inhibitor
›160 mg SC on day 1, 80 mg at week 2, then 40 mg SC weekly from week 4
›Contraindicated in NYHA class III to IV heart failure and in active serious infection
›Risk of tuberculosis reactivation, hepatitis B reactivation, and demyelinating disease
›Secukinumab, an IL-17A inhibitor
›300 mg SC weekly for 5 weeks, then 300 mg SC every 4 weeks, escalating to every 2 weeks if response is inadequate
›May worsen inflammatory bowel disease; use an alternative if Crohn disease coexists
›Mucocutaneous candidiasis risk
›Bimekizumab, an IL-17A and IL-17F inhibitor
›320 mg SC every 2 weeks through week 16, then every 2 to 4 weeks
›Oral candidiasis is common; same inflammatory bowel disease caution as other IL-17 agents
›Infliximab 5 mg per kg IV at weeks 0, 2, and 6, then every 8 weeks, off-label, favoured when Crohn disease coexists
›Infusion reactions; same TB and hepatitis B screening and heart failure caution as adalimumab
›Hormonal therapy in women
›Combined oral contraceptive containing ethinylestradiol, avoiding progestin-only and androgenic progestins
›Spironolactone 50 to 100 mg PO daily, up to 150 mg
›Check potassium and renal function; avoid with an ACE inhibitor or ARB and in significant renal impairment
›If potassium is elevated, obtain an ECG and look for peaked T waves, PR prolongation, and QRS widening
›Contraindicated in pregnancy because anti-androgen effect can feminize a male fetus
›Finasteride 5 mg PO daily
›Strictly avoided in people who may become pregnant, including handling of crushed tablets
›Metformin as a metabolic adjunct, especially with insulin resistance or PCOS
›Metformin 500 mg PO daily, titrated to 500 mg two to three times daily, maximum 2000 to 2550 mg per day
›Avoid at eGFR below 30 ml/min/1.73 m2 and hold around iodinated contrast and acute kidney injury
›Oral retinoid for follicular disease with prominent comedones
›Acitretin 25 mg PO daily, roughly 0.3 to 0.5 mg per kg per day
›Powerfully teratogenic: no pregnancy during treatment and for 3 years after, no alcohol, and no blood donation during treatment or for 3 years
›Short systemic corticosteroid as a bridge for a severe acute flare only, never maintenance
›Prednisone 0.5 to 0.7 mg per kg per day PO, tapered over 7 to 14 days
›Expect transient hyperglycemia and counsel diabetic patients on closer monitoring; flare rebound can follow withdrawal
›Adjuncts with limited evidence
›Zinc gluconate 90 mg PO daily as maintenance; GI upset and, with prolonged use, copper deficiency
›Dapsone 50 to 150 mg PO daily; check G6PD first and monitor for hemolysis and methemoglobinemia
›Methotrexate is generally ineffective for HS and is not recommended
Adjunctive and lifestyle measures
›Smoking cessation, addressed at every encounter
›Offer nicotine replacement, and refer for varenicline or bupropion
›Even reduction in daily cigarettes is associated with fewer flares
›Weight management
›Dietitian referral, structured weight loss, and bariatric surgery referral when criteria are met
›Weight loss reduces friction, shear, and disease severity
›Local skin care
›Antiseptic washes: chlorhexidine 4% or benzoyl peroxide 5 to 10%, several times weekly
›Loose breathable cotton clothing, avoidance of tight waistbands, and avoidance of irritant antiperspirants during flares
›Wound and dressing care
›Superabsorbent or foam dressings for draining tracts; avoid adhesives directly on fragile perilesional skin
›Community nursing support for Hurley II to III dressing burden
›Psychological and social support
›Screen for depression and suicidality; refer to mental health services and to HS peer-support resources
›Pain psychology for the chronic-pain component
Interventions to avoid and iatrogenic harms
›Simple linear incision and drainage as definitive therapy
›Recurrence approaches 100%; use only for acute pain relief and always pair it with a dermatology referral
›Wide local excision performed in the ED
›Not an ED procedure; inadequate margins lead to recurrence and poor cosmesis
›Tight wound packing
›Poorly tolerated and of little benefit; use loop drainage or light packing
›Indefinite systemic antibiotic monotherapy without dermatology involvement
›Drives resistance and C. difficile; antibiotic courses in HS are defined and time-limited
›Long-term opioids
›High dependence risk in a young population; restrict to 2 to 3 days after a procedure or for a severe flare
›Continuing or starting a TNF or IL-17 biologic during an active undrained infection
›Hold the biologic until the infection is controlled; do not stop it permanently without dermatology input because rebound flares occur
›Injecting corticosteroid, intralesional or systemic, into frank pus
›Drain first; steroid into an infected collection worsens infection
›Missing squamous cell carcinoma
›Biopsy any non-healing ulcer, exophytic mass, or new induration in anogenital disease of more than 10 years; HS-associated SCC has high metastatic potential and mortality
›Missing perianal Crohn disease
›Knife-cut fissures, fistula-in-ano, oral aphthae, or GI symptoms warrant gastroenterology referral before choosing immunosuppression
›Over-interpreting wound cultures
›HS lesions are frequently colonized by coagulase-negative staphylococci, corynebacteria, and anaerobes; treat only when clinical infection is present
›NSAIDs or a steroid taper in an undiagnosed diabetic
›Check glucose; a steroid course can unmask or worsen hyperglycemia and precipitate DKA
›Prescribing a tetracycline, retinoid, spironolactone, or finasteride without confirming a negative beta-hCG
›Femoral vascular access, IABP, or ECMO cannulation through an infected scarred Hurley III groin
›Use an alternative access site and flag the disease to the proceduralist; groin HS is a vascular-access hazard
›Assuming standard airway positioning
›Severe nuchal and axillary disease can limit neck extension and arm abduction; anticipate a difficult airway and difficult peripheral access, and plan a clean central-access site
›Anticoagulation and fibrinolysis have no HS-specific contraindication
›Large actively draining lesions are a bleeding site; plan pressure dressings and monitor after dosing
›Vasopressors and sedation follow standard sepsis practice
›There is no HS-specific contraindication; the priority error is failing to achieve source control alongside them