Treatment is in 2 tiers. The first involves lifestyle changes. Patients are told to wear loose clothing, lose weight, avoid antiperspirants, avoid shaving under their arms and avoid sweating. As you would expect, these measures are generally ineffective. Hydrotherapy and cleansing agents are employed next, as well as topical antibiotics. It does appear that topical clindamycin works as well as systemic antibiotics. The systemic antibiotics we use are similar to those used to treat acne, including tetracycline and erythromycin. Because of the involvement of MRSA, we have also used Bactrim and clindamycin. There are a number of protocols using clindamycin and rifampin, 300 mg each BID for 14 days. This approach seems to have the best outcomes of all the treatment regimens.
Second tier treatment is reserved for those patients with severe and recurrent disease. Because of the presumed hormonal triggers associated with HS, people have used Cyprostat, which is an anti-androgen, and Proscar, which is a treatment for benign prostatic hypertrophy, with benefit to some patients. The retinoids have also been used. Accutane has had inconsistent results, but Acetretin, which is used to treat eczema, appears to be better and more consistent. Steroids can be used either topically or intralesionally. Cyclosporine has been used experimentally. Biological agents, like infliximab, have had limited trials. Radiation therapy has been used with a 78% aggregate response - 30% in remission and 48% improved - but there is real downside to radiation exposure in kids.
When it comes to surgical treatment of HS, less is really more. We try to avoid the concept of incision and drainage, which would usually be done with a more conventional abscess. I think surgical unroofing of complex cavities and sinuses is of value, but the only thing that I have seen that is effective is wide excision with uninvolved margins.