For a patient with hidradenitis suppurativa who has completed a 30‑day course of doxycycline 100 mg daily and daily benzoyl‑peroxide 5 % wash and now reports marked skin improvement, what is the recommended next step in management?

Continue Benzoyl Peroxide Wash and Transition to Maintenance Therapy

For this patient with hidradenitis suppurativa who has achieved marked improvement after 30 days of doxycycline 100 mg daily plus benzoyl peroxide 5% wash, continue the benzoyl peroxide wash indefinitely as maintenance therapy and discontinue the doxycycline. 1

Rationale for This Approach

Why Continue Benzoyl Peroxide

• Benzoyl peroxide is supported by expert opinion for ongoing use as a skin cleanser in HS and helps prevent bacterial colonization that can trigger flares 1
• The patient has tolerated it well without significant irritation
• It reduces the risk of Staphylococcus aureus resistance that develops with prolonged topical or systemic antibiotics 1
• No data support stopping effective topical antiseptic therapy once disease control is achieved

Why Stop Doxycycline Now

The evidence base for doxycycline monotherapy in HS is notably weak:

• Doxycycline 100 mg twice daily was studied in combination with adalimumab but was not independently linked to better outcomes 1
• The single RCT of tetracycline (a related antibiotic) showed only 30% reduction in abscesses with no significant patient-reported outcome improvements 1
• Systemic antibiotics are intended for acute flares or as adjunctive therapy, not long-term monotherapy 1, 2
• Prolonged antibiotic use increases antimicrobial resistance risk 2
• The patient has already completed a reasonable 30-day course and achieved the desired response

Specific Management Plan

Immediate Actions

1. Discontinue doxycycline (30-day course completed)
2. Continue benzoyl peroxide 5% wash daily to armpits, groin, and outer labia
   • Allow 1-2 minutes contact time before rinsing
   • Can reduce to every other day if irritation develops
3. Maintain lifestyle modifications: loose clothing, minimize friction, avoid squeezing lesions

Monitoring Strategy

• Schedule follow-up in 4-8 weeks to assess sustained remission
• Educate patient on early flare signs: new painful nodules, increased drainage, worsening pain
• If flare occurs before scheduled follow-up, return immediately for assessment

If Disease Recurs or Worsens

The treatment escalation pathway depends on severity:

For mild recurrence (few inflammatory nodules):

• Consider clindamycin 300 mg + rifampin 300 mg twice daily for 8-12 weeks (response rates 71-93%) 1
• Can be repeated intermittently as needed 1

For moderate-to-severe disease or inadequate response to antibiotics:

• Transition to adalimumab (the only FDA-approved biologic with strong evidence) 3
• Consider secukinumab or bimekizumab (IL-17 inhibitors with strong recommendations) 3
• Surgical intervention for localized disease unresponsive to medical therapy 1

Critical Pitfalls to Avoid

⚠️ Do not continue doxycycline indefinitely - this increases antimicrobial resistance without proven long-term benefit in HS 1, 2

⚠️ Do not stop benzoyl peroxide - ongoing antiseptic skin care is a cornerstone of HS maintenance 1

⚠️ Do not wait for severe flare before escalating - if patient experiences frequent recurrences (>2-3 flares requiring antibiotics within 6 months), this indicates need for systemic immunomodulatory therapy rather than repeated antibiotic courses 1, 3

⚠️ Ensure lab results are reviewed - the ordered hepatitis, HIV, TB, and metabolic panels are essential if future escalation to biologics becomes necessary 4

Alternative Consideration

If the patient experiences relapse within 1-3 months, this suggests the disease is more active than Hurley stage I and you should not attempt another course of doxycycline monotherapy. Instead, move directly to combination clindamycin-rifampin or consider biologic therapy, as monotherapy antibiotics have lower response rates and increased recurrence in more advanced disease 1.