What oral antibiotics are safe for treating hydradenitis suppurativa (acne inversa) during pregnancy?

Oral Antibiotics for Hidradenitis Suppurativa During Pregnancy

For pregnant patients with hidradenitis suppurativa requiring oral antibiotics, clindamycin is the recommended first-line treatment, while amoxicillin/clavulanic acid can be used as an alternative when clinically indicated. 1

Safe Oral Antibiotics During Pregnancy

The 2025 North American Clinical Practice Guidelines for hidradenitis suppurativa (HS) in special populations provides clear recommendations for antibiotic management during pregnancy:

First-Line Options:

• Clindamycin: Recommended as first-line therapy for pregnant patients with HS requiring systemic antibiotics 1

  • Dosing typically follows standard HS protocols
  • Monitor for potential GI side effects

• Amoxicillin/clavulanic acid: Recommended as an alternative when clinically indicated 1

  • Particularly useful when broader spectrum coverage is needed
  • Well-established safety profile in pregnancy

Second-Line Options:

• Rifampin: Can be used in select cases, but with caution regarding potential risk of preterm birth, low birthweight, and hemolysis 1
  • Should be reserved for cases unresponsive to first-line agents
  • Consider risk-benefit ratio carefully

Antibiotics to Avoid During Pregnancy

The guidelines explicitly recommend avoiding the following antibiotics during pregnancy:

• Doxycycline: Strong recommendation to avoid due to:

  • Increased risk of congenital anomalies
  • Potential binding to fetal bones
  • Risk of tooth discoloration 1

• Erythromycin: Strong recommendation to avoid due to:

  • Increased risk of adverse outcomes
  • Potential for elevated liver enzymes 1

Treatment Algorithm for HS in Pregnancy

1. Assess disease severity using Hurley staging or IHS4 score
2. First-line treatment: Oral clindamycin
3. Alternative first-line: Amoxicillin/clavulanic acid
4. Treatment-resistant cases: Consider rifampin with careful risk-benefit assessment
5. For severe, treatment-resistant cases: Consider biologics (adalimumab has strongest recommendation) 1

Important Considerations

• HS often requires ongoing management throughout pregnancy, as only 20% of patients experience symptom remission during pregnancy, while 72% experience no relief and 8% may deteriorate 2
• Pregnant women with HS have higher odds of gestational hypertension (OR 1.44) and cesarean deliveries (OR 1.28) 3
• Coordinated care between dermatologists and obstetric providers is essential for optimal outcomes 3

Pitfalls to Avoid

• Don't assume pregnancy will improve HS symptoms - most patients require continued treatment
• Don't prescribe tetracyclines (doxycycline, minocycline) during pregnancy due to fetal risks
• Don't overlook the potential need for biologics in severe cases - adalimumab has the strongest recommendation for use during pregnancy if needed 1
• Don't delay treatment as uncontrolled HS can lead to complications and reduced quality of life

For severe cases unresponsive to antibiotics, biologics may be considered, with adalimumab having the strongest recommendation (Strong, Moderate quality evidence) for use during pregnancy 1.