What antibiotic and for how long to treat hidradenitis suppurativa?

Antibiotic Treatment for Hidradenitis Suppurativa

For hidradenitis suppurativa, first-line treatment should be oral tetracyclines (doxycycline 100 mg or lymecycline 408 mg) once or twice daily for at least 12 weeks, followed by clindamycin 300 mg plus rifampicin 300 mg twice daily for 10-12 weeks if tetracyclines fail. 1, 2

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

1. First-line: Oral tetracyclines

   • Doxycycline 100 mg daily or twice daily OR
   • Lymecycline 408 mg daily or twice daily
   • Duration: At least 12 weeks 1, 2
   • Consider treatment breaks to assess ongoing need and limit antimicrobial resistance 1

2. Adjunctive therapy: Topical clindamycin 1% solution twice daily 1, 2

3. If inadequate response: Proceed to combination antibiotic therapy

Moderate-to-Severe Disease (Hurley Stage II-III) or Failed Tetracycline Treatment

1. First-line combination: Clindamycin 300 mg + Rifampicin 300 mg, both twice daily

   • Duration: 10-12 weeks 1, 2, 3
   • Clinical trials show this combination can substantially improve HS in ~80% of cases and achieve remission in ~50% of cases for stage I and mild stage II disease 3

2. If inadequate response or intolerance: Consider alternative treatments

   • Acitretin 0.3-0.5 mg/kg/day (males and non-fertile females) 1
   • Dapsone 1
   • Adalimumab (for moderate-to-severe disease unresponsive to conventional therapy) 1, 2

Evidence for Antibiotic Regimens

Tetracyclines

• Strong recommendation for use as first-line therapy for at least 12 weeks 1
• Effective for mild-to-moderate disease 2
• Pediatric patients ≥8 years old can be treated with doxycycline 2

Clindamycin-Rifampicin Combination

• Strong recommendation for use in patients unresponsive to oral tetracyclines 1
• The rationale for combining these drugs is to increase bactericidal action and reduce rifampicin resistance 4
• More effective than clindamycin monotherapy, with studies showing greater reduction in disease severity scores 4

Clindamycin Monotherapy

• May be considered as an alternative when rifampicin is contraindicated 5
• Less effective than the combination therapy based on comparative studies 4

Factors Affecting Treatment Response

• High BMI and smoking are predictive factors of poor response to antibiotics 4
• In patients receiving clindamycin-rifampicin combination, smoking pack-years positively correlate with disease severity 4

Special Considerations

1. Pediatric patients:

   • Doxycycline for patients ≥8 years old 2
   • Adalimumab for patients 12 years and older requiring biologics 1

2. Patients with malignancy:

   • Doxycycline is recommended as it has evidence of safety 1
   • Coordinate biologic therapy with oncology 2

3. Treatment monitoring:

   • Regularly assess inflammatory lesion count, pain levels, and quality of life measures 2
   • Consider treatment breaks with tetracyclines to assess ongoing need and limit antimicrobial resistance 1

When to Consider Surgical Options

• For patients with persistent disease despite medical therapy 2
• Consider extensive excision when conventional systemic treatments have failed 1

Common Pitfalls and Caveats

1. Avoid prolonged continuous antibiotic use without treatment breaks to limit antimicrobial resistance 1

2. Do not offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 1

3. Rifampicin is highly mutagenic and prolonged use should be discouraged 5

4. Monitor for side effects of clindamycin, particularly severe diarrhea and C. difficile colitis 1

5. Rifampicin enhances safety when combined with clindamycin for HS treatment as it is effective against C. difficile, a pathogen that can arise during clindamycin treatment 3