What antibiotics are recommended for the treatment of hidradenitis suppurativa?

Antibiotic Treatment for Hidradenitis Suppurativa

Oral tetracyclines (doxycycline 100 mg once or twice daily) are the first-line antibiotic treatment for mild-to-moderate hidradenitis suppurativa for at least 12 weeks, while the combination of clindamycin 300 mg twice daily and rifampicin 300 mg twice daily is recommended as second-line therapy or first-line for more severe disease. 1

Treatment Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line: Tetracyclines (doxycycline 100 mg daily or twice daily, or lymecycline 408 mg daily) for 12 weeks 1
• Topical option: Clindamycin 1% solution applied twice daily to affected areas 1
  • Note: Topical clindamycin may reduce pustules but carries a high risk of bacterial resistance 2
• For individual inflammatory lesions: Intralesional corticosteroid injections (triamcinolone 10 mg/mL) 1

Moderate Disease (Hurley Stage II)

• First-line: Tetracyclines for 12 weeks 1
• Second-line: Clindamycin 300 mg twice daily + Rifampicin 300 mg twice daily for 10-12 weeks 2, 1
  • This combination has shown response rates of 71-93% according to systematic reviews 1
  • Rifampicin is a key component due to its effects on bacterial biofilms and immunomodulatory properties 3

Severe Disease (Hurley Stage III)

• First-line: Clindamycin + Rifampicin combination 2, 1
• Alternative: Moxifloxacin, metronidazole, and rifampicin combination 2
  • Dosing: Rifampicin (10 mg/kg once daily), moxifloxacin (400 mg daily), and metronidazole (500 mg three times daily) for 6 weeks 3
  • Metronidazole is typically stopped at week 6, while rifampicin and moxifloxacin are continued if improvement occurs 3
• For severe cases as rescue therapy: IV ertapenem can be considered as a one-time rescue therapy or as a bridge to surgery or other maintenance therapy 2

Important Clinical Considerations

Duration of Treatment

• Standard course for tetracyclines: 12 weeks minimum 1
• Clindamycin + Rifampicin: 10-12 weeks 1
• Treatment duration should balance clinical benefit against the risk of antibiotic resistance 2
• Recurrence following cessation of antibiotics is frequent 2

Monitoring and Side Effects

• For clindamycin: Monitor for severe diarrhea and C. difficile colitis 1
• For tetracyclines: Avoid in pregnancy and limit to 3 weeks without repeating courses in breastfeeding patients 1
• For rifampicin: Note that it enhances safety when combined with clindamycin as it is effective against C. difficile 3

Special Populations

• Pediatric patients ≥8 years: Can be treated with doxycycline 1
• HIV patients: Prefer doxycycline (added benefit of STI prophylaxis); avoid rifampicin due to potential antiretroviral therapy interactions 1

Alternative Antibiotic Approaches

• Subantimicrobial dosing: Modified-release doxycycline 40 mg once daily has shown comparable efficacy to regular-release doxycycline 100 mg twice daily, with potentially lower risk of antibiotic resistance 4
• Dapsone: May be effective for a minority of patients with Hurley stage I or II disease as long-term maintenance therapy 2

Factors Affecting Treatment Response

• High body mass index (BMI) and smoking habits are predictive factors of poor response to antibiotic therapy 5
• Consider smoking cessation and weight management referrals to improve treatment outcomes 1

When Antibiotics Fail

• If antibiotics are ineffective, consider biologics such as adalimumab or infliximab 2, 1
• Surgical interventions are often needed alongside medical therapy, especially for recurrent lesions 6

Remember that hidradenitis suppurativa is a chronic inflammatory disease rather than primarily an infectious disease, so antibiotics are used for both their antimicrobial and anti-inflammatory properties 4, 7.