What antibiotics are used to treat hidradenitis suppurativa?

Antibiotic Treatment for Hidradenitis Suppurativa

For hidradenitis suppurativa, the first-line antibiotic therapy should be oral tetracyclines (doxycycline 100 mg once or twice daily) for 12 weeks, followed by the combination of clindamycin 300 mg twice daily plus rifampin 300 mg twice daily for moderate-to-severe disease. 1

First-Line Antibiotic Options

Tetracyclines

• Doxycycline: 100 mg once or twice daily for 12 weeks 1

  • Preferred first-line option due to anti-inflammatory properties
  • Safe in patients with history of malignancy 2
  • Particularly beneficial in HIV-positive patients due to added prophylactic benefit against bacterial STIs 2
  • Can be used in pediatric patients ≥8 years old 2
  • Modified-release doxycycline 40 mg daily has shown comparable efficacy to regular-release doxycycline with potentially lower antibiotic resistance 3

• Minocycline: Alternative for patients with doxycycline intolerance 2

  • Safe in patients with history of malignancy 2
  • Recommended for pediatric patients ≥8 years old with doxycycline intolerance 2

• Tetracycline: Alternative option with moderate evidence of safety 2

Topical Options

• Topical clindamycin 1% solution twice daily to affected areas 1
  • May reduce pustules but carries risk of bacterial resistance 2
  • Can be used alongside systemic antibiotics

Second-Line Antibiotic Options

Combination Therapy

• Clindamycin + Rifampin: 300 mg clindamycin twice daily + 300 mg rifampin twice daily for 10-12 weeks 1, 4, 5
  • Recommended for moderate-to-severe disease or when tetracyclines fail
  • Response rates of 71-93% reported in systematic reviews 1
  • More effective than clindamycin monotherapy in reducing disease severity 4
  • Rifampin provides additional anti-inflammatory effects by inhibiting pro-inflammatory cytokines (IL-1β, IL-6, IL-8, TNF-α) 6
  • Monitor for severe diarrhea and C. difficile colitis with clindamycin 2
  • Use caution with rifampin in patients with hepatitis B/C due to hepatotoxicity risk 2
  • Avoid rifampin in HIV-positive patients due to potential drug interactions with antiretroviral therapy 2

Third-Line Antibiotic Options

• Moxifloxacin + Metronidazole + Rifampin: For moderate-to-severe disease 2, 1

  • Consider when other antibiotic regimens fail
  • Monitor for QT prolongation with moxifloxacin, especially in patients on certain chemotherapy agents 2

• Dapsone: For mild-to-moderate disease (Hurley stage I or II) 2

  • Can be used as long-term maintenance therapy 2
  • Provides added prophylactic benefit against Pneumocystis jirovecii pneumonia in HIV-positive patients 2
  • Safe in patients with history of malignancy 2

• IV Ertapenem: For severe, recalcitrant cases 2

  • Can be used as rescue therapy or bridge to other treatments 2
  • Safe in patients with history of malignancy 2

Special Patient Populations

Pediatric Patients

• Doxycycline recommended for patients ≥8 years old 2
• Minocycline for patients ≥8 years old with doxycycline intolerance 2
• Combination therapy with rifampin and clindamycin can be considered 2

Patients with Malignancy

• Doxycycline, tetracycline, minocycline, moxifloxacin, clindamycin, dapsone, and IV ertapenem are all considered safe 2

HIV-Positive Patients

• Doxycycline preferred due to added prophylactic benefit against bacterial STIs 2
• Avoid rifampin due to potential drug interactions with antiretroviral therapy 2
• Consider dapsone or co-trimoxazole for added prophylactic benefits 2

Treatment Algorithm Based on Disease Severity

1. Mild Disease (Hurley Stage I):

   • Tetracyclines for 12 weeks
   • Topical clindamycin 1% solution twice daily

2. Moderate Disease (Hurley Stage II):

   • Start with tetracyclines for 12 weeks
   • If inadequate response, switch to clindamycin + rifampin for 10-12 weeks
   • Consider dapsone for maintenance therapy

3. Severe Disease (Hurley Stage III):

   • Clindamycin + rifampin for 10-12 weeks
   • Consider IV ertapenem for severe flares
   • If inadequate response, consider moxifloxacin + metronidazole + rifampin

Important Considerations

• Antibiotic treatment should balance benefits with the risk of antibiotic resistance 2
• Disease recurrence is common after antibiotic cessation 2, 7
• Antibiotics in HS work through both antimicrobial and anti-inflammatory mechanisms 6, 7
• High BMI and smoking appear to be predictive factors of poor response to antibiotic therapy 4
• Consider antiseptic washes (chlorhexidine, zinc pyrithione) alongside antibiotics to decrease bacterial resistance 2, 1