What is the dosage of doxycycline for hidradenitis suppurativa?

Doxycycline Dosing for Hidradenitis Suppurativa

For hidradenitis suppurativa, doxycycline should be prescribed at 100 mg twice daily for 12 weeks as first-line therapy for mild to moderate disease. 1

Disease Assessment and Treatment Selection

• Determine disease severity using Hurley staging:

  • Hurley I (mild): Limited inflammatory nodules without scarring/sinus tracts
  • Hurley II (moderate): Recurrent nodules with sinus tract formation and scarring
  • Hurley III (severe): Diffuse involvement with multiple interconnected tracts and scarring

• Document baseline measurements:

  • Pain level using Visual Analog Scale (VAS)
  • Quality of life using Dermatology Life Quality Index (DLQI)
  • Lesion count and number of flares in the last month 1

Doxycycline Treatment Protocol

First-line therapy for mild-moderate disease:

• Dosage: 100 mg twice daily 1
• Duration: 12 weeks 2, 1
• Mechanism: Provides both antimicrobial and anti-inflammatory effects

Treatment Response Assessment:

• Evaluate after 12 weeks of therapy 2, 1
• Measure:
  • Reduction in inflammatory lesion count
  • Improvement in pain levels
  • Quality of life measures

Alternative Antibiotic Options

If doxycycline is ineffective after 12 weeks, consider:

1. Clindamycin 300 mg + Rifampin 300 mg both twice daily for 10-12 weeks 2, 1

   • Higher efficacy with response rates of 71-93% 2
   • Monitor for diarrhea and C. difficile colitis

2. For severe cases (Hurley III):

   • Consider immediate clindamycin and rifampin therapy 2
   • Or referral for biologic therapy (adalimumab) 1

Evidence Comparison and Clinical Considerations

• While a single RCT comparing tetracycline 500 mg twice daily with topical clindamycin showed a 30% reduction in abscesses in both groups, doxycycline has become the preferred tetracycline due to better tolerability and twice-daily dosing 2

• A 2021 prospective study comparing tetracyclines found that standard tetracycline provided the greatest clinical improvement measured by Hidradenitis Suppurativa Score, but doxycycline remains the most commonly prescribed due to availability and dosing convenience 3

• Subantimicrobial, modified-release doxycycline 40 mg once daily showed comparable efficacy to regular-release doxycycline 100 mg twice daily in a 2022 study, with HiSCR achieved by 64% vs 60% of patients respectively 4

Important Considerations and Pitfalls

• Adherence concerns: Treatment fidelity to oral doxycycline was only 52% after 3 months in the THESEUS study due to lack of effectiveness, patient preference, and adverse effects 5

• Combination therapy: Doxycycline can be used alongside topical clindamycin 1% solution twice daily for affected areas 2, 1

• Adjunctive measures:

  • Provide dressings for pus-producing lesions
  • Offer smoking cessation referral (smoking has OR 12.55 for HS) 6
  • Recommend weight management (each BMI unit increases HS risk with OR 1.1) 6
  • Screen for depression/anxiety and cardiovascular risk factors 2, 1

• Special populations:

  • Safe in patients with history of malignancy
  • Beneficial in HIV-positive patients (provides prophylaxis against bacterial STIs)
  • Can be used in pediatric patients ≥8 years old 1

Remember that treatment response should be assessed at 12 weeks, and if inadequate, progression to combination antibiotic therapy or biologics should be considered based on disease severity.