What is the antibiotic treatment for hidradenitis suppurativa?

Antibiotic Treatment for Hidradenitis Suppurativa

For hidradenitis suppurativa, the first-line antibiotic treatment is oral tetracyclines (doxycycline or lymecycline) for at least 12 weeks, followed by combination therapy with oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks if tetracyclines are ineffective. 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

1. First-line:

   • Topical clindamycin 1% solution 1, 2
   • Oral tetracyclines (doxycycline or lymecycline) for at least 12 weeks 1

2. If inadequate response:

   • Combination therapy with oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1, 2

Moderate-to-Severe Disease (Hurley Stage II-III)

1. First-line:

   • Combination therapy with oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1, 2, 3

2. If inadequate response:

   • Consider adalimumab (biologic therapy) 1, 2
   • Consider infliximab if adalimumab fails 1, 2

Evidence for Antibiotic Efficacy

Tetracyclines

• Recommended as first-line therapy for at least 12 weeks 1
• Consider treatment breaks to assess ongoing need and limit antimicrobial resistance 1
• Caution: Avoid doxycycline in pregnant patients due to risk of congenital anomalies and tooth discoloration 1

Clindamycin-Rifampicin Combination

• Strong evidence supports this combination for moderate-to-severe disease 1, 3
• Studies show dramatic improvement in Sartorius score after 10 weeks of treatment 3
• Response rates of 71-93% reported in systematic reviews 2
• Provides both antibacterial and anti-inflammatory effects 4

Clindamycin Monotherapy

• May be considered as an alternative to combination therapy in selected patients 5
• Studies show significant reduction in disease severity parameters during 12-week treatment 5
• Less effective than combination therapy, with combination therapy showing higher reduction in mSartorius score (Δ = -13.2, P = .058) and AISI (Δ = -4.91, P = .034) 6

Important Considerations and Monitoring

Side Effects and Precautions

• Monitor for severe diarrhea and C. difficile colitis with clindamycin 2
• Use caution with rifampicin in patients with hepatitis B/C due to hepatotoxicity risk 2
• Avoid rifampicin in HIV-positive patients due to potential drug interactions with antiretroviral therapy 2
• Consider that approximately 6.9% of patients may discontinue clindamycin-rifampicin combination due to side effects 3

Factors Affecting Treatment Response

• High BMI and smoking habits may be predictive factors of poor response to antibiotics 6
• In patients receiving clindamycin-rifampicin combination, smoking pack-years positively correlate with disease severity 6

Pregnancy Considerations

• For pregnant patients requiring systemic antibiotics:
  • Cephalexin or azithromycin are suggested as safer options 1
  • Clindamycin monotherapy may be considered 1
  • Avoid doxycycline, erythromycin, metronidazole, co-trimoxazole, and dapsone 1

Beyond Antibiotics

• Consider intralesional corticosteroid injections for acute, localized flares 1, 2
• For persistent disease despite antibiotic therapy, consider surgical options or biologic therapy 1, 2
• Address lifestyle factors: smoking cessation and weight management services 1
• Screen for associated comorbidities including depression, anxiety, and cardiovascular risk factors 1, 2