What antibiotics are used to treat hidradenitis suppurativa?

Antibiotic Treatment for Hidradenitis Suppurativa

Oral doxycycline 100mg twice daily is recommended as the first-line oral antibiotic for patients with hidradenitis suppurativa, due to its well-established safety profile and demonstrated efficacy in reducing inflammatory lesions. 1

First-Line Antibiotic Options

Mild Disease (Hurley Stage I)

• Topical antibiotics:
  • Clindamycin 1% solution/gel twice daily for 12 weeks 1
• Systemic antibiotics:
  • Doxycycline 100mg once or twice daily for 12 weeks 1

Moderate Disease (Hurley Stage II)

• First-line combination:
  • Clindamycin 300mg + rifampicin 300mg twice daily for 10-12 weeks 1
  • Alternative dosing: Clindamycin 300mg twice daily + rifampicin 600mg once daily for 10-12 weeks 1

Severe Disease (Hurley Stage III)

• Antibiotics may be used as adjunctive therapy
• Biologics (adalimumab) are recommended as first-line therapy 1

Antibiotic Selection Based on Efficacy

The highest effectiveness against bacterial isolates in hidradenitis suppurativa has been observed with:

• Penicillins with β-lactamase inhibitors (only 11.9% resistant strains) 2
• Fluoroquinolones (only 11.9% resistant strains) 2
• Carbapenems (only 8.5% resistant strains) 2

Special Populations

Pregnant Patients

• Cephalexin or azithromycin are suggested as safer options 1

Breastfeeding Patients

• Recommended options: 3
  • Rifampin
  • Amoxicillin/clavulanic acid
  • Erythromycin
  • Azithromycin
  • Metronidazole
• Limited use: Doxycycline (limit to 3 weeks without repeating courses) 3
• Exercise caution: Clindamycin (may increase risk of GI side effects in the infant) 3

HIV-Positive Patients

• Recommended: Doxycycline (provides added prophylactic benefit against bacterial STIs) 3
• Also consider: 3
  • Dapsone (provides prophylaxis against Pneumocystis jirovecii pneumonia)
  • Co-trimoxazole (trimethoprim/sulfamethoxazole) (lowers mortality and infection rates)
• Use with caution: Rifampin (potential drug interactions with HIV therapies) 3

Patients with Hepatitis B or C

• Recommended: 3
  • Ciprofloxacin (especially with evidence of cirrhosis)
  • Co-trimoxazole (especially with evidence of cirrhosis)
  • Doxycycline (approach similar to general population)
• Use with caution: Rifampin (potential risk of hepatotoxicity) 3

Alternative Antibiotic Regimens

For refractory cases, a combination of rifampin, moxifloxacin, and metronidazole has shown efficacy:

• Complete remission was achieved in 100% of Hurley stage I and 80% of Hurley stage II patients 4
• Median treatment duration: 2.4 months for stage I and 3.8 months for stage II 4
• Common adverse events: gastrointestinal disorders (64%) and vaginal candidiasis (35% of females) 4

Treatment Assessment

• Evaluate response at 12 weeks using:
  • Lesion count
  • Pain scores (Visual Analog Scale)
  • Quality of life measures 1

Monitoring for Adverse Effects

• Clindamycin: Monitor for severe diarrhea and C. difficile colitis 1
• Rifampin: Monitor for drug interactions and hepatotoxicity 3
• Doxycycline: Monitor for photosensitivity and esophageal irritation 1

Common Pitfalls to Avoid

1. Prolonged antibiotic use without assessment: Evaluate response at 12 weeks and consider alternative therapies if inadequate response
2. Ignoring bacterial resistance: Consider culture and sensitivity testing in refractory cases
3. Overlooking comorbidities: Adjust antibiotic selection based on comorbid conditions (HIV, hepatitis, pregnancy)
4. Monotherapy for moderate-severe disease: Combination therapy is more effective for moderate disease
5. Relying solely on antibiotics for severe disease: Biologics should be considered for Hurley stage III

Antibiotics remain a cornerstone of HS management, especially for mild to moderate disease, and serve as adjunctive or bridge treatments in severe cases when biologics may not be accessible due to cost, availability, or contraindications 5.