What medications are used to treat hidradenitis suppurativa?

Medications for Hidradenitis Suppurativa

The most effective first-line medications for hidradenitis suppurativa (HS) are doxycycline 100mg twice daily or the combination of clindamycin 300mg twice daily with rifampicin 600mg once daily for 10-12 weeks, with adalimumab being the preferred treatment for moderate to severe disease. 1

First-Line Medication Options Based on Disease Severity

Mild Disease (Hurley Stage I)

• Topical therapies:
  • Clindamycin 1% solution
  • Antiseptic washes
  • Resorcinol 15% cream
• Systemic antibiotics:
  • Doxycycline 100mg twice daily for 12 weeks 1

Moderate Disease (Hurley Stage II)

• First-line combination therapy:
  • Clindamycin 300mg orally twice daily + Rifampicin 600mg orally once daily for 10-12 weeks 1
• If inadequate response:
  • Adalimumab (160mg at week 0, 80mg at week 2, then 40mg weekly) 1, 2

Severe Disease (Hurley Stage III)

• First-line biologic therapy:
  • Adalimumab as first-line therapy (160mg at week 0, 80mg at week 2, then 40mg weekly) 1, 2
  • Clinical trials showed 42-59% of patients achieved Hidradenitis Suppurativa Clinical Response (HiSCR) with adalimumab compared to 26-28% with placebo 2

Alternative Antibiotic Options

• Rifampin (use with caution due to drug interactions) 1
• Amoxicillin/clavulanic acid 1
• Erythromycin 1
• Azithromycin 1
• Metronidazole 1

Special Populations

Pregnant Patients

• Cephalexin or azithromycin are safer options 1

Pediatric Patients

• Doxycycline for patients ≥8 years old 1

Breastfeeding Patients

• Avoid doxycycline or limit to 3 weeks without repeating courses 1

Patients with HIV

• Doxycycline preferred (added benefit of STI prophylaxis) 1
• Avoid rifampin (potential interactions with antiretroviral therapy) 1

Monitoring and Follow-up

• Evaluate response at 12 weeks using:
  • Lesion count
  • Pain scores
  • Quality of life measures 1
• Monitor for side effects:
  • With resorcinol: local skin irritation 1
  • With adalimumab: serious infections including tuberculosis (screen for latent TB before starting) 1, 2
  • With clindamycin: severe diarrhea and C. difficile colitis 1

Important Clinical Considerations

• Weight loss is the most important lifestyle modification for HS management 3
• Smoking and high BMI are predictive factors of poor response to antibiotics 4
• Adalimumab serum concentrations reach approximately 7-8 mcg/mL at Week 2 and Week 4 after initial loading doses, with steady-state concentrations of 7-11 mcg/mL during weekly treatment 2
• For patients who cannot tolerate clindamycin-rifampicin combination, clindamycin monotherapy (300mg twice daily) may be an alternative, though combination therapy shows better efficacy 5, 4

Adjunctive Treatments

• Intralesional corticosteroid injections for acute flares 3
• De-roofing fluctuant nodules 3
• Surgical excision or CO2 laser ablation for definitive treatment of recurrent or persistent lesions 1, 3

By following this medication algorithm based on disease severity, patients with hidradenitis suppurativa can achieve significant improvement in symptoms and quality of life.