What are the recommended antibiotics for treating hidradenitis abscess?

Recommended Antibiotics for Hidradenitis Suppurativa Abscesses

For hidradenitis suppurativa (HS) abscesses, the recommended first-line antibiotic treatment is a combination of oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks. 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• Topical clindamycin 1% solution/gel twice daily for 12 weeks as first-line therapy 1, 2
• Intralesional corticosteroid injections for acute, inflamed individual lesions 1
• Oral tetracyclines (doxycycline 100 mg once or twice daily) for 12 weeks if topical therapy fails 1, 2

Moderate Disease (Hurley Stage II)

• Oral tetracyclines (doxycycline 100 mg once or twice daily or lymecycline 408 mg daily) for 12 weeks as first-line therapy 1, 2
• Combination of oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks as second-line therapy 1, 3
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1, 2

Severe Disease (Hurley Stage III)

• Combination of oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1
• For more severe or refractory cases, consider triple antibiotic therapy with moxifloxacin, metronidazole, and rifampicin 1, 4
• IV ertapenem can be considered as rescue therapy for severe disease or as a bridge to surgery 1
• Adalimumab 40 mg weekly for moderate-to-severe disease unresponsive to conventional systemic therapy 1

Evidence for Clindamycin-Rifampicin Combination

The combination of clindamycin and rifampicin has strong evidence supporting its efficacy:

• A retrospective study of 116 patients showed dramatic improvement in disease severity after 10 weeks of treatment with clindamycin 300 mg twice daily and rifampicin 600 mg daily 3
• A prospective study demonstrated 73% clinical response rate after 12 weeks of treatment with clindamycin 600 mg and rifampicin 600 mg daily 5
• The rationale for combining these two antibiotics is to increase bactericidal action and reduce rifampicin resistance 6

Special Considerations

• Clindamycin monotherapy (300 mg twice daily) may be considered as an alternative in selected patients when rifampicin is contraindicated 7
• High BMI and smoking habits appear to be predictive factors of poor response to antibiotic therapy 6
• For recurrent abscesses, culture the lesions and treat with a 5-10 day course of an antibiotic active against the isolated pathogen 1
• Consider a 5-day decolonization regimen (intranasal mupirocin, chlorhexidine washes, decontamination of personal items) for recurrent S. aureus infections 1

Monitoring and Follow-up

• Assess treatment response after 12 weeks using recognized instruments for pain and quality of life 1, 8
• For patients on adalimumab, include inflammatory lesion count in assessment 1
• Be aware that recurrence following cessation of antibiotics is frequent 1
• Monitor for side effects of antibiotic therapy, particularly gastrointestinal symptoms with clindamycin (6.9% of patients may discontinue treatment due to side effects) 3

Cautions and Pitfalls

• Avoid long-term antibiotic use without treatment breaks to reduce risk of antimicrobial resistance 1, 2
• Do not offer isotretinoin unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk 1
• Be aware that non-surgical methods rarely result in lasting cure for advanced disease 2, 8
• Screen for associated comorbidities including depression, anxiety, and cardiovascular risk factors 1