Is mupirocin effective for treating hidradenitis suppurativa?

Mupirocin is NOT Recommended for Treating Hidradenitis Suppurativa

Mupirocin has no established role in the treatment of hidradenitis suppurativa and should not be used for this condition. The evidence shows mupirocin is mentioned only in the context of preventing recurrent skin abscesses (not hidradenitis suppurativa specifically), and even for that indication, its efficacy is questionable in the current era of community-acquired MRSA 1.

Why Mupirocin is Not Appropriate for HS

The IDSA guidelines explicitly distinguish hidradenitis suppurativa from simple recurrent abscesses, noting that recurrent abscesses may be caused by local factors including hidradenitis suppurativa, but the treatment approach differs fundamentally 1. The guidelines state that "eradication of which can be curative" refers to treating the underlying hidradenitis suppurativa itself, not using mupirocin 1.

Key evidence against mupirocin for HS:

• A randomized trial in military personnel showed that twice-daily intranasal mupirocin for 5 days did NOT reduce the frequency of subsequent skin infections in MRSA carriers 1
• The benefits of adjunctive antimicrobial therapy (including mupirocin) in preventing recurrences are unknown 1
• Mupirocin is a topical decolonization agent for nasal MRSA carriage, not a treatment for the chronic inflammatory disease process of hidradenitis suppurativa 1

What SHOULD Be Used Instead

For Mild HS (Hurley Stage I):

• Topical clindamycin 1% solution/gel twice daily for 12 weeks is the first-line therapy 2, 3
• Consider combining with benzoyl peroxide to reduce Staphylococcus aureus resistance risk 2
• Intralesional triamcinolone (10 mg/mL) for inflamed lesions 2, 3

For Moderate HS (Hurley Stage II):

• First-line: Tetracycline 500 mg twice daily for up to 4 months OR doxycycline 100 mg once or twice daily 2, 3
• Second-line: Clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg daily for 10-12 weeks 2, 3

For Severe HS (Hurley Stage III):

• Adalimumab: 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 2, 3
• Surgical intervention is often necessary for definitive treatment 2, 4

Critical Clinical Pitfall

Do not confuse hidradenitis suppurativa with simple skin abscesses or furunculosis. HS is a chronic inflammatory disease requiring systemic anti-inflammatory therapy (antibiotics with anti-inflammatory properties or biologics), not topical decolonization strategies 2, 5. The pathogenesis involves innate immune mechanisms (IL-1β, TNF), T-cell mechanisms (IL-17), and chronic inflammation leading to irreversible skin damage with tunnel formation 5.

Treatment Algorithm Based on Severity

1. Assess Hurley stage to determine disease severity 2, 3
2. Mild disease: Start topical clindamycin 2, 3
3. Moderate disease: Start oral tetracyclines, escalate to clindamycin/rifampicin if needed 2, 3
4. Severe disease: Initiate adalimumab AND refer to HS surgical multidisciplinary team 2, 4
5. Monitor response at 12 weeks using HiSCR (Hidradenitis Suppurativa Clinical Response) 2, 3

Additional Management Considerations

• Encourage smoking cessation (tobacco associated with worse outcomes) 2, 3
• Promote weight loss in patients with obesity 2, 3
• Screen for depression/anxiety and cardiovascular risk factors 2, 4
• Provide appropriate wound care for draining lesions 2, 3
• Consider treatment breaks after antibiotic courses to limit antimicrobial resistance 2