What is the role of doxycycline (antibiotic) in the treatment of hidradenitis suppurativa?

Doxycycline for Hidradenitis Suppurativa

Doxycycline 100 mg once or twice daily for 12 weeks is a reasonable first-line oral antibiotic option for mild-to-moderate hidradenitis suppurativa (Hurley Stage I-II), but it is NOT independently linked to better outcomes and should NOT be used as first-line therapy for Hurley Stage II disease with abscesses or deep inflammatory nodules—clindamycin plus rifampicin is superior for these presentations. 1, 2

Role in Treatment Algorithm

Mild Disease (Hurley Stage I)

• Doxycycline 100 mg once or twice daily for 12 weeks is an acceptable first-line oral antibiotic for widespread mild disease after topical clindamycin 1% has been tried 1, 2
• Alternative tetracycline options include lymecycline 408 mg once or twice daily for 12 weeks 1, 3
• Tetracycline 500 mg twice daily demonstrated only a 30% reduction in abscesses in the single RCT comparing it to topical clindamycin, with no significant improvement in patient-reported outcomes 1

Moderate Disease (Hurley Stage II)

• Doxycycline monotherapy is NOT recommended as first-line for Hurley Stage II disease with abscesses or inflammatory nodules 1
• The PIONEER studies demonstrated that doxycycline 100 mg twice daily used in combination with adalimumab or placebo was not independently linked to better outcomes in either arm 1
• Clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks is the preferred first-line antibiotic regimen for moderate disease, with response rates of 71-93% in systematic reviews 1, 2, 3, 4

Evidence Quality and Limitations

The evidence supporting doxycycline in HS is notably weak:

• Only one RCT exists comparing tetracycline to topical clindamycin, showing modest 30% abscess reduction 1
• Doxycycline has been evaluated primarily in combination with biologics (PIONEER studies), where it showed no independent benefit 1
• A 2022 RCT comparing subantimicrobial modified-release doxycycline 40 mg daily to regular-release doxycycline 100 mg twice daily showed 60% achieved HiSCR at 12 weeks, but this was a small study (n=49) 5
• Real-world data from 2019 showed doxycycline achieved 60% HISCR response, which was higher than rifampicin-clindamycin (46.4%) in that particular cohort, but this contradicts guideline-level evidence favoring clindamycin-rifampicin 6

Treatment Duration and Monitoring

• Treat for 12 weeks initially, then reassess using pain VAS score, inflammatory lesion count, and quality of life measures (DLQI) 1, 2, 3
• Treatment can be extended up to 4 months (16 weeks) for more widespread mild disease 1, 2
• Do NOT continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit 2
• Fidelity to oral doxycycline in real-world practice is only 52% after 3 months due to lack of effectiveness, participant preference, and adverse effects 7

When to Escalate Treatment

If no clinical response after 12 weeks of doxycycline:

• Escalate to clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks 2, 3, 4
• Consider triple therapy (moxifloxacin + metronidazole + rifampin) as second/third-line treatment 1, 4
• Refer to dermatology for consideration of biologics (adalimumab) or surgical intervention 1, 2

Critical Pitfalls to Avoid

• Do NOT use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses—it has minimal effect on these lesions 1, 2
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk 1, 3
• Consider treatment breaks after 10-12 weeks to assess need for ongoing therapy 1, 3
• Recurrence following cessation of antibiotics is frequent, so plan for maintenance strategies 3

Adjunctive Measures

Regardless of antibiotic choice, always address:

• Smoking cessation referral (tobacco use associated with worse outcomes) 1, 2
• Weight management referral if BMI elevated 2, 4
• Pain management with NSAIDs for symptomatic relief 1, 2, 4
• Appropriate wound dressings for draining lesions 1, 4
• Screen for depression/anxiety and cardiovascular risk factors (BP, lipids, HbA1c) 1, 2, 4