What is the role of doxycycline 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 for mild-to-moderate hidradenitis suppurativa (Hurley Stage I and mild Stage II), but it should not be used as first-line therapy for Hurley Stage II disease with abscesses or deep inflammatory nodules, where clindamycin plus rifampicin is superior. 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 after topical clindamycin 1% has been tried. 1, 2
• Alternative tetracycline options include lymecycline 408 mg once or twice daily for 12 weeks or tetracycline 500 mg twice daily. 1, 2
• Treatment duration can be extended up to 4 months (16 weeks) for more widespread mild disease. 2

Moderate Disease (Hurley Stage II)

• Doxycycline is NOT recommended as first-line therapy for Hurley Stage II disease with abscesses or inflammatory nodules. 2
• Clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks is the superior first-line choice for Hurley Stage II disease, with response rates of 71-93%. 1, 2
• Doxycycline monotherapy shows only modest efficacy, with one RCT demonstrating a 30% reduction in abscesses compared to topical clindamycin, with no significant improvement in patient-reported outcomes. 2

Evidence Quality and Limitations

The evidence supporting doxycycline in hidradenitis suppurativa is notably weak. 2

• Only one randomized controlled trial exists comparing tetracycline to topical clindamycin, showing modest 30% abscess reduction. 2
• Doxycycline has been evaluated primarily in combination with biologics (PIONEER studies), where it showed no independent benefit. 2
• A 2022 study demonstrated that subantimicrobial modified-release doxycycline 40 mg once daily showed comparable efficacy to regular-release doxycycline 100 mg twice daily, with HiSCR achieved in 64% vs 60% of patients respectively. 3
• A 2021 prospective study of 108 patients found that tetracycline provided the greatest clinical improvement measured by Hidradenitis Suppurativa Score compared to doxycycline and lymecycline. 4

Treatment Duration and Monitoring

• Treat for 12 weeks initially, then reassess using pain Visual Analog Scale (VAS) score, inflammatory lesion count, and Dermatology Life Quality Index (DLQI). 1, 2
• Fidelity to oral doxycycline is only 52% after 3 months due to lack of effectiveness, participant preference, and adverse effects. 5
• Do not continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit. 2

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. 1, 2

• For severe disease or failure of clindamycin-rifampicin after 12 weeks, escalate to adalimumab (160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4). 2, 6
• Consider referral to dermatology for biologics 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, as it has minimal effect on these lesions. 2
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 1, 2
• Do not use doxycycline monotherapy for Hurley Stage III disease; these patients require immediate clindamycin-rifampicin therapy or biologics. 1

Special Populations

HIV-Positive Patients

• In patients with HS and HIV positivity who require systemic antibiotics, doxycycline is suggested due to its added prophylactic benefit against bacterial sexually transmitted infections. 1

Pediatric Patients

• For children aged 8 years and older requiring systemic antibiotics, oral doxycycline is recommended. 2

Adjunctive Measures (Essential Regardless of Antibiotic Choice)

• Smoking cessation referral (98.1% of HS patients are heavy smokers). 1, 7
• Weight management referral if BMI elevated (86% of HS patients have raised BMI). 1, 5
• Pain management with NSAIDs for symptomatic relief. 1, 2
• Appropriate wound dressings for draining lesions. 1, 2
• Screen for depression/anxiety and cardiovascular risk factors (blood pressure, lipids, HbA1c). 1, 2
• Topical clindamycin 1% twice daily can be combined with oral doxycycline; consider adding benzoyl peroxide wash to reduce Staphylococcus aureus resistance risk. 2, 6