What antibiotics are used to treat hidradenitis suppurativa?

Antibiotic Treatment for Hidradenitis Suppurativa

For mild disease (Hurley Stage I), use topical clindamycin 1% twice daily for 12 weeks; for moderate disease (Hurley Stage II), use oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks; for severe disease (Hurley Stage III), use the same clindamycin-rifampicin combination as bridge therapy while initiating adalimumab. 1

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• First-line: Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks 1, 2, 3
• Critical caveat: Always combine topical clindamycin with benzoyl peroxide wash or chlorhexidine 4% wash to reduce Staphylococcus aureus resistance risk, as monotherapy significantly increases antimicrobial resistance 2, 3
• Adjunctive therapy: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed individual nodules provides rapid symptom relief within 1 day 1, 2
• Alternative topical option: Resorcinol 15% cream reduces pain and abscess duration but causes irritant dermatitis in many patients; consider this when antibiotic resistance is a concern 1, 4

Moderate Disease (Hurley Stage II)

• First-line: Oral tetracyclines—doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily for 12 weeks 1, 2
• Second-line (preferred for abscesses/inflammatory nodules): Clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg daily for 10-12 weeks 1, 2, 5
  • This combination achieves response rates of 71-93%, far superior to tetracycline monotherapy 2, 5
  • The clindamycin-rifampicin combination is the superior choice for Hurley Stage II with deep inflammatory lesions or abscesses 2
• Critical pitfall: Do not use doxycycline as first-line for Hurley Stage II with abscesses or deep inflammatory nodules—it has minimal effect on these lesions 2

Severe Disease (Hurley Stage III)

• First-line: Clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg daily for 10-12 weeks as bridge therapy while initiating adalimumab 1, 2
• Adalimumab dosing: 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 2
• Rescue therapy: Ertapenem 1g IV daily for 6 weeks for severe disease requiring intravenous antibiotics during surgical planning 2
• Triple therapy option: Rifampin + moxifloxacin + metronidazole for refractory cases achieves complete remission in 100% of Hurley Stage I, 80% of Stage II, and 17% of Stage III patients 6

Treatment Duration and Monitoring

• Standard duration: 12 weeks for all oral antibiotics, with reassessment using pain VAS score, inflammatory lesion count, and DLQI 1, 2
• Extended duration: Tetracyclines can be continued up to 4 months (16 weeks) for more widespread mild disease 1, 2
• Treatment breaks: Always implement treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1, 2
• Response criteria: Use HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) at 12 weeks 2

When to Escalate Treatment

• After tetracycline failure: Escalate to clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks 2
• After clindamycin-rifampicin failure: Escalate directly to adalimumab (FDA-approved for moderate-to-severe HS in patients ≥12 years) 2
• After adalimumab failure: Consider infliximab 5 mg/kg at weeks 0,2,6, then every 2 months, OR secukinumab (64.5-71.4% response in adalimumab-failure patients), OR ustekinumab 2

Special Considerations

• Recurrent abscesses: Culture lesions and treat with a 5-10 day course of an antibiotic active against the isolated pathogen 1
• Recurrent S. aureus: Implement 5-day decolonization regimen (intranasal mupirocin, chlorhexidine washes, decontamination of personal items) 1
• Pediatric patients: For children ≥12 years with moderate-to-severe disease, use adalimumab; for children ≥8 years requiring systemic antibiotics, use oral doxycycline 2

Essential Adjunctive Measures (Always Implement)

• Smoking cessation referral: Tobacco use is associated with worse outcomes 2
• Weight management referral if BMI elevated 2
• Pain management: NSAIDs for symptomatic relief 2
• Appropriate wound dressings for draining lesions 2
• Screen for comorbidities: Depression, anxiety, cardiovascular risk factors (BP, lipids, HbA1c) 1, 2

Critical Pitfalls to Avoid

• Never use topical clindamycin monotherapy without benzoyl peroxide or chlorhexidine—this significantly increases S. aureus resistance 2, 3
• Never use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses 2
• Never continue antibiotics beyond 4 months without reassessment—prolonged use increases antimicrobial resistance without proven additional benefit 2
• Never use long-term antibiotics without treatment breaks to reduce antimicrobial resistance risk 1, 2
• Do not delay surgical referral for extensive disease with sinus tracts and scarring—combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2