What is the recommended antibiotic (abx) treatment for Hurley stage 3 hidradenitis suppurativa?

Hurley Stage III Hidradenitis Suppurativa: Antibiotic Treatment

For Hurley Stage III hidradenitis suppurativa, immediate combination therapy with clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks should be initiated, though antibiotics alone rarely achieve lasting cure in severe disease and surgical intervention should be planned concurrently. 1

Initial Management Approach

Immediate referral to dermatology secondary care is essential for all Hurley Stage III disease. 1 The British Association of Dermatologists explicitly recommends bypassing tetracycline monotherapy and proceeding directly to combination antibiotic therapy in severe disease. 1

First-Line Antibiotic Regimen

Start clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks immediately. 1 This combination demonstrates:

• Response rates of 71-93% across multiple studies 1, 2
• Dramatic improvement in Sartorius scores (median reduction from 29 to 14.5, p<0.001) 2
• Superior efficacy compared to clindamycin monotherapy, with 13.2-point greater reduction in modified Sartorius score 3

The rationale for this combination is that rifampin increases bactericidal action, reduces rifampicin resistance, disrupts bacterial biofilms, and provides anti-inflammatory and immunomodulatory effects beyond simple antimicrobial activity. 4 Rifampin also protects against Clostridium difficile infection that can arise from clindamycin use. 4

Expected Outcomes in Stage III Disease

Realistic expectations must be set: antibiotics provide temporary control but rarely achieve lasting cure in Hurley Stage III disease. 1 The North American guidelines report that triple antibiotic therapy (moxifloxacin-metronidazole-rifampin) achieved remission in only 16.7% of Hurley Stage III patients, compared to 100% in Stage I and 80% in Stage II. 1

Surgical Planning

Extensive surgical excision should be planned concurrently with antibiotic therapy, not sequentially. 1 The British Association of Dermatologists recommends:

• Referral to hidradenitis suppurativa surgical multidisciplinary team 1
• Extensive excision to minimize recurrence rates 1
• Secondary intention healing or thoracodorsal artery perforator (TDAP) flap closure for axillary wounds 1

Surgery is often necessary for lasting cure in advanced disease with sinus tracts and scarring characteristic of Stage III. 5

Alternative Antibiotic Regimens

If clindamycin-rifampicin fails or cannot be tolerated, consider triple therapy with moxifloxacin 400 mg daily, metronidazole 500 mg three times daily, and rifampin 300 mg twice daily. 1 Metronidazole should be stopped at 6 weeks to avoid neurologic toxicity, while moxifloxacin and rifampin continue if improvement occurs. 1

Ertapenem 1 g intravenously daily for 6 weeks can be used as rescue therapy or bridge to surgery, though relapses are frequent upon discontinuation. 1 This is reserved as third-line therapy given practical barriers to home infusions and antimicrobial resistance concerns. 1

Biologic Therapy Escalation

If antibiotics fail after 12 weeks, escalate to adalimumab 40 mg weekly (not every other week). 1 The dosing schedule is:

• 160 mg at week 0
• 80 mg at week 2
• 40 mg weekly starting at week 4 5

Do not use adalimumab 40 mg every other week, as this dosing is explicitly not recommended. 1

For adalimumab failures, consider infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks. 1

Critical Adjunctive Measures

Regardless of antibiotic choice, address:

• Pain management with NSAIDs 1
• Appropriate wound dressings for draining lesions 1
• Smoking cessation referral (smoking pack-years correlate with poor antibiotic response) 1, 3
• Weight management referral (high BMI predicts poor antibiotic response) 1, 3
• Screen for depression, anxiety, and cardiovascular risk factors (blood pressure, lipids, HbA1c) 1

Treatment Monitoring

Reassess at 12 weeks using:

• Pain visual analogue scale 1
• Inflammatory lesion count 1
• Quality of life measures (DLQI) 1
• Hidradenitis Suppurativa Clinical Response (HiSCR): ≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas 5

Common Pitfalls to Avoid

Do not start with tetracycline monotherapy (doxycycline or lymecycline) in Hurley Stage III disease - these are ineffective for severe disease with deep inflammatory lesions, abscesses, and sinus tracts. 6, 5 The British Association of Dermatologists pathway explicitly states to bypass tetracyclines and proceed directly to clindamycin-rifampicin in Stage III. 1

Do not continue antibiotics indefinitely without surgical planning - antibiotics provide temporary control but non-surgical methods rarely result in lasting cure for advanced disease. 5 Consider treatment breaks after 10-12 weeks to assess ongoing need and limit antimicrobial resistance. 1

Do not delay multidisciplinary team involvement - manage via multidisciplinary approach from the outset, particularly when surgical interventions are anticipated. 1