What is the best treatment option for a patient with hidradenitis suppurativa (HS) who has multiple abscesses in the axilla and between the thighs, considering oral (doxycycline (Doxycycline)) or topical/clindamycin (Clindamycin) therapy?

Treatment of Hidradenitis Suppurativa with Multiple Abscesses

Direct Answer

For a patient with hidradenitis suppurativa presenting with multiple abscesses in the axilla and between the thighs (indicating moderate-to-severe disease), oral clindamycin 300 mg twice daily combined with rifampicin 300-600 mg daily for 10-12 weeks is the superior first-line treatment choice, achieving response rates of 71-93%. 1, 2, 3 Neither oral doxycycline monotherapy nor topical clindamycin alone is appropriate for this clinical presentation with multiple active abscesses. 1, 2

Why the Other Options Are Inadequate

Option A: Oral Doxycycline - Inappropriate for Multiple Abscesses

• Doxycycline monotherapy has minimal effect on deep inflammatory lesions and abscesses characteristic of moderate-to-severe HS and should not be used as first-line therapy for patients with multiple abscesses. 1, 2
• Tetracycline antibiotics demonstrated only a 30% reduction in abscesses in randomized controlled trials, with no significant improvement in patient-reported outcomes. 2
• Doxycycline is not independently linked to better outcomes in Hurley Stage II disease (which your patient has, given multiple abscesses and scarring). 1
• The American Academy of Dermatology explicitly recommends against using doxycycline as first-line for disease with abscesses or inflammatory nodules. 1, 2

Option B: Topical Clindamycin - Insufficient for Moderate-to-Severe Disease

• Topical clindamycin 1% is recommended only for mild disease (Hurley Stage I) with isolated nodules without sinus tracts or scarring. 1, 2
• Your patient has already progressed beyond mild disease with multiple abscesses in two anatomic locations plus scarring, indicating at minimum Hurley Stage II disease. 1
• Topical therapy cannot adequately penetrate to treat deep-seated abscesses and inflammatory nodules. 1

Correct Treatment: Oral Clindamycin + Rifampicin Combination

Dosing Regimen

• Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks. 1, 2, 3
• This combination achieves response rates of 71-93%, far superior to any monotherapy option. 1, 3
• The rationale for combining these two drugs is to increase bactericidal action and reduce rifampicin resistance, as rifampicin is highly mutagenic. 4

Evidence Supporting This Approach

• The American Academy of Dermatology recommends this combination as first-line therapy for moderate disease (Hurley Stage II). 1, 2
• The British Association of Dermatologists recommends this as second-line therapy after tetracyclines, but given your patient's presentation with multiple abscesses, this should be first-line. 1, 2
• A retrospective study of 116 patients showed dramatic improvement in Sartorius scores (median 29 to 14.5, p<0.001) with this combination. 5
• Recent 2021 data confirms higher reduction in disease severity scores with clindamycin-rifampicin combination versus clindamycin monotherapy (Δ = -13.2 in mSartorius score, P = .058). 4

Assessment Before Starting Treatment

• Document baseline Hurley stage (likely Stage II given multiple abscesses and scarring). 1, 3
• Record baseline pain using Visual Analog Scale (VAS) and inflammatory lesion count. 1, 3
• Measure quality of life using Dermatology Life Quality Index (DLQI). 1, 3
• Screen for cardiovascular risk factors (blood pressure, lipids, HbA1c), depression, and anxiety. 1, 2

Reassessment and Treatment Escalation

• Reassess at 12 weeks using pain VAS score, inflammatory lesion count, and DLQI. 1, 3
• If inadequate response after 12 weeks of clindamycin-rifampicin, escalate to adalimumab (160 mg at week 0,80 mg at week 2, then 40 mg weekly). 1, 2, 3
• Consider urgent dermatology referral for biologic therapy if Hurley Stage III disease is present (diffuse involvement with sinus tracts). 3

Essential Adjunctive Measures

• Refer to smoking cessation services immediately, as tobacco use predicts poor antibiotic response and worsens outcomes. 3, 4
• Refer to weight management services if BMI is elevated, as high BMI is a predictive factor of poor response to antibiotics. 3, 4
• Provide pain management with NSAIDs for symptomatic relief. 1, 3
• Apply appropriate wound dressings for draining lesions. 1
• Consider intralesional triamcinolone 10 mg/mL for acutely inflamed nodules to provide rapid symptom relief. 1

Critical Pitfalls to Avoid

• Do not use doxycycline or topical clindamycin for patients with multiple abscesses, as they are ineffective for this severity of disease. 1, 2
• Do not continue ineffective antibiotics beyond 12 weeks, as prolonged use increases antimicrobial resistance risk without additional benefit. 1, 3
• Monitor for Clostridioides difficile colitis with oral clindamycin use, as this is a known risk. 6
• Be aware that only 6.9% of patients discontinue clindamycin-rifampicin due to side effects, making it generally well-tolerated. 5

Special Population Considerations

• If the patient is pregnant, oral clindamycin can be used (conditional recommendation, moderate quality evidence), though the data for clindamycin monotherapy are less robust than for the rifampicin combination. 6
• If the patient has a history of malignancy, oral clindamycin is safe with monitoring for severe diarrhea and C. difficile colitis. 6
• If the patient is HIV-positive, exercise caution with rifampicin due to potential drug interactions with certain HIV therapies. 6