When is tetracycline used in the treatment of hidradenitis suppurativa?

When Tetracycline is Used in Hidradenitis Suppurativa

Tetracycline 500 mg twice daily is used as first-line oral antibiotic therapy for moderate disease (more widespread Hurley Stage I or mild Hurley Stage II) without deep inflammatory lesions or abscesses, administered for up to 4 months. 1

Disease Severity Assessment Required Before Prescribing

• Tetracyclines are specifically indicated when disease is more widespread but lacks deep abscesses or inflammatory nodules 1
• Assess Hurley staging: tetracyclines work for Hurley I (isolated nodules without sinus tracts) or mild Hurley II (recurrent nodules with limited sinus tracts) 1
• Do NOT use tetracyclines as first-line for Hurley Stage II with abscesses or deep inflammatory nodules—they have minimal effect on these lesions, showing only 30% abscess reduction in the single RCT comparing tetracycline to topical clindamycin 1, 2

Specific Tetracycline Regimens and Duration

• Tetracycline 500 mg twice daily for up to 4 months (12-16 weeks) 1
• Doxycycline 100 mg once or twice daily for 12 weeks as alternative first-line option 1, 3
• Lymecycline 408 mg once or twice daily for 12 weeks as alternative first-line option 3
• A 2021 prospective study of 108 patients found tetracycline provided the greatest clinical improvement in Hidradenitis Suppurativa Score compared to doxycycline and lymecycline 4

When Tetracyclines Are NOT Appropriate

• Hurley Stage II with active abscesses or deep inflammatory nodules—escalate directly to clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks (response rates 71-93%) 1, 3, 5
• Hurley Stage III disease (extensive sinus tracts, scarring)—requires adalimumab or surgical intervention 1, 3
• When used in combination with adalimumab in the PIONEER studies, doxycycline showed no independent benefit in either arm 1

Treatment Assessment and Escalation Algorithm

• Reassess at 12 weeks using pain VAS score, inflammatory lesion count, and DLQI 3
• If no clinical response after 12 weeks of tetracyclines, escalate to clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks 1, 3, 5
• If clindamycin-rifampicin fails after 12 weeks, escalate to adalimumab (160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4) 1, 3
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 3, 5

Critical Evidence Limitations

• Only one RCT exists comparing tetracycline to topical clindamycin, showing modest 30% abscess reduction with no significant improvement in patient-reported outcomes 1, 2
• The evidence quality is weak (Level IIb), based primarily on this single double-blind trial of 46 patients 1, 2
• Tetracyclines performed no better than topical clindamycin 1% in the only head-to-head comparison 1, 2

Essential Adjunctive Measures Regardless of Antibiotic Choice

• Smoking cessation referral (tobacco worsens outcomes) 3
• Weight management referral if BMI elevated 3, 5
• Pain management with NSAIDs for symptomatic relief 3, 5
• Appropriate wound dressings for draining lesions 3, 5
• Screen for depression/anxiety and cardiovascular risk factors (BP, lipids, HbA1c) 3, 5

Common Pitfall to Avoid

The most critical error is using tetracycline monotherapy for Hurley Stage II disease with abscesses—this population requires the clindamycin-rifampicin combination from the outset, as tetracyclines have minimal effect on deep inflammatory lesions and will delay appropriate treatment. 1, 3