What is the antibiotic of choice for a patient with hidradenitis suppurativa (HS) presenting with a skin abscess, specifically a scullery abscess?

Antibiotic Treatment for Skin Abscess in Hidradenitis Suppurativa

For a patient with hidradenitis suppurativa presenting with a skin abscess, incision and drainage is the primary treatment, with adjunctive antibiotics indicated only if systemic signs of infection (SIRS) are present; when antibiotics are warranted, clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks is the treatment of choice. 1, 2, 3

Primary Treatment Approach

• Incision and drainage is the definitive treatment for abscesses in HS patients, regardless of antibiotic therapy 1
• Antibiotics should be added as adjunctive therapy based on the presence of systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min, or WBC >12,000 or <4,000 cells/µL 1
• For isolated abscesses without SIRS, incision and drainage alone is sufficient without antibiotics 1

First-Line Antibiotic Regimen When Indicated

Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks is the recommended first-line systemic antibiotic therapy for HS-associated abscesses requiring antimicrobial treatment 2, 3, 4

• This combination achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy (30% abscess reduction) 2, 3
• The rationale for combination therapy is to increase bactericidal action and reduce rifampicin resistance, as rifampicin is highly mutagenic 3, 4
• This regimen specifically targets both coagulase-negative staphylococci (particularly Staphylococcus lugdunensis, found in 58% of HS nodules/abscesses) and anaerobes (found in 24% of abscesses) 5, 6

Alternative Antibiotic Options

If clindamycin-rifampicin combination is unavailable or contraindicated:

• Tetracyclines (doxycycline 100 mg once or twice daily OR lymecycline 408 mg daily) for 12 weeks can be used, though they are generally less effective for acute abscesses 2, 3
• Do NOT use tetracyclines as first-line for abscesses or deep inflammatory nodules, as they have minimal effect on these lesions 2

MRSA Coverage Considerations

• An antibiotic active against MRSA is recommended if the patient has markedly impaired host defenses, SIRS, penetrating trauma, evidence of MRSA infection elsewhere, nasal MRSA colonization, or injection drug use 1
• In these scenarios, vancomycin or another agent effective against both MRSA and streptococci should be used 1

Critical Pitfalls to Avoid

• Do NOT rely on antibiotics alone without drainage - incision and drainage is the primary treatment for abscesses 1
• Do NOT use topical clindamycin for abscesses - it only reduces superficial pustules, not inflammatory nodules or abscesses 2, 7
• Do NOT use doxycycline or tetracycline monotherapy as first-line for abscesses - these show only 30% abscess reduction and have minimal effect on deep inflammatory lesions 2
• Avoid long-term antibiotics without treatment breaks to reduce antimicrobial resistance risk 2, 3
• Ensure rifampicin dose is 300-600 mg daily (not lower doses) and clindamycin must be 300 mg twice daily for systemic effect 3

Adjunctive Measures

Regardless of antibiotic choice, always address:

• Appropriate wound dressings for draining lesions 3
• Pain management with NSAIDs for symptomatic relief 2, 3
• Smoking cessation referral (tobacco use worsens outcomes) 2, 4
• Weight management referral if BMI elevated (high BMI predicts poor antibiotic response) 2, 4
• Screen for depression/anxiety and cardiovascular risk factors (BP, lipids, HbA1c) 2, 3

Treatment Duration and Monitoring

• Treat for 10-12 weeks initially 2, 3, 4
• Assess response at 12 weeks using pain scores, quality of life measures (DLQI), and lesion count 2, 3
• Consider treatment break after completion to assess need for ongoing therapy and limit antimicrobial resistance 2, 3

When to Escalate Treatment

If no response after 12 weeks of clindamycin-rifampicin:

• Consider triple therapy: moxifloxacin + metronidazole + rifampin as second/third-line treatment 3
• Refer to dermatology for consideration of biologics (adalimumab) or surgical intervention 2, 3
• For severe disease with extensive sinus tracts and scarring, radical surgical excision may be necessary for lasting cure 1, 2

Important Context on Antibiotic Resistance

Recent microbiological data show high resistance rates in HS patients: clindamycin 65.7%, rifampicin 69.3%, tetracycline 84.7% 8. However, the clindamycin-rifampicin combination remains guideline-recommended first-line therapy based on superior clinical response rates 2, 3, 4. Culture-guided therapy should be considered for recurrent or refractory cases 1, 8.