What is the recommended antibiotic treatment for a patient with hidradenitis suppurativa?

Recommended Antibiotic Treatment for Hidradenitis Suppurativa

For mild disease (Hurley Stage I), start with 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 as first-line therapy, achieving response rates of 71-93%. 1, 2, 3

Disease Severity Assessment and Treatment Algorithm

Before initiating antibiotic therapy, determine disease severity using the Hurley staging system 2, 4:

• Hurley Stage I (Mild): Isolated nodules and abscesses without sinus tracts or scarring 2, 4
• Hurley Stage II (Moderate): Recurrent nodules with limited sinus tracts and scarring 2, 4
• Hurley Stage III (Severe): Diffuse involvement with multiple interconnected sinus tracts and extensive scarring—requires immediate dermatology referral 1, 2, 4

Document baseline pain using Visual Analog Scale (VAS), inflammatory lesion count, and quality of life using Dermatology Life Quality Index (DLQI) 2, 4

First-Line Antibiotic Therapy by Disease Severity

Mild Disease (Hurley Stage I)

Topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks 1, 2, 3, 4

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 2, 5
• For acute inflamed nodules, add intralesional triamcinolone 10 mg/mL (0.2-2.0 mL), which provides rapid symptom relief within 1 day 2, 3
• Critical pitfall: Topical clindamycin monotherapy increases rates of clindamycin-resistant S. aureus (63% vs 17% in non-users); always combine with benzoyl peroxide 5

Moderate Disease (Hurley Stage II)

Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks 1, 2, 3, 4

This combination is vastly superior to tetracycline monotherapy, with response rates of 71-93% versus only 30% abscess reduction with tetracyclines 2, 3

Alternative first-line option for widespread mild disease or mild Hurley Stage II without deep inflammatory lesions:

• Doxycycline 100 mg once or twice daily for 12 weeks 1, 2, 4
• Lymecycline 408 mg once or twice daily for 12 weeks 1, 2
• Tetracycline 500 mg twice daily for up to 4 months 1, 2

Critical pitfall: Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses or deep inflammatory nodules—these agents have minimal effect on deep lesions and show only 30% abscess reduction 2, 3, 4

Treatment Duration and Reassessment

Reassess at 12 weeks using 2, 4:

• Pain VAS score
• Inflammatory lesion count
• Number of flares in preceding month
• DLQI (quality of life)
• HiSCR (≥50% reduction in inflammatory lesion count with no increase in abscesses or draining fistulas) 2, 3

Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance risk 1, 2

Treatment Escalation for Inadequate Response

If no clinical response after 12 weeks of first-line antibiotics:

Escalate to clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks (if not already tried) 2, 3, 4

If clindamycin-rifampicin fails after 12 weeks or for severe disease (Hurley Stage III):

Escalate to adalimumab (FDA-approved biologic for moderate-to-severe HS) 1, 2, 3:

• 160 mg subcutaneous at week 0
• 80 mg at week 2
• 40 mg weekly starting at week 4
• HiSCR response rates: 42-59% at week 12 2, 3

Second-line biologic options after adalimumab failure 1, 2:

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1, 2
• Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients) 1, 2
• Ustekinumab 1, 2

Special Populations

Pediatric Patients (≥8 years old)

• Doxycycline 100 mg once or twice daily for patients ≥8 years 1, 3
• Clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks 1
• Adalimumab for patients ≥12 years with moderate-to-severe disease 1, 3

Breastfeeding Patients

• Preferred: Amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole 1
• Limit doxycycline to ≤3 weeks without repeating courses 1
• Exercise caution with oral clindamycin due to increased GI side effects in infants 1

Patients with HIV

• Doxycycline provides added prophylactic benefit against bacterial STIs 1
• Avoid rifampicin due to drug interactions with certain HIV therapies 1
• Co-trimoxazole (trimethoprim/sulfamethoxazole) provides added benefit of lowering mortality and infection rates 1

Antimicrobial Resistance Considerations

The evidence reveals concerning resistance patterns 5:

• Topical clindamycin users: 63% grow clindamycin-resistant S. aureus vs 17% in non-users
• Ciprofloxacin users: 100% grow ciprofloxacin-resistant MRSA vs 10% in non-users
• Trimethoprim/sulfamethoxazole users: 88% grow resistant Proteus species vs 0% in non-users
• No significant resistance observed with tetracyclines or oral clindamycin 5

Highest effectiveness against HS isolates 6:

• Carbapenems (8.5% resistant strains)
• Penicillins with β-lactamase inhibitors (11.9% resistant strains)
• Fluoroquinolones (11.9% resistant strains)

Mandatory Adjunctive Measures for All Patients

Regardless of antibiotic choice, address 1, 2, 4:

• Smoking cessation referral (tobacco use predicts poor antibiotic response) 2, 4
• Weight management referral if BMI elevated (obesity strongly associated with disease severity) 2, 4
• Pain management with NSAIDs for symptomatic relief 2, 4
• Appropriate wound dressings for draining lesions 2, 4
• Screen for comorbidities: depression/anxiety, diabetes, hypertension, hyperlipidemia, inflammatory bowel disease 1, 2, 4

Surgical Considerations

Surgery is often necessary for lasting cure, especially in advanced disease with sinus tracts and scarring 2, 3, 4:

• Deroofing for recurrent nodules and tunnels 2, 3
• Radical surgical excision for extensive disease when conventional systemic treatments have failed 1, 2, 3
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2

Critical Pitfalls to Avoid

• Do NOT continue ineffective antibiotics beyond 12 weeks without reassessment—this increases antimicrobial resistance risk 2, 4
• Do NOT use tetracyclines as first-line for severe flares—they are ineffective for deep inflammatory lesions and sinus tracts 4
• Do NOT use topical clindamycin alone for Hurley Stage II—it only reduces superficial pustules, not inflammatory nodules or abscesses 3
• Do NOT prescribe long-term antibiotics without treatment breaks to assess ongoing need and limit resistance 1, 2