What are the recommended antibiotics for a patient with moderate to severe hidradenitis suppurativa?

Recommended Antibiotics for Hidradenitis Suppurativa

For moderate to severe hidradenitis suppurativa, clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks is the first-line antibiotic regimen, achieving response rates of 71-93%—far superior to all other antibiotic options. 1

Treatment Algorithm 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
• Must be combined with benzoyl peroxide wash or chlorhexidine 4% wash daily to prevent Staphylococcus aureus resistance 1, 2
• Topical clindamycin only reduces superficial pustules—it has no effect on inflammatory nodules or abscesses 2
• For more widespread mild disease, escalate to oral tetracyclines rather than continuing topical therapy 1

Moderate Disease (Hurley Stage II)

First-line: Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks 1, 3

This combination is dramatically superior to alternatives:

• Response rates: 71-93% in systematic reviews 1
• Significantly better outcomes for abscesses and inflammatory nodules compared to tetracycline monotherapy (30% abscess reduction) 1
• The rationale for combining these drugs is to increase bactericidal action and reduce rifampicin resistance 3

Alternative first-line (if rifampicin contraindicated): Tetracycline 500 mg twice daily OR doxycycline 100 mg once or twice daily for 12-16 weeks 1

• However, tetracyclines show only modest efficacy (30% abscess reduction) and should NOT be used as first-line for Hurley Stage II with abscesses or deep inflammatory nodules 1

Clindamycin monotherapy: Clindamycin 300 mg twice daily alone for 12 weeks may be considered as a rifampicin-sparing alternative in selected patients 4, 5

• Demonstrated significant reduction in disease severity scores in retrospective studies 4, 5
• However, combination therapy (clindamycin + rifampicin) shows higher reduction in disease severity scores, particularly for abscesses and draining fistulae 3

Severe Disease (Hurley Stage III) or Antibiotic Failure

• Do NOT continue antibiotics beyond 12 weeks without response 1
• Escalate directly to adalimumab: 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting week 4 1
• HiSCR response rates: 42-59% at week 12 1
• If adalimumab fails after 16 weeks, consider second-line biologics: infliximab, secukinumab, or ustekinumab 1

Critical Adjunctive Measures for All Patients

These are mandatory, not optional:

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules—provides rapid symptom relief within 1 day 1
• Smoking cessation referral (tobacco use associated with odds ratio 36 for worse outcomes) 6
• Weight management referral if BMI elevated (obesity associated with odds ratio 33 for worse outcomes and predicts poor antibiotic response) 6, 3
• Pain management with NSAIDs 1
• Appropriate wound dressings for draining lesions 1
• Screen for depression/anxiety and cardiovascular risk factors (BP, lipids, HbA1c) 1

Treatment Duration and Monitoring

• Reassess at 12 weeks using objective measures: HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas), pain VAS score, inflammatory lesion count, and DLQI 1, 6
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 1
• Do NOT continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit 1

Critical Pitfalls to Avoid

• Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses—these have minimal effect on deep inflammatory lesions, showing only 30% abscess reduction 1
• Do NOT use topical clindamycin alone for Hurley Stage II—it only reduces superficial pustules, not inflammatory nodules or abscesses 2
• Do NOT use topical clindamycin without benzoyl peroxide or chlorhexidine—monotherapy significantly increases Staphylococcus aureus resistance rates 2
• Do NOT use adalimumab 40 mg every other week—this dosing is ineffective; weekly dosing is required 1

Predictors of Poor Antibiotic Response

High BMI and smoking pack-years are predictive factors of poor response to antibiotics 3:

• In the clindamycin + rifampicin group, smoking pack-year positively correlates with disease severity 3
• In the clindamycin monotherapy group, BMI positively correlates with disease severity 3
• These patients may require earlier escalation to biologic therapy 3

Surgical Considerations

Radical surgical excision should be considered concurrently with medical therapy for extensive disease with sinus tracts and scarring, as combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1