What antibiotic is used to treat Hidradenitis Suppurativa (HS)?

Antibiotic Treatment for Hidradenitis Suppurativa

For moderate Hidradenitis Suppurativa, use clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks as first-line antibiotic therapy, achieving response rates of 71-93%. 1, 2, 3

Treatment Algorithm Based on Disease Severity

Mild Disease (Hurley Stage I)

• Start with topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks as first-line therapy for isolated nodules and abscesses without sinus tracts or scarring 1, 2, 4
• Combine topical clindamycin with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 2, 4
• For acute inflamed nodules, inject intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for rapid symptom relief within 1 day 2, 3, 4

Moderate Disease (Hurley Stage II)

• First-line systemic antibiotic: 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 achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy which shows only 30% abscess reduction 1, 2, 3
• Alternative first-line option: Tetracyclines (doxycycline 100 mg once or twice daily OR tetracycline 500 mg twice daily) for 12 weeks for more widespread mild disease or mild Hurley Stage II without deep inflammatory lesions or abscesses 1, 2, 3
• Do NOT use tetracyclines as first-line for Hurley Stage II with abscesses or deep inflammatory nodules, as they have minimal effect on these lesions 2, 3

Severe Disease (Hurley Stage III)

• Clindamycin 300 mg twice daily plus rifampicin 300-600 mg twice daily for 10-12 weeks as first-line antibiotic, often as adjunct to biologic therapy or bridge to surgery 1, 2, 3
• IV ertapenem 1g daily for 6 weeks for severe, recalcitrant cases as rescue therapy or bridge to surgery 1, 2
• Second-line triple therapy: Moxifloxacin, metronidazole, and rifampin combination for moderate-to-severe disease that fails clindamycin-rifampicin 1

Special Population Considerations

Pediatric Patients

• For children ≥8 years old requiring systemic antibiotics: Doxycycline 100 mg once or twice daily OR clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10-12 weeks 1, 2
• For children <8 years old: Topical clindamycin 1% twice daily combined with antiseptic washes 4

Patients with History of Malignancy

• Doxycycline is the safest choice with strong evidence of safety (strong recommendation, moderate quality evidence) 1
• Oral clindamycin can be used with monitoring for severe diarrhea and C. difficile colitis (conditional recommendation, low quality evidence) 1, 3
• Moxifloxacin can be used with monitoring for QT prolongation from drug-drug interactions with certain chemotherapy agents 1

Pregnant and Breastfeeding Patients

• For breastfeeding patients: Amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole are preferred 2
• Limit doxycycline to ≤3 weeks without repeating courses in breastfeeding patients 2
• Oral clindamycin can be used in pregnancy with caution (conditional recommendation, moderate quality evidence) 3

HIV-Positive Patients

• Avoid rifampicin due to drug interactions with certain HIV therapies 2, 3
• Use doxycycline for added prophylactic benefit against bacterial STIs 2

Treatment Duration and Monitoring

• Reassess treatment response at 12 weeks using pain VAS score, inflammatory lesion count, number of flares, and quality of life (DLQI) 1, 2, 3, 4
• For clindamycin-rifampicin: Treatment typically lasts 10-12 weeks and can be repeated intermittently 1, 2, 3
• For tetracyclines: Initial course of 12 weeks, can extend up to 4 months (16 weeks) for more widespread mild disease 1, 2
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 2

When to Escalate Treatment

• 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 2, 3
• 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) 2, 4
• For severe disease or inadequate response to antibiotics, refer to dermatology for consideration of biologics or surgical intervention 2, 4

Critical Pitfalls to Avoid

• Do NOT use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules, not inflammatory nodules or abscesses 3
• Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses, as these have minimal effect on deep inflammatory lesions 2, 3
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk 1, 2, 3
• Do NOT continue doxycycline beyond 4 months without reassessment, as prolonged use increases antimicrobial resistance risk without proven additional benefit 2
• Monitor for Clostridioides difficile colitis with oral clindamycin use 1, 3
• Only 6.9% of patients discontinue clindamycin-rifampicin due to side effects, making it generally well-tolerated 3

Mandatory Adjunctive Measures

• Smoking cessation referral - tobacco use worsens outcomes 2, 4
• Weight management referral if BMI elevated - obesity is associated with worse disease 2, 4
• Pain management with NSAIDs for symptomatic relief 2, 4
• Appropriate wound dressings for draining lesions 2, 4
• Screen for depression/anxiety and cardiovascular risk factors (BP, lipids, HbA1c) 2, 4