What treatment options are available for a patient with multiple abscesses caused by Hidradenitis Suppurativa (HS) who has failed treatment with doxycycline and topical clindamycin (clindamycin)?

Treatment of Multiple Abscesses in Hidradenitis Suppurativa After Antibiotic Failure

Start oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks immediately, combined with intralesional triamcinolone 10 mg/mL injections into the most inflamed abscesses for rapid symptom relief. 1, 2

Why This Combination is First-Line for Multiple Abscesses

The clindamycin-rifampicin combination achieves response rates of 71-93% in patients with moderate-to-severe HS, which is dramatically superior to the doxycycline monotherapy you've already failed (which only shows 30% abscess reduction). 1, 2, 3

Key point: Your patient has already failed doxycycline and topical clindamycin, which are appropriate only for mild disease without deep inflammatory lesions or abscesses. 1, 2 Multiple abscesses indicate at least Hurley Stage II disease, where tetracyclines have minimal effect on deep inflammatory lesions. 1, 2

Specific Dosing Regimen

• Clindamycin: 300 mg orally twice daily 1, 2, 4
• Rifampicin: 300-600 mg orally once daily (or 300 mg twice daily) 1, 2, 4
• Duration: 10-12 weeks 1, 2, 4
• Intralesional triamcinolone: 10 mg/mL (0.2-2.0 mL) injected directly into inflamed nodules and abscesses provides rapid symptom relief within 1 day, with significant reductions in erythema, edema, suppuration, and pain 1

Evidence Supporting This Approach

A retrospective study of 116 consecutive patients showed the Sartorius score dramatically improved after 10 weeks of clindamycin-rifampicin (median score dropped from 29 to 14.5, p < 0.001), with only 6.9% discontinuing due to side effects. 3 A 2021 multilinear regression analysis confirmed higher reduction in disease severity scores with clindamycin-rifampicin combination versus clindamycin monotherapy (Δ = -13.2 for mSartorius, P = .058; Δ = -4.91 for AISI, P = .034). 5

Reassessment and Treatment Escalation

• At 12 weeks: Reassess using pain VAS score, inflammatory lesion count, number of flares, and quality of life (DLQI) 1, 2, 4
• If inadequate response after 12 weeks: Escalate directly to adalimumab (160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting week 4), which achieves HiSCR response rates of 42-59% at week 12 1, 2
• If adalimumab fails: Consider second-line biologics including infliximab, secukinumab, or ustekinumab 1, 2

Critical Pitfalls to Avoid

• Do NOT continue doxycycline or tetracycline monotherapy for Hurley Stage II with abscesses—these have minimal effect on deep inflammatory lesions 1, 2
• Do NOT use topical clindamycin alone for multiple abscesses—it only reduces superficial pustules, not inflammatory nodules or abscesses 1, 2
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk 1, 2, 4
• Consider treatment breaks after completing the 10-12 week course to assess need for ongoing therapy 1, 2

Mandatory Adjunctive Measures

• Smoking cessation referral: Tobacco use worsens outcomes and smoking pack-years correlate with worse disease severity scores 1, 2, 5
• Weight management referral: High BMI is a predictive factor of poor response to antibiotics 1, 2, 5
• Pain management with NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for draining lesions 1, 2
• Screen for depression/anxiety and cardiovascular risk factors (BP, lipids, HbA1c) 1, 4

Special Considerations

• If pregnant: Oral clindamycin can be used with caution (conditional recommendation, moderate quality evidence) 4
• If HIV-positive: Exercise caution with rifampicin due to drug interactions with certain HIV therapies; consider doxycycline instead 2
• Monitor for Clostridioides difficile colitis with oral clindamycin use 4

Surgical Considerations

If medical therapy fails after 12 weeks of clindamycin-rifampicin and a trial of adalimumab, consider radical surgical excision for extensive disease with sinus tracts and scarring, as combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy. 1, 2