Should I start antibiotics for a patient with Hidradenitis Suppurativa presenting with abscesses?

Should You Start Antibiotics for Hidradenitis Suppurativa Abscesses?

Yes, start antibiotics immediately for hidradenitis suppurativa (HS) abscesses—the specific regimen depends on disease severity, with clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks being the first-line choice for moderate-to-severe disease with active abscesses, achieving response rates of 71-93%. 1, 2

Disease Severity Assessment First

Before prescribing, determine the Hurley stage by examining all intertriginous areas (axillae, groin, buttocks, inframammary) 3, 2:

• Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 2
• Hurley Stage II: Recurrent nodules with limited sinus tracts and scarring—this is where most patients with "abscesses" fall 2
• Hurley Stage III: Diffuse involvement with multiple interconnected sinus tracts and extensive scarring—requires immediate dermatology referral 3, 2

Antibiotic Regimen by Severity

For Mild Disease (Hurley Stage I with isolated abscesses)

Start with topical clindamycin 1% solution or gel applied twice daily to all affected areas for 12 weeks 1, 2. Combine this with:

• Benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1, 2
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) injected directly into acutely inflamed abscesses for rapid symptom relief within 1 day 1, 2

For Moderate Disease (Hurley Stage II with multiple abscesses)

This is the critical scenario where oral antibiotics are mandatory. Start clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks 3, 1, 2. This combination:

• Achieves response rates of 71-93% in systematic reviews 1, 4
• Is superior to tetracycline monotherapy, which shows only 30% abscess reduction 1
• Reduces both bactericidal load and rifampicin resistance 4

Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses—these have minimal effect on deep inflammatory lesions and abscesses 1, 5.

For Severe Disease (Hurley Stage III or extensive abscesses with sinus tracts)

While awaiting dermatology referral, start the clindamycin-rifampicin combination above 1. However, these patients will likely require:

• Adalimumab (160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4) as first-line biologic therapy 3, 2
• Ertapenem 1g IV daily for 6 weeks can be considered as rescue therapy for severe disease, with dramatic improvement shown in the Sartorius score (median drop from 49.5 to 19.0) 1, 6

Critical Pitfalls to Avoid

Do not prescribe antibiotics without addressing these mandatory adjunctive measures 3, 2:

• Smoking cessation referral (smoking worsens outcomes and predicts poor antibiotic response) 5, 4
• Weight management referral if BMI elevated (high BMI predicts poor antibiotic response) 4
• Pain management with NSAIDs for symptomatic relief 3, 2
• Appropriate wound dressings for draining lesions 3, 2
• Screen for depression, anxiety, and cardiovascular risk factors (diabetes, hypertension, hyperlipidemia) 3, 2

Avoid long-term continuous antibiotic use—after completing the 10-12 week course, take treatment breaks to assess need for ongoing therapy and limit antimicrobial resistance risk 3, 1, 5.

When Antibiotics Alone Are Insufficient

Reassess at 12 weeks using pain VAS score, inflammatory lesion count, number of flares, and quality of life (DLQI) 1, 2. If no clinical response after 12 weeks of clindamycin-rifampicin:

• Escalate to adalimumab (FDA-approved biologic for moderate-to-severe HS) 1, 2
• Consider surgical excision for extensive disease with sinus tracts when conventional systemic treatments fail—combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1, 2

Antibiotic Resistance Considerations

Recent data show concerning resistance patterns in HS lesions 7:

• 76.9% resistance to penicillin in Staphylococcus aureus 7
• 62.5% resistance to erythromycin in anaerobes 7
• 53.3% resistance to penicillin in Staphylococcus lugdunensis 7

This reinforces why clindamycin-rifampicin combination is superior to monotherapy—the combination reduces resistance development and provides broader coverage against the polymicrobial flora typical of HS 4, 8.

Special Population Considerations

• Pregnant patients: Oral clindamycin can be used with caution (conditional recommendation, moderate quality evidence) 1
• HIV-positive patients: Exercise caution with rifampicin due to drug interactions with certain HIV therapies; consider doxycycline instead 1
• Pediatric patients ≥8 years: Doxycycline 100 mg once or twice daily, or clindamycin-rifampicin combination 1