What is the first‑line oral antibiotic regimen for hidradenitis suppurativa in an adult without contraindications?

First-Line Oral Antibiotic for Hidradenitis Suppurativa

For moderate hidradenitis suppurativa (Hurley Stage II), the first-line oral antibiotic regimen is clindamycin 300 mg twice daily plus rifampicin 300–600 mg once or twice daily for 10–12 weeks, achieving response rates of 71–93%. 1, 2

Treatment Algorithm by 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 before escalating to oral antibiotics. 1, 2
• Intralesional triamcinolone 10 mg/mL can be added for acutely inflamed nodules, providing rapid symptom relief within 1 day. 1

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 is the superior first-line choice, with documented response rates of 71–93% in systematic reviews. 1, 2, 3
• This combination significantly outperforms tetracycline monotherapy, which shows only 30% abscess reduction. 1
• A 2021 prospective European cohort study of 283 patients confirmed that clindamycin-rifampicin achieved HiSCR (≥50% reduction in inflammatory lesions) in 48.2% of patients at 12 weeks. 4

Alternative First-Line Options (When Clindamycin-Rifampicin Is Contraindicated)

• Doxycycline 100 mg once or twice daily for 12 weeks can be used for widespread mild disease or mild Hurley Stage II without deep inflammatory lesions or abscesses. 1, 2
• Tetracycline 500 mg twice daily for up to 4 months is an alternative, though evidence is weak (single RCT showing only 30% abscess reduction). 1
• Critical caveat: 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 such lesions. 1, 2

Reassessment at 12 Weeks

• Evaluate treatment response using pain VAS score, inflammatory lesion count (nodules + abscesses), number of flares, and quality of life (DLQI). 1, 2
• HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) is the validated outcome measure. 1, 2
• If no clinical response after 12 weeks of first-line antibiotics, escalate to adalimumab (160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4). 1, 2

Essential Adjunctive Measures (All Patients)

• Smoking cessation referral is mandatory—tobacco use predicts poor antibiotic response and worse outcomes. 1, 2
• Weight management referral if BMI is elevated—obesity prevalence exceeds 75% in HS patients and correlates with disease severity. 1, 2
• Pain management with NSAIDs for symptomatic relief. 1, 2
• Appropriate wound dressings for draining lesions. 1, 2
• Screen for depression, anxiety, diabetes (HbA1c), hypertension, and hyperlipidemia at baseline. 1, 2

Critical Pitfalls to Avoid

• Do NOT continue antibiotics beyond 10–12 weeks without reassessment—prolonged use increases antimicrobial resistance risk without proven additional benefit. 1, 2
• Do NOT use doxycycline as first-line for Hurley Stage II with abscesses—it is ineffective for deep inflammatory lesions. 1, 2
• Do NOT use topical clindamycin alone for Hurley Stage II—it only reduces superficial pustules, not inflammatory nodules or abscesses. 1
• Consider treatment breaks after completing the 10–12 week course to assess need for ongoing therapy and limit antimicrobial resistance. 1, 2

Special Population Considerations

• HIV-positive patients: Use doxycycline for added prophylactic benefit against bacterial STIs; exercise caution with rifampicin due to drug interactions with certain HIV therapies. 1
• Pregnant patients: Oral clindamycin can be used with caution (conditional recommendation, moderate quality evidence). 3
• Pediatric patients ≥8 years: Doxycycline 100 mg once or twice daily, or clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10–12 weeks. 1

Evidence Quality

The clindamycin-rifampicin combination is supported by multiple guidelines from the American Academy of Dermatology and British Association of Dermatologists, with response rates of 71–93% documented in systematic reviews. 1, 2, 3 In contrast, tetracycline monotherapy has weak evidence (Level IIb), based on a single RCT of 46 patients showing only 30% abscess reduction. 1 A 2021 prospective cohort study confirmed comparable efficacy between tetracyclines (HiSCR 40.1%) and clindamycin-rifampicin (HiSCR 48.2%), though the latter is preferred for moderate disease with abscesses. 4