In a patient with hidradenitis suppurativa who is controlled on adalimumab but experiences intermittent acute flares, should doxycycline or rifampicin be added, and what antibiotic regimen is recommended?

Adding Antibiotics to Adalimumab for Intermittent Flares in Hidradenitis Suppurativa

For patients controlled on adalimumab who experience intermittent acute exacerbations, add clindamycin 300 mg twice daily plus rifampicin 300–600 mg daily for 10–12 weeks during flares, rather than doxycycline monotherapy, because this combination achieves response rates of 71–93% and directly targets the inflammatory nodules and abscesses characteristic of acute flares. 1, 2

Rationale for Clindamycin-Rifampicin Over Doxycycline

• Clindamycin-rifampicin is the superior antibiotic regimen for moderate-to-severe HS flares, demonstrating 71–93% response rates in systematic reviews, far exceeding the modest 30% abscess reduction seen with tetracycline monotherapy. 1, 2

• Doxycycline monotherapy is not recommended for acute flares with abscesses or deep inflammatory nodules because it has minimal effect on these lesions—the very features that define an acute exacerbation in a patient already on adalimumab. 1, 2

• The clindamycin-rifampicin combination works through both antimicrobial and anti-inflammatory mechanisms, making it ideal for managing breakthrough inflammatory activity while maintaining biologic therapy. 3, 4

Specific Antibiotic Regimen During Flares

• Clindamycin 300 mg orally twice daily combined with rifampicin 300–600 mg orally once or twice daily for 10–12 weeks during each acute exacerbation. 1, 2

• This regimen can be repeated intermittently as needed for flares, functioning as adjuvant therapy in patients with severe disease already on biologics. 1

• After completing each 10–12 week course, implement a treatment break to assess ongoing need and limit antimicrobial resistance risk. 1, 2

Adjunctive Measures for Acute Flares

• Intralesional triamcinolone 10 mg/mL (0.2–2.0 mL) injected directly into acutely inflamed nodules provides rapid symptom relief within 24 hours, with significant reductions in pain, erythema, edema, and suppuration. 1

• NSAIDs for pain management and appropriate wound dressings for any draining lesions should be provided during the flare. 1, 2

Reassessment Protocol

• Evaluate treatment response at 12 weeks using pain VAS score, inflammatory lesion count, number of flares, and quality of life (DLQI). 1, 2

• If flares persist despite clindamycin-rifampicin courses, consider dose escalation of adalimumab (if currently on every-other-week dosing, switch to weekly 40 mg dosing, which is the only effective regimen for moderate-to-severe HS). 1

• If flares continue despite weekly adalimumab plus intermittent antibiotics, escalate to second-line biologics (infliximab 5 mg/kg at weeks 0,2,6, then every 8 weeks; secukinumab; or ustekinumab). 1

Critical Pitfalls to Avoid

• Do not use adalimumab 40 mg every other week—this dosing is explicitly not recommended and is ineffective for moderate-to-severe HS; weekly dosing is required. 5, 1

• Do not prescribe doxycycline monotherapy for acute flares with abscesses, as it lacks efficacy against deep inflammatory lesions and will delay appropriate treatment. 1, 2

• Do not continue antibiotics beyond 12 weeks without reassessment, as prolonged use increases antimicrobial resistance without proven additional benefit. 1, 2

• Do not use topical clindamycin alone for breakthrough flares in a patient with moderate-to-severe disease, as it only reduces superficial pustules, not the nodules and abscesses that characterize acute exacerbations. 2

Mandatory Lifestyle and Comorbidity Management

• Reinforce smoking cessation at every visit, as tobacco use worsens outcomes and increases treatment failure rates. 1, 2

• Address weight management if BMI is elevated, as obesity (present in >75% of HS patients) increases mechanical friction and pro-inflammatory cytokines. 1

• Screen for depression and anxiety using validated tools, as these comorbidities are highly prevalent and significantly impact quality of life. 1

• Monitor cardiovascular risk factors (blood pressure, lipids, HbA1c) annually, as HS patients have nearly doubled mortality risk from cardiovascular disease. 1

When to Consider Surgical Intervention

• If intermittent flares persist despite optimized medical therapy (weekly adalimumab plus intermittent clindamycin-rifampicin courses), combining adalimumab with surgical deroofing or radical excision results in greater clinical effectiveness than adalimumab monotherapy. 1

• Surgery is particularly indicated for established sinus tracts and scarring (Hurley Stage II–III features), which may be driving recurrent flares despite biologic therapy. 1