Can Benzoyl Peroxide 10% Be Used for Hidradenitis Suppurativa?
Benzoyl peroxide 10% is not recommended as a primary treatment for hidradenitis suppurativa, but it may be used as an adjunctive skin cleanser in combination with topical clindamycin to reduce Staphylococcus aureus resistance risk. 1
Role in HS Treatment Algorithm
Benzoyl peroxide does not appear in any guideline as a standalone therapy for hidradenitis suppurativa. Its use is limited to the following context:
Adjunctive cleanser only: The North American Clinical Management Guidelines support the use of benzoyl peroxide as a skin cleanser based on expert opinion, alongside chlorhexidine and zinc pyrithione, but provide no data for specific agents or concentrations. 1
Combination with topical clindamycin: When topical clindamycin 1% is prescribed for mild HS (Hurley Stage I), benzoyl peroxide may be added to reduce the risk of Staphylococcus aureus resistance that develops with clindamycin monotherapy. 1, 2
Evidence Quality and Limitations
The evidence supporting benzoyl peroxide in HS is notably weak:
No direct efficacy data: No randomized controlled trials or case series have evaluated benzoyl peroxide specifically for hidradenitis suppurativa lesions. 1
Extrapolated from acne literature: The recommendation derives from acne vulgaris studies showing that benzoyl peroxide prevents antibiotic resistance when combined with topical antibiotics. 1, 3
Expert opinion only: The North American guidelines classify benzoyl peroxide use as supported by expert opinion rather than clinical trial evidence. 1
Practical Application
If you choose to use benzoyl peroxide in a patient with HS:
Apply as a wash: Use benzoyl peroxide 10% wash or chlorhexidine 4% wash daily to all affected intertriginous areas. 2
Always combine with topical clindamycin: Prescribe topical clindamycin 1% solution or gel twice daily to affected areas for 12 weeks as the primary therapy. 1, 2
Limit to Hurley Stage I only: This approach is appropriate only for patients with isolated nodules and abscesses without sinus tracts or scarring. 2
When Benzoyl Peroxide Is Inappropriate
Do not rely on benzoyl peroxide for:
Hurley Stage II or III disease: Patients with recurrent abscesses, sinus tracts, or scarring require systemic antibiotics (clindamycin 300 mg + rifampicin 300-600 mg daily for 10-12 weeks) or biologics (adalimumab). 1, 2
Inflammatory nodules or abscesses: Benzoyl peroxide has no demonstrated effect on deep inflammatory lesions characteristic of HS. 1
Monotherapy: Benzoyl peroxide should never be used alone for HS; it serves only as an adjunct to reduce antibiotic resistance. 1, 2
Evidence-Based First-Line Therapies for HS
Instead of benzoyl peroxide, prioritize guideline-supported treatments:
Mild disease (Hurley I): Topical clindamycin 1% twice daily for 12 weeks. 1, 2
Moderate disease (Hurley II): Clindamycin 300 mg orally twice daily + rifampicin 300-600 mg daily for 10-12 weeks (71-93% response rate). 1, 2
Severe disease (Hurley III): Adalimumab 160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4. 1, 2
Critical Pitfall
The most common error is treating HS like acne vulgaris. While benzoyl peroxide is highly effective for acne 3, 4, 5, hidradenitis suppurativa is a chronic inflammatory disease of the hair follicle requiring systemic anti-inflammatory therapy, not topical antimicrobials alone. 1, 6