What is the most appropriate first‑line antibiotic for hidradenitis suppurativa?

Best Antibiotic for Hidradenitis Suppurativa

For moderate hidradenitis suppurativa (Hurley Stage II), the best first-line antibiotic regimen is oral 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 Selection 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 as first-line therapy for isolated nodules and abscesses without sinus tracts. 1, 2
• This approach targets superficial pustules and early inflammatory lesions before systemic therapy becomes necessary. 2

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
• This combination significantly outperforms tetracycline monotherapy, which shows only 30% abscess reduction. 2
• The clindamycin-rifampicin regimen is particularly effective for abscesses and inflammatory nodules characteristic of Hurley Stage II disease. 2

Alternative First-Line Options (Limited Role)

• Oral tetracyclines (doxycycline 100 mg once or twice daily OR lymecycline 408 mg once or twice daily) for 12 weeks can be used for more widespread mild disease or mild Hurley Stage II without deep inflammatory lesions or abscesses. 1, 2
• However, tetracyclines have minimal effect on deep inflammatory lesions and abscesses, showing only modest 30% abscess reduction in the single available RCT. 2
• A 2021 comparative study found lymecycline monotherapy more effective for nodular-type HS, while clindamycin-rifampicin was superior for abscess/tunnel-type disease. 3

Critical Evidence Comparison

The evidence strongly favors clindamycin-rifampicin over tetracyclines for moderate disease. While a 2022 RCT showed subantimicrobial doxycycline achieved 64% HiSCR response versus 60% for regular-dose doxycycline 4, these rates pale in comparison to the 71–93% response rates documented for clindamycin-rifampicin in systematic reviews 2. The British Association of Dermatologists 2019 guidelines explicitly recommend clindamycin-rifampicin as second-line therapy after tetracyclines fail 1, but more recent 2025 North American guidelines position it as first-line for moderate disease 2.

Treatment Duration and Monitoring

• Treat for the full 10–12 weeks, then reassess using pain VAS score, inflammatory lesion count, and Dermatology Life Quality Index (DLQI). 1, 2
• Measure treatment response using HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas). 2
• After completing the course, consider a treatment break to assess need for ongoing therapy and limit antimicrobial resistance risk. 1, 2

When to Escalate Beyond Antibiotics

• If no clinical response after 12 weeks of clindamycin-rifampicin, escalate directly to adalimumab (160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4). 2, 5
• For Hurley Stage III (severe disease with extensive sinus tracts and scarring), initiate clindamycin-rifampicin while arranging urgent referral to dermatology for biologic therapy or surgical evaluation. 5, 6

Adjunctive Measures for All Patients

• Add intralesional triamcinolone 10 mg/mL (0.2–2.0 mL) for acutely inflamed nodules to provide rapid symptom relief within 24 hours. 2
• Provide NSAIDs for pain management and appropriate wound dressings for draining lesions. 2, 6
• Refer to smoking cessation services (70–75% of HS patients smoke) and weight management if BMI elevated, as these factors predict poor antibiotic response. 2, 5
• Screen for depression, anxiety, and cardiovascular risk factors (diabetes, hypertension, hyperlipidemia) at baseline. 1, 6

Critical Pitfalls to Avoid

• Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses, as these have minimal effect on deep inflammatory lesions. 2, 6
• Do NOT continue ineffective antibiotics beyond 12 weeks without formal reassessment, as prolonged use increases antimicrobial resistance without proven additional benefit. 2, 5
• Do NOT use topical clindamycin alone for Hurley Stage II, as it only reduces superficial pustules, not inflammatory nodules or abscesses. 2
• Avoid long-term continuous antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 1, 2

Special Population Considerations

• For pediatric patients ≥8 years old requiring systemic antibiotics, use doxycycline 100 mg once or twice daily, or clindamycin-rifampicin combination. 2
• For patients with HIV, consider doxycycline for added prophylactic benefit against bacterial STIs, but exercise caution with rifampicin due to drug interactions with certain HIV therapies. 2
• For breastfeeding patients, limit doxycycline to ≤3 weeks without repeating courses, or use amoxicillin/clavulanic acid, erythromycin, azithromycin, or metronidazole instead. 2