Hidradenitis Suppurativa Antibiotic Treatment Guidelines

Introduction to Treatment

The American Academy of Dermatology recommends a combination of oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks as first-line antibiotic treatment for hidradenitis suppurativa (HS) abscesses 1, 2

For mild disease (Hurley Stage I), the American Academy of Dermatology recommends topical clindamycin 1% solution/gel twice daily for 12 weeks as first-line therapy 1, 3
For mild disease (Hurley Stage I), intralesional corticosteroid injections can be used for acute, inflamed individual lesions 1, 2
For moderate disease (Hurley Stage II), the British Journal of Dermatology recommends oral tetracyclines (doxycycline 100 mg once or twice daily) for 12 weeks as first-line therapy 2, 3
For severe disease (Hurley Stage III), the American Academy of Dermatology recommends a combination of oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1, 2

For recurrent abscesses, the Infectious Diseases Society of America recommends culturing the lesions and treating with a 5-10 day course of an antibiotic active against the isolated pathogen 4
For recurrent S. aureus infections, consider a 5-day decolonization regimen (intranasal mupirocin, chlorhexidine washes, decontamination of personal items) 4

The British Journal of Dermatology recommends assessing treatment response after 12 weeks using recognized instruments for pain and quality of life 2, 5
For patients on adalimumab, include inflammatory lesion count in assessment 2
Be aware that recurrence following cessation of antibiotics is frequent 1

The British Journal of Dermatology recommends avoiding long-term antibiotic use without treatment breaks to reduce risk of antimicrobial resistance 2, 3
Screen for associated comorbidities including depression, anxiety, and cardiovascular risk factors 2

The American Academy of Dermatology recommends clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks as first-line therapy for moderate disease (Hurley Stage II) 6

Clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks achieves response rates of 71-93% 6
The British Association of Dermatologists recommends this combination as second-line therapy after tetracyclines, but it should be considered first-line for patients with multiple abscesses 6

For pregnant patients, oral clindamycin can be used with caution (conditional recommendation, moderate quality evidence) 7, 8, 9
Patients with a history of malignancy can safely use oral clindamycin with monitoring for severe diarrhea and C. difficile colitis 6
For HIV-positive patients, exercise caution with rifampicin due to potential drug interactions with certain HIV therapies 10

Monitor for Clostridioides difficile colitis with oral clindamycin use, as this is a known risk 6
Only 6.9% of patients discontinue clindamycin-rifampicin due to side effects, making it generally well-tolerated 6