Hidradenitis Suppurativa - Antibiotic Prescribing

History

  • Recurrent abscesses and boils with sinus formation in flexural apocrine sweat gland bearing skin e.g. axillae, groin, perineum, inframammary areas, inguinal region and the suprapubic region
  • May present as recurring ‘ingrowing hairs’, abscesses or occasionally pilonidal sinuses

Exam

  • Open double-headed comedones
  • Painful firm papules and nodules
  • Pustules, fluctuant pseudocysts and abscesses
  • Draining sinuses linking inflammatory lesions
  • Hypertrophic and atrophic scars

The Hurley system, the most widely used assessment tool, describes three clinical stages:

abscess formation
Recurrent abscesses
abscesses and significant scarring

Record Hurley stage at area worst affected.

Early referral to Dermatologist is key to access systemic therapy for moderate to severe cases.

Treatment

General measures for treating Hidradenitis Suppurativa include:

  • Weight loss in an obese patient is essential
  • Smoking cessation
  • Loose fitting clothing
  • Absorbent dressings if discharging nodules present
  • Analgesics
  • Management of anxiety and depression

Hurley stage 1 or mild Hurley stage II disease

Topical Treatment

Drug Dose Duration +/- Notes
1st choice options for Adults and Children
Clindamycin (Dalacin T®) lotion 10mg/ml Apply thinly to affected areas every 12 hours Assess response after 6 months Apply after thorough cleansing. Counsel patient that this product may cause stinging

Oral Treatment indicated for papules or nodules

Drug Dose Duration +/- Notes
1st choice options for adults
Lymecycline 408mg every 24 hours Assess response after 12 weeks. Consider treatment break to assess need for ongoing therapy and to limit risk of antimicrobial resistance.

Avoid in Pregnancy and consider contraception in women of child bearing age.

Each capsule contains 408mg Lymecycline equivalent to 300mg of Tetracycline base (Tetralysal® 300mg).

Please Note:

Minocycline may be initiated in secondary care and if transcribing prescription advise patient of and monitor for abnormal LFT’s, irreversible cutaneous pigmentation and reversible drug induced lupus. Minocycline can cause a blue-grey discolouration of inflamed skin.

Hurley Stage III: Severe Inflammatory flares

Rifampicin 300mg every 12 hours and clindamycin 300mg every 12 hours may be initiated in secondary care by a Consultant Dermatologist and if transcribing prescription please note that rifampicin is an enzyme inducer, refer to interaction table. and refer to HPRA. Please note that rifampicin is never prescribed as monotherapy.

Treatment of acute abscesses

Drug Dose Duration +/- Notes
1st choice option for adults
Flucloxacillin 500mg every 6 hours 7 days Should be taken at least 1 hour before or 2 hours after meals.
2nd choice option
Cefalexin 500mg every 12 hours 7 days  
Children: 1st Choice Option
Flucloxacillin See Flucloxacillin dosing for children 7 days  

Adalimumab (Humira) is licensed for the treatment of severe Hidradenitis suppurativa initiated by a Consultant Dermatologist. The regimen is a higher loading dose and more frequent maintenance dose than in psoriasis.

Patient Information

Safe Prescribing (visit the safe prescribing page)

Reviewed January 2022