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:

Stage I: solitary or multiple isolated abscess formation and double comedones. Image source/credit: Dermnet https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode
Stage II: Recurrent abscesses, single or multiple widely spaced lesions, with sinus tract formation. Image source/credit: Dermnet https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode
Stage III: Diffuse involvement of an area with multiple interconnected sinus tracts, abscesses and significant scarring. Image source/credit: Dermnet https://creativecommons.org/licenses/by-nc-nd/3.0/nz/legalcode

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

Hidradenitis suppurativa leaflet (British Association of Dermatologists website)

Safe Prescribing (visit the safe prescribing page)

Doses are oral and for adults unless otherwise stated
Dosing in children quick reference dosage/weight guide
Penicillin allergy – tips on prescribing in penicillin allergy
Safety in Pregnancy and Lactation
Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed January 2022