Oral Treatments for Hidradenitis Suppurativa

Oral Antibiotics

Antibiotics are widely used and considered to be one of the mainstays of treatment of HS, even though bacteria do not appear to cause HS.  A dermatologist can help you determine what antibiotic or combination of antibiotics may help to reduce your symptoms. Tetracyclines, lincosamides, flouroquinilones, carbapenems, rifampin, dapsone, and metronidazole are some of the most commonly used antibiotics or classes of antibiotics which are frequently used in mono or combination therapy for HS. It is unclear why antibiotics help to ameliorate the symptoms of HS and even induce remission in less severe cases, but it has been hypothesized that anti-inflammatory properties, a reduction of the bacterial load, or even alterations to the immune system may influence the response that is seen after a prolonged course of antibiotics.

Overall, research evaluating the efficacy of antibiotics in HS is limited, but currently available studies do support their use. Dual therapy with clindamycin and rifampin is supported in the literature and is reported to be most efficacious in patients with Hurley stage I HS, and less so in patients with Hurley Stage II and III disease.1-4 Triple therapy with rifampin, moxifloxacin, and metronidazole has also been shown in the literature to reliably reduce pain, drainage, and redness, in Hurley stage I and II disease and infrequently after prolonged courses in patients with Hurley stage III HS.5 Dapsone has also been shown to be effective in less severe cases in a study with a total of 24 patients.6 In addition to the studies above, there are several smaller case reports or case series reporting efficacy of various antibiotics. Flares in HS are frequently reported after taking antibiotics, and are not considered definitive management. The course of antibiotics that you can expect to take for HS may also be longer (up to several weeks to months) than you may have taken for other indications. Concerns regarding bacterial resistance prevent physicians from using antibiotics for long term control. Resultantly your dermatologist may suggest taking antibiotics to gain control of the pain, drainage, and redness and then may suggest additional management such as surgery or another type of medical management.

Hormonal Therapies

Data regarding hormone levels in patients with HS is mixed, but many patients report flares associated with the menstrual cycle and symptoms of irregular or anovulatory menstrual cycles. More importantly, reports of successful alleviation of symptoms have been reported with hormonal therapy. Therapies can be directed at correcting abnormal hormone levels, if present, or blocking hormone receptors to reduce their actions. Examples include careful selection of birth control agents, spironolactone, cyproterone acetate, finasteride, or dutasteride.7

Metformin

Metformin, an oral medication used to treat diabetes, often helps control the symptoms of HS in patients who are resistant to other treatments.7 It also helps in weight reduction.

Intravenous Ertapenem

Surgical management remains the cornerstone of treatment for advanced hidradenitis suppurativa, but the invasive nature of surgical interventions and extent of lesion involvement can limit the feasibility of this treatment option. Control of symptoms is also critical when undergoing a surgical intervention. Oral antibiotics are less effective in severe HS and intravenous (IV) antibiotics can be used in cases of inadequate control. Various IV antibiotics have been used for HS, but controlled studies supporting their use are limited. Ertapenem is an IV antibiotic for which the most data exists. In a retrospective study involving 30 patients with severe HS, dramatic improvement in symptoms and validated scoring measures was achieved. The authors suggested that coupled with surgery, and optimized consolidation treatments, ertapenem may play an important and promising role in the management of severe HS.9

Resources
  • Bettoli V, Zauli S, Borghi A, et al. Oral clindamycin and rifampicin in the treatment of hidradenitis suppurativa-acne inversa: a prospective study on 23 patients. J Eur Acad Dermatol Venereol. 2014;28(1):125-126.
  • van der Zee HH, Boer J, Prens EP, Jemec GB. The effect of combined treatment with oral clindamycin and oral rifampicin in patients with hidradenitis suppurativa. Dermatology. 2009;219(2):143-147.
  • Gener G, Canoui-Poitrine F, Revuz JE, et al. Combination therapy with clindamycin and rifampicin for hidradenitis suppurativa: a series of 116 consecutive patients. Dermatology. 2009;219(2):148-154.
  • Mendonca CO, Griffiths CE. Clindamycin and rifampicin combination therapy for hidradenitis suppurativa. Br J Dermatol. 2006;154(5):977-978.
  • Join-Lambert O, Coignard H, Jais JP, et al. Efficacy of rifampin-moxifloxacin-metronidazole combination therapy in hidradenitis suppurativa. Dermatology. 2011;222(1):49-58.
  • Yazdanyar S, Boer J, Ingvarsson G, Szepietowski JC, Jemec GB. Dapsone therapy for hidradenitis suppurativa: a series of 24 patients. Dermatology. 2011;222(4):342-346.
  • Karagiannidis I, Nikolakis G, Zouboulis CC. Endocrinologic Aspects of Hidradenitis Suppurativa. Dermatol Clin. 2016;34(1):45-49.
  • Alavi A, Kirsner RS. Local wound care and topical management of hidradenitis suppurativa. J Am Acad Dermatol. 2015;73(5 Suppl 1):S55-61.