Centre of Evidence of Dermatology Best practice guidelines

Guidelines hidradenitis suppurativa Updated on august 2019


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Prescribing antibiotics is recommended in HS patients with the following possible indications: in response to a severe outbreak, as secondary prophylaxis and as a pre-operative measure.

The microbiology of HS lesions varies depending on the lesion stage: certain bacteria of the skin flora for Hurley stage Ⅰ lesions (Staphylococcus lugdunensis, Cutibacterium spp) or anaerobic bacteria, and complex anaerobic flora for Hurley stage Ⅱ and Ⅲ lesions. For this reason, antibiotherapy in HS is probabalistic and does not require the analysis of local bacteriological samples or blood cultures.

In the rare cases of fever in HS, however, local microbiological samples (pus) and blood sample investigations should be conducted to find the bacteria causing the invasive infection.

Microbiological biopsy in HS patients is therefore only recommended in case of fever, which remains exceptional.

Antibiotherapy should be prescribed at anti-infective doses in the most severe cases. Antibiotherapy should not exceed 21 days.

When secondary prophylaxis is targeted, a clinical assessment should be scheduled every 24 weeks, and every 12 weeks if the disease worsens or stagnates.

Suggestions for treatment

Table 1.

Proposal for outpatient management of Hurley stage Ⅰ patients
Severe outbreak (pain, erythema, with or without suppuration)
Cleansing with soap and water.
Oral antibiotherapy from the outset of symptoms for 7 days (subject to expert opinion).

• Amoxicillin-clavulanic acid 50 mg/kg/d for 7 days (3x 1g/d; maximum 4.5 g/d)

• Pristinamycin: 3 g/d (in 3 doses)		 
• Delivery of prescriptions in advance
< 4 outbreaks per year
No prophylactic treatment
≥ 4 outbreaks per year
Additional prophylactic treatment

• Cyclins antibiotics:
doxycyclin 100 mg/d or lymecycline 300 mg/d (double dose if weight > 80 kg)

• If treatment fails or is contraindicated:
prescription of co-trimoxazole 400/80 mg/d can be suggested, weighing the expected benefits against the risk of serious toxidermia (double dose if weight > 80 kg)
Reassessment after 6 months of treatment
(expert agreement)

Table 2.

Proposal for outpatient management of Hurley stage Ⅱ patients
in failure of previous strategy and Hurley stage Ⅲ patients
Initial treatment
Ceftriaxone 1 g/d (< 60 kg) to 2 g/d (≥ 60 kg) IV, IM and metronidazole oral dose 3x 500 mg/d


Levofloxacin (500 mg, 1-2x/d) and clindamycin (600 mg, 3x /d).
Maximum length of treatment: 15-21 days
Followed by
Surgery of the area affected


Cyclins antibiotics (doxycycline 100 mg/d or lymecycline 300 mg/d) (double dose if weight > 80 kg).


Co-trimoxazole 400/80 mg/d in case of treatment failure, intolerance or contraindication for cyclins, weighing the expected benefits against the risk of serious toxidermia (double dose if weight > 80 kg).


Immunomodulator treatment

During flares:

Expert commentary:

  • On advanced prescriptions, some experts suggest continued treatment with amoxicillin-clavulanic acid or pristinamycin for up to 21 days.
  • Some experts question the choice of levofloxacin associated with clindamycin instead of ofloxacin associated with clindamycin, which has been reported in the literature in case series. The working group’s detailed justification is available in the argumentative text.
  • Concerning the association or rifampicin with clindamycin, 4 of the 6 experts made a comment on this point. Two of them wish to recommend the use of this association, given its wide dissemination, the greater number of published observational studies than for other antibiotic therapies and the recommendations of other learned societies (EDF, NICE, etc.) advocating this association. On the other hand, the 2 other experts were not in favour of the use of this combination.

For preventive treatment, in patients weighing more than 80kg, some experts propose to increase the dose up to 200mg for doxycycline and up to 600mg for lymecycline.

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