The Role of Antibiotics in the Treatment of HS

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Despite the fact that the clinical response to antibiotics is poor and that bacteria are found in only 50% of lesions, the recommendation for systemic antibiotics is clear and this is derived from empirical attempts to control the disease. Also, it is reasonable to try antibiotic treatment, as various bacteria are suspected as having a role in the inflammatory process and in destructive scarring in HS patients. Approximately 10% of patients have some benefit from the use of systemic antibiotics [57].

If the drainage from lesions is available, bacterial cultures and antibiotic sensitivity should be performed and the antibiotic treatment should be tailored according to these results. Collaboration between the dermatologist and the bacteriologist is an important factor in finding the best treatment option. Acute episodes and relapses are treated as bacterial infections for a 2-week period [21]. Oral antibiotics such as minocycline, erythromycin in combination with metronidazole, ciprofloxacin, cephalospo-rins or semisynthetic penicillins may be used [7, 19, 21]. Bukley and Sarkany [10] reported a case of severe HS who improved after systemic clindamycin treatment.

Long-term administration of tetracyclines or erythromycin may be used in regimens similar to acne vulgaris and seems to prevent episodic flares [19, 21].

Topical clindamycin was found to be superior to placebo in a randomized double-blind clinical trial [12] and Jemec and Wendelboe did not find any difference between systemic tetracy-cline and topical clindamycin in another randomized clinical trial [30]. However, after withdrawal of antibiotic treatment, HS very often relapses [3, 13].

As is the case with acne vulgaris, it is not known whether the most important factor in the treatment of HS is antibacterial or anti-inflammatory. Lincosamides and tetracyclines have been known for their immunomodulatory effects. Clindamycin suppresses the complement-derived chemotaxis of polymorphonucle-ar leukocytes in vitro, thereby reducing the inflammation potential [43, 52]. Tetracyclines

Table 11.4. Anti-inflammatory and immunomodulatory properties of antibiotics used in the treatment of HS




- Inhibition of metalloproteases

- Inhibition of free radicals

- Modulation of IL-1a

- Inhibition of lipases

and proteases

- Inhibition of nitric oxide

synthetase and caspase 1

and 3 production

- Modulation of cytokine


- Reduction in the production

of free radicals secreted by poly-

morphonuclear leukocytes

- Reduction in the formation

of inflammatory granuloma


- Suppression of complement-derived chemotaxis of poly-morphonuclear leukocytes

are known as good candidates for the treatment of inflammatory disorders. The anti-inflammatory properties are enumerated in Table 11.4 [43, 44].

Hindle et al. treated seven patients with a combination therapy of clindamycin (300 mg twice daily) and rifampicin (300 mg twice daily) for a 10-week period [25]. Three patients did not tolerate the combination, two because of diarrhea associated with Clostridium difficile, and three of them responded well and remained clear at 12 months. The combination of rifampi-cin and clindamycin was also successfully used for two other chronic and difficult-to-treat conditions: folliculitis decalvans [45] and acne ke-loidalis nuchae [25]. Clindamycin is a lincos-amide antibiotic active against Gram-positive cocci (except enterococci) and most anaerobic bacteria [52]. Rifampicin is a broad spectrum antibacterial agent that inhibits the growth of the majority of Gram-positive bacteria as well as many Gram-negative microorganisms [55]. It is highly active against both Staphylococcus aureus and coagulase-negative staphylococci. Rapid emergence of resistance when the drug was used alone has limited the use except in association with another anti-staphylococcal drug [2]. The

combination therapy was introduced to prevent resistance development against rifampicin and to cover a broad antibacterial spectrum.

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