Therapy

Despite the widespread use of antibiotic therapy, there is a paucity of information in the literature. One trial found topical clindamycin superior to its vehicle while another showed no dif

Table 15.1. Bacterial cultures in hidradenitis suppurativa

Patients

Cultures

No growth

Staphylococcus

Streptococcus

GNB

(n)

(n)

(%)

aureus (%)

pyogenes (%)

(%)

Axilla

60

330

90

8

1

1

Perineum

55

255

80

10

2

8

Buttocks

20

110

90

7

0

3

Submammary

15

60

95

5

0

0

Table 15.2. Published trials of antibiotics in HS

Design

Number of patients

Drugs

Duration of therapy (months)

Result

Reference

1 Randomized

27

Clindamycin

3

10% topical clindamycin

Clemmensen

controlled trial

versus placebo

superior to placebo

[10]

2 Randomized

46

Topical clinda-

3

No significant difference

Jemec and

controlled

mycin versus

between topical clinda-

Wendelboe

double-blind trial

systemic tetra-

mycin and systemic

[11]

cycline

tetracycline

ference between topical clindamycin and systemic tetracycline - neither worked well [10, 11] (see Table 15.2).

Short courses of antibiotics aimed at stopping an exacerbation of the disease are usually useless. In the experience of one author (J.R.) there is a subset of HS patients with mild disease who may benefit from such treatment. These patient have only a few outbreaks of one - or several - painful nodules during a year. If they start the antibiotic treatment immediately, within 1 h, of the first symptom they have a 50% chance of preventing the "normal" evolution, i.e., pain, swelling, and incision of the abscess.

Systemic clindamycin targeting anaerobic bacteria has been used in high doses, 1200 mg and 2400 mg respectively, in two patients with good improvement [8]. More recently the combination of systemic clindamycin (600 mg daily) and rifampicin (600 mg daily) was given for 10 weeks to seven patients with HS [12]. Two patients experienced diarrhea related to Clostridium difficile; three responded well and remained clear at 12 months. The same team has reported their experience with 14 patients - 9 women and 5 men - with long-lasting HS of mean duration 10.5 years [13]. Eight patients achieved long-lasting complete remission: 1-4 years of follow-up without recurrence. Two other patients achieved remission after minocycline was substituted for clindamycin because of diarrhea. The four other patients could not tolerate the course of treatment because of diarrhea.

One of us (J.R.) has recently confirmed these results by treating 42 HS patients (26 women, 16 men) with long-lasting disease, mean duration

11 years [14]. All were severely affected, with 21 being at stage II of Hurley's classification and 21 at stage III. All of them had more than 15 days/ month of pain and 34 had permanent, painful lesions. Twenty patients had already used antibiotics, either as a short course of less than 15 days or as continuous treatment with tetra-cyclines. Twelve patients were followed-up by their referring physician and no data on treatment results were available. In the remaining 30 patients, 9 had a complete remission, 9 an important improvement and 11 a moderate improvement. Of these 29, 20 had had no relapse after a follow-up of 3 months to 1 year. One patient had to stop because of spontaneously healing diarrhea; eight other patients experienced mild diarrhea, recovering without stopping the treatment.

Confirmation and extension of these studies is necessary. Studies should focus on the role of infection in severely affected patients with long-lasting disease. One cannot expect such treatment to cure the disease, but it raises the hope of bringing a significant number of patients into remission. Whether other drugs, namely tetracyclines and non-steroidal anti-inflammatory drugs, can prolong a state of complete or near-complete remission will have to be explored in the future.

A note of caution about chronic antibiotic therapy, which can disrupt the normal flora of sites including the oral cavity, gastrointestinal tract and vagina; this risk needs to be weighed against the benefit seen in patients who are not colonized by pathogens.

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