CONCISE COMMUNICATION DOI 10.1111/j.1365-2133.2006.07155.x Clindamycin and rifampicin combination therapy for hidradenitis suppurativa C.O. Mendonc¸a and C.E.M. Griffiths The Dermatology Centre, Hope Hospital, The University of Manchester, Salford, Manchester M6 8HD, U.K.

Summary

Correspondence Background Hidradenitis suppurativa (HS) is a chronic inflammatory condition C.E.M. Griffiths. affecting apocrine gland-bearing areas of the skin. There is currently no satisfac- E-mail: christopher.griffi[email protected] tory treatment. Objectives To assess the efficacy of a 10-week course of combination clindamycin Accepted for publication 21 October 2005 300 mg twice daily and rifampicin 300 mg twice daily in the treatment of HS. Methods Patients who had received combination therapy with clindamycin and rif- Key words ampicin for HS at one U.K. Dermatology Centre between the years 1998 and clindamycin, combination therapy, hidradenitis 2003 were identified from pharmacy records. Their records were analysed retro- suppurativa, rifampicin spectively. Conflicts of interest Results Fourteen patients with HS had received treatment with combination ther- None declared. apy. Eight of these patients achieved remission and a further two achieved remis- sion when minocycline was substituted for clindamycin. Four patients were unable to tolerate therapy. Conclusions This small retrospective study indicates that combination therapy with clindamycin and rifampicin may be effective for HS. However, there is a need for a placebo-controlled trial.

Hidradenitis suppurativa (HS), a chronic disease manifested by 300 mg twice daily and clindamycin 300 mg twice daily recurrent abscesses, sinus tracts and scarring, is associated with between 1998 and 2003. The duration of disease ranged from high morbidity. HS arises most commonly, but not exclu- 2 to 30 years (mean 10Æ5). All patients had previously sively, from apocrine gland-bearing areas. The disease begins received other systemic therapies including tetracycline, isotre- after puberty, when apocrine glands in the axillae and perineal tinoin and flucloxacillin, or had been treated surgically region are fully formed, and can occasionally persist into the (Table 1). seventh decade. Staphylococcus aureus and S. epidermidis are patho- 1 gens most frequently found in early lesions of HS. Results Treatment of HS is, in general, unsatisfactory. Surgical exci- sion can result in a cosmetically unacceptable result and does Eight patients (four women and four men) achieved complete not preclude recurrence.2 The combination of oral rifampicin remission of HS of between 1 and 4 years after only one 300 mg twice daily and clindamycin 300 mg twice daily for course of treatment, and a further two patients achieved 10 weeks has been shown to be effective for other follicular remission after substituting minocycline (100 mg daily) for occlusion disorders such as folliculitis decalvans.3,4 Rifampicin clindamycin because of transient diarrhoea. These 10 patients is highly soluble and can sterilize staphylococcal abcesses.5 have not subsequently relapsed. Six responders had perineal However, the emergence of resistance when rifampicin is used involvement only; one perineum, axillae and neck; and three as monotherapy is problematic. Clindamycin was first intro- perineum and axillae only. Four patients were unable to com- duced in the 1970s and several studies have assessed the efficacy plete the course of treatment because of diarrhoea and were of topical clindamycin for HS.6,7 At the Dermatology Centre, not willing to change therapy. Hope Hospital (Manchester, U.K.), we performed a retrospec- tive review of patients with HS who had received 10 weeks of Discussion combination therapy with rifampicin and clindamycin. Therapy of HS is often frustrating and relapses are common. Patients and methods Our open, retrospective study demonstrates that combination therapy with rifampicin and clindamycin appears to be effect- Fourteen patients (nine women and five men) with HS had ive in the treatment of HS in those patients who are able to received 10 weeks of combination therapy with rifampicin tolerate the side-effects. Treatment options include oral

2006 British Association of Dermatologists • British Journal of Dermatology 2006 154, pp977–978 977 978 Hidradenitis suppurativa therapy, C.O. Mendonc¸a and C.E.M. Griffiths

Table 1 Patient demographics and prior therapies

Patient Age (years)/sex Disease duration(years) Affected area Prior therapy Remission 1 26/F 4 Axillae, breast ery, min, dian N 2 32/F 5 Axillae fluc N 3 37/M 2Æ5 Axillae, perineal lym N 4 64/F 6 Perineal ery Y 5 51/F 10 Perineal ery Y 6 56/M 14 Perineal fluc, pen, isot Y 7 29/F 10 Axillae, perineal ery, isot Y 8 20/M 3 Perineal ery Y 9 24/F 2 Axillae, perineal ery, min, fluc, dian Y 10 39/M 9 Axillae, perineal oxytet Y 11 37/F 17 Axillae, perineal, neck top clind, amp, exc, isot Y/M 12 47/F 30 Perineal isot, cef, min N 13 54/F 25 Perineal ery, top clind Y/M 14 47/M 10 Perineal ery Y

ery, erythromycin; min, minocycline; dian, Dianette (co-cyprindiol); fluc, flucloxacillin; lym, lymecycline; pen, penicillin; isot, isotretin- oin; oxytet, oxytetracycline; top clind, topical clindamycin; amp, ampicillin; exc, excision; cef, cefalexin; Y, yes; N, no; Y/M, yes following substitution of minocycline for clindamycin.

contraceptives,8 isotretinoin,9 cyproterone acetate,10 acitretin11 2 Harrison BJ, Mudge M, Hughes LE. Recurrence after surgical treat- and long-term antibiotics as used for treatment of acne. The ment of hidradenitis supurativa. BMJ 1987; 294:487–9. effect of topical clindamycin has been shown to be as effective 3 Brooke RCC, Griffiths CEM. Folliculitis decalvans. Clin Exp Dermatol 2001; 26:120–2. as oral tetracycline in HS.6,7 There are recent reports of the 4 Powell JJ, Dawber RPR, Gatter K. Folliculitis decalvans including use of infliximab in the treatment of HS although the long- tufted folliculitis: clinical, histological and therapeutic findings. Br J 12,13 term risks of therapy are unknown. The outcomes of rif- Dermatol 1999; 140:328–33. ampicin/clindamycin combination therapy appear to be better 5 Lorber B. Rifampicin in the treatment of chronic granulomatous than those in studies with isotretinoin when used for HS.9 disease (Letter). N Engl J Med 1980; 303:111. Furthermore, this combination appears to be most effective in 6 Jemec GBE, Wendelboe P. Topical clindamycin versus systemic tet- those patients who have mainly perineal involvement. A 10- racycline in the treatment of hidradenitis suppurativa. J Am Acad Dermatol 1998; 39:971–4. week course of combination therapy is a relatively low-cost 7 Clemmenson OJ. Topical treatment of hidradenitis suppurativa effective option. Patients should be warned to stop taking the with clindamycin. Int J Dermatol 1983; 22:325–8. combination if they develop diarrhoea as clindamycin is asso- 8 Mortimer PS, Dawber RPR, Gales MA et al. Mediation of hidradeni- ciated with the development of Clostridium difficile colitis. Rif- tis suppurativa by androgens. BMJ 1996; 292:245–8. ampicin is a good antibiotic against C. difficile; this and the 9 Jemec GBE. Long-term results of isotretinoin in the treatment of relatively young age group of the patients may explain why C. 68 patients with hidradenitis suppurativa. J Am Acad Dermatol 1999; difficile-induced diarrhoea was not encountered, although those 41:658. 10 Sawers RS, Randall VA, Ebling FJG. Control of hidradenitis suppu- subjects who developed diarrhoea were not screened for C. rativa in women using combined antiandrogen (cyproterone acet- difficile. However, if diarrhoea occurs clindamycin can be sub- ate) and oestrogen therapy. Br J Dermatol 1986; 115:269–74. stituted by minocycline 100 mg daily to prevent resistance. 11 Hogan DJ, Light MJ. Successful treatment of hidradenitis suppurati- We recommend review of patients after 4 weeks of therapy va with acitretin. J Am Acad Dermatol 1988; 19:355–6. and monitoring of liver function tests and full blood count at 12 Sullivan TP, Welsh E, Kerdel FA et al. Infliximab for hidradenitis baseline, 4 weeks and end of treatment. suppurativa. Br J Dermatol 2003; 149:1046–9. These promising results indicate the need for a randomized, 13 Lebwohl B, Sapadin AN. Infliximab for the treatment of hidradeni- tis suppurativa. J Am Acad Dermatol 2003; 49 (Suppl. 5):S275–6. controlled trial of this combination therapy for HS.

References

1 Jemec GBE, Faber M, Gutschik E, Wendelboe P. The bacteriology of hidradenitis suppurativa. Dermatology 1996; 193:203–6.

2006 British Association of Dermatologists • British Journal of Dermatology 2006 154, pp977–978