Authors:

Franklin R. Blum, Rishab Revankar, Christopher J. Sayed

Chapter 17

Antibiotics

Chapter contents

I. Introduction

As previously described, HS is a chronic skin condition that flares and recedes over time. Although HS is frequently treated with systemic antibiotics, it is important to remember that the main cause of HS is not infection. HS is a long-term condition in which inflammation in the skin has become overactive, but antibiotics have been used with some benefit for decades. Antibiotics can be taken by mouth, injection, or intravenously through an IV.

Occasionally, an infection can develop in HS-affected skin, but antibiotics probably work for other reasons. This may prompt you to ask, if the condition is not thought to be caused by infection, why are antibiotics effective?

While antibiotics are often used to treat infection because they kill dangerous bacteria, they have other effects that are important in the treatment of HS.

II. Antibiotics: Role in Treatment of HS

We all have normal bacteria on our skin, but the mix of bacteria present can be different in people with HS. It is likely that the immune system in people with HS can be triggered by bacteria that are usually considered “normal.” One theory is that antibiotics alter the number and type of skin bacteria in a way that reduces how inflammation is triggered. Another well-observed effect of some antibiotics is that they can be anti-inflammatory. This means that antibiotics can calm down areas of the body that are irritated or inflamed. Since inflammation is increased with HS, the anti-inflammatory effects of antibiotics is likely beneficial. Several commonly used antibiotics for HS treatment and their most notable side effects are listed in Table 17.1, though many other types of antibiotics may be used based on patient and provider preference.

Antibiotics help improve the bothersome symptoms of HS that include drainage, pus, and odor. Pus is an inflammatory substance that the body creates as a reaction to different types of infection, including infections from bacteria (like a “staph” infection, for example). In the case of HS, the body creates pus possibly as a reaction to normal skin bacteria or possibly for other reasons that are not yet completely clear to researchers at this time. The pus and bacteria that live in the pus may produce odors. Since antibiotics alter the number and type of skin bacteria, the body does not produce as much pus and drainage when antibiotics are taken, which can provide relief for HS patients. Some antibiotics are also thought to directly block inflammation, though the role of antibiotics in reducing inflammation specifically for patients with HS is still unclear.

III. Choosing an Antibiotic

As outlined in Table 17.1, if a person has mild to moderate HS, a healthcare provider may choose to prescribe one antibiotic or a combination of antibiotics.

In many cases, the initial antibiotics chosen for a patient may not be effective or may cause side effects, so alternatives might be chosen. As the disease becomes more severe, it is typical to combine two or three oral antibiotics at a time.

Increasing the number of antibiotics that you take can increase the risk of side effects; however, the benefits may outweigh the risks. Antibiotics may be taken intermittently for flares, or – in some cases – they may be taken for months or years for longer-term control when they work well.

In the most severe cases, IV antibiotics, such as ertapenem, may be given for weeks at a time. Since symptoms tend to recur quickly after the course of treatment ends, it is important to have a long-term treatment plan in place.

Antibiotic side effects should be taken into consideration when a treatment plan is made. If you have a history of any allergic or unpleasant reactions to an antibiotic, be sure to inform your healthcare provider. As with all medications, the benefits of taking antibiotics must be weighed against their side effects. It is hard to predict how individual people will react to different antibiotics. Most antibiotics can cause stomach upset for some people. Other side effects are less common; however, if you have a bad reaction to a medication, it is important to stop taking the medication and let your healthcare provider know.

Table 17.1. Systemic Antibiotics for HS
Name HS Severity Usage Notable Side Effects
Tetracyclines (e.g., doxycycline, minocycline) Mild, Moderate Acute flares, long-term management Abdominal pain, increased sun sensitivity, not safe in pregnant women
Clindamycin Mild, Moderate, Severe May be used on its own or combined with other antibiotics Diarrhea, nausea, vomiting
Rifampin Mild, Moderate, Severe Combination therapy with other antibiotics Hepatitis, can reduce birth control effectiveness, can turn urine and other bodily fluids orange in color
IV Ertapenem Severe 12 week course, requires a special IV called a PICC line for home IV infusion Nausea, vomiting, skin rash, requires regular lab tests
Metronidazole (Flagyl®) Mild, Moderate, Severe Combination therapy with rifampin and moxifloxacin Nausea, vomiting, severe reaction with alcohol use
Cephalosporins (e.g., cephalexin/Keflex®, cefdinir) Mild, Moderate Acute flares, long-term management Nausea, vomiting, rashes, dizziness
Fluoroquinolones Moderate, Severe Combination therapy with rifampin or metronidazole Tendon inflammation (more common in elderly patients), heart arrhythmias, nausea, vomiting, not safe in children and pregnant women
Trimethoprim Sulfamethoxazole (i.e., Bactrim®) Mild, Moderate Acute flares, long-term management Nausea, vomiting, severe rash, not safe in pregnant women

It is possible that, in milder cases, your healthcare provider might start treatment with a single antibiotic such as doxycycline, then change the type of antibiotic or add others as the condition worsens or as certain antibiotics are shown not to improve the condition. For people with more severe disease, a regimen of two or three antibiotics, or even IV antibiotics, might be started immediately. As the severity is reduced with treatment, some antibiotics with more risks might be stopped or avoided. Sometimes, if one antibiotic stops working, it helps to rotate to different antibiotics over time.

Doxycycline and minocycline are commonly used to treat other skin conditions like acne, and are frequently prescribed to treat people with mild-to-moderate HS symptoms. Clindamycin and rifampin used in combination are frequently used as well, though some studies show rifampin may reduce how well clindamycin works over time. Common combinations for disease flares that are used for shorter periods of time include antibiotics such as a quinolone (levofloxacin, ciprofloxacin, or moxifloxacin) in addition to metronidazole and rifampin. In very severe cases, an IV antibiotic like ertapenem may be used for 6-12 weeks with home IV infusions. Both short and long-term side effects limit how often some of these antibiotics should be used. Some antibiotics may interact with other medications to make them either less effective or more likely to have side effects; an example is rifampin, which can make oral. contraceptive pills (birth control pills) work less well and lead to pregnancy. Discuss possible medication interactions with your healthcare provider.

There is no specific antibiotic that works best for every person with HS, but in many cases the right antibiotic can play a positive role. Flares generally require shorter courses of antibiotic treatment, whereas more chronic disease may require long-term antibiotic treatment. It may take time to figure out which antibiotics help you the most and do not cause side effects, and sometimes non-antibiotic options end up being a better choice. The benefits and risks of current HS symptoms can be weighed against antibiotic side effects and over all effectiveness when determining the treatment plan. While antibiotics are not curative, they may be an important part of treatment to control your HS.

IV. Questions and Answers

Question 1 Can taking antibiotics create “superbugs”? Answer

Sometimes. “Superbugs” is a general term used to describe bacteria that have become highly resistant to our available antibiotics in people that have been exposed to many antibiotics. This is more common in patients staying in hospitals. Using one or two antibiotics does not create resistance to all antibiotics, so you are unlikely to develop an infection that could not be treated with a different antibiotic. Make sure to use antibiotics as directed by a physician to help reduce issues of resistance.

Question 2 Will HS antibiotic treatment mess up my microbiome? Answer

Not usually. Microbiome is the collection of all microbes. The bacteria microbiome includes bacteria that naturally live on our bodies and inside us, commonly known as “healthy bacteria.” With HS, the goal of antibiotic treatment is to alter bacteria on the skin and reduce inflammation. However, antibiotics can also inadvertently target healthy gut bacteria. Most of the time, the change in normal bacteria does not cause problems, and the bacteria normalize once the antibiotic is stopped. Usually, the benefits of treating HS outweigh the potential risks. Further more, dermatologists experienced in treating HS can help people with HS by identifying combination therapies that reduce the risk of long-term side effects of antibiotic regimens.

Question 3 How long should I take antibiotics for? Answer

It depends. Short courses of antibiotics may be used on an as-needed basis to treat occasional flares for 1-2 weeks at a time. Often, treatment lasts longer, but there is typically an effort to limit treatment with a specific antibiotic to an 8-12 week period. In some instances, people who achieve very good disease control only while on certain antibiotics may consider taking them for months or years if the benefits seem to outweigh the risks in their particular case. Speak with your healthcare provider to determine the proper treatment length for you.

Question 4 Should I take probiotics? Answer

Some research studies have pointed to certain aspects of the microbiome that are altered in people with HS. These alterations could potentially play a role in contributing to the development of HS. As with other chronic inflammatory skin diseases, probiotics could be a helpful part of the treatment plan for HS; however, more conclusive evidence is needed to understand if they truly help, and – if so – which probiotic strains would be the most optimal.

Question 5 Can I get vaginal yeast infections if I take antibiotics? Answer

Yes. Vaginal yeast infections are possible in women who take antibiotics that target a broad range of bacteria, including healthy bacteria normally found in the vagina. Antibiotics reduce healthy bacteria, which can allow yeast to grow more, causing a yeast infection. Symptoms of a yeast infection include burning (especially with urination), itching, odor, rash, and non-menstrual vaginal discharge (may appear milky white or watery). Oftentimes, vaginal yeast infections occur within 1-2 weeks of starting antibiotics, although they can occur later in an antibiotic treatment course. Talk with your healthcare provider before starting antibiotics if you have a history of vaginal yeast infections. They can often provide medication to reduce this risk or treat the yeast infection if this occurs.

Question 6 Some antibiotics upset my stomach. How can I prevent that? Answer

Taking antibiotics with meals can usually decrease the risk of stomach upset, though certain foods can decrease effectiveness of certain antibiotics. Check the label on your prescription or ask your provider to determine whether your prescribed antibiotic should be taken on an empty stomach or with meals. To reduce the chance of nausea, especially if you are prescribed multiple antibiotics, your provider may have you start one antibiotic, take it for a few days, and then have you start the next antibiotic if you are not experiencing nausea. Sometimes spacing out antibiotics throughout the day (for example, taking them once in the morning and once at night) can also reduce the chance of nausea. Lastly, nausea medicines may be helpful, but if this problem persists, it is probably time to switch to another antibiotic or different kind of treatment. If diarrhea, nausea, or vomiting persists for more than one week after stopping antibiotics, make sure to discuss this with your doctor.

Question 7 Can inflammatory bowel disease impact antibiotic effect ? Answer

Yes. HS is associated with a number of comorbidities (having more than one medical condition in the same person), including inflammatory bowel disease (IBD). Fundamentally, IBD can affect absorption of food, nutrients, and medications as they pass through the gastrointestinal track. This means that, compared to a normal healthy person, a person with IBD may not absorb the same amount of medication. This means that there is potential for antibiotic treatment to be less effective in patients with HS and IBD compared to patients with HS without IBD, though definitive research in this area is lacking.

Question 8 Will my HS come back after I finish my antibiotics? Answer

Very often, HS symptoms improve while on antibiotic treatment and can worsen once the treatment stops. Unfortunately, HS is a long-term condition that improves and worsens periodically over time. While taking antibiotics for a flare may calm things down to an extent, recurrence is common. Long-term treatment with antibiotics is sometimes used to help manage the disease over the long term, but it is important to remember that antibiotics are not curative.

In most cases, your doctor will not use antibiotics as your only treatment. For many, antibiotics are a short-term solution to a more long-term condition that requires additional treatments. Most patients with HS take antibiotics in addition to other treatments, which may include taking medications that alter hormones or making diet and lifestyle changes. However, if a patient with HS finds that taking an antibiotic alone is beneficial and they are not experiencing any side effects, the benefits of taking antibiotics alone outweigh the risks (such as antibiotic resistance) that are associated with long-term use.

Question 9 What antibiotics should I avoid if I am pregnant? Answer

Tetracyclines, fluoroquinolones, and trimethoprim-sulfamethoxazole/Bactrim® are generally avoided during pregnancy. However, clindamycin and cephalosporins are usually considered safe to use for pregnant patients with HS. Please see Table 17.1 for full descriptions of antibiotics and their side effects.

Question 10 What method of antibiotic administration should I avoid Answer

PICC: peripherally inserted central catheter. A PICC line is often placed in a blood vessel on the inner part of your upper arm. The line remains in your arm for the duration of treatment, but is kept covered with sterile bandaging when not in use. A PICC line during pregnancy is associated with risk of infection and blood clots. Thus, it should be avoided unless deemed absolutely necessary and discussed with obstetrician.