If you have HS, you may have tried treating painful lumps with washes, creams or antibiotics, only to find they keep returning. You should know that HS is a chronic inflammatory condition, so antibiotics may help reduce inflammation as well as treat infection when needed.
You and your dermatologist can choose treatment based on how often you flare, whether you have tunnels or scarring and how you respond to treatment. You may be offered antibiotics, corticosteroid injections or biologic medicines when you need stronger control.
Why Does HS Need Medical Treatment?
You should know that HS is different from an ordinary skin infection. A typical boil may settle after draining, while your HS can cause recurring lumps, drainage, tunnels and scarring.
You and your dermatologist can focus on controlling the underlying inflammation rather than treating each lump separately. Your treatment will depend on your symptoms, health conditions, medicines and previous response to treatment.
When Are Antibiotics Used for HS?
You may be prescribed antibiotics for HS even though HS is not simply a bacterial infection. You should know that some antibiotics can help reduce inflammation as well as treat bacteria, and your doctor may also use them if your lesion develops signs of a secondary infection.
You and your dermatologist can decide how long you need antibiotics based on your symptoms, previous treatment and any signs of infection. You may have your treatment reviewed rather than taking antibiotics indefinitely, as longer use can cause side effects and contribute to antibiotic resistance.
Which Antibiotics May Be Considered?
You should know that oral antibiotics such as doxycycline or lymecycline may be prescribed for around 12 weeks or longer, depending on your response. They are used to help control HS inflammation, not just treat a short-term infection.
If your HS does not improve enough, you and your dermatologist may consider clindamycin with rifampicin for a defined course. Rifampicin can interact with other medicines, so your treatment should be monitored carefully.
Why Are Antibiotics Sometimes Used Even When There Is No Infection?
You should know that pus does not automatically mean your HS is mainly a bacterial infection. HS involves inflammation around hair follicles, and some antibiotics may help by reducing this inflammation as well as treating bacteria when needed.
You and your dermatologist can decide whether antibiotics are suitable based on your HS pattern and previous response to treatment. You should not assume that every flare needs another short antibiotic course, especially if your HS keeps returning and may need a different long-term approach.
Can You Have Antibiotics Alongside Other HS Treatments?
Yes, your dermatologist may use antibiotics alongside other HS treatments when appropriate. You may also receive a biologic for immune-related inflammation or a corticosteroid injection for one particularly inflamed lump, with each treatment targeting a different part of your HS.
You should not combine treatments on your own. You and your healthcare team can review possible interactions, side effects and benefits, so make sure your GP, dermatologist and pharmacist know about all the medicines you take.
Research Insight
If you start a biologic, your dermatologist may use the Hidradenitis Suppurativa Clinical Response (HiSCR) to measure your response. HiSCR50 means at least a 50% reduction in abscesses and inflammatory nodules, with no increase in abscesses or draining tunnels. NICE uses treatment-specific continuation criteria for adalimumab and secukinumab in NHS care, so your treatment is reviewed at the relevant time point.
What Are Intralesional Corticosteroid Injections?
An intralesional corticosteroid injection places a small amount of steroid directly into your inflamed HS lesion. You may be offered this treatment when you have one or a few painful, very inflamed nodules, as it may help reduce swelling and pain in selected inflamed lesions.
Triamcinolone has been used for intralesional treatment of inflamed HS lesions, but this treatment is not suitable for every flare. You and your dermatologist can decide whether a targeted injection is appropriate for you based on your lesion and overall HS pattern.
When Might a Steroid Injection Be Useful?
You may be offered an intralesional corticosteroid injection when you have a particularly painful, inflamed HS nodule. You should know that it is mainly used for short-term relief and does not prevent new HS lesions from developing elsewhere.
You and your dermatologist can decide whether an injection is suitable for you based on the lesion’s location, severity and expected benefit. You should also know that injections can cause local effects such as skin thinning or changes in pigmentation, so they need to be given carefully by a trained clinician.
How Quickly Can Steroid Injections Help an HS Flare?
You may notice fairly quick pain relief after an intralesional corticosteroid injection for a very inflamed HS lesion, although your response can vary.
You and your dermatologist can decide whether an injection is suitable after checking for infection or a deeper tunnel. It can target a specific inflamed lesion but does not replace your overall HS treatment plan.
Evidence Note
If you are offered an intralesional corticosteroid injection, you should know that the evidence remains limited and mixed. You may get short-term improvement in pain or inflammation in a selected lesion, but your injection does not replace your overall HS treatment plan.
What Are Biologic Medicines for HS?
You may be offered biologic medicines when you have moderate to severe HS that has not improved enough with other treatments. Unlike antibiotics, biologics target specific inflammatory pathways involved in HS.
You and your dermatologist can discuss options such as adalimumab, secukinumab or bimekizumab based on your symptoms, previous treatments and overall health. You may need checks before starting treatment and regular monitoring afterwards to make sure the benefits and risks are appropriate for you.
How Do Your Main HS Treatment Options Compare?
| Treatment | When it may be considered for you | What it does for your HS | What you should know |
| Oral tetracyclines | Mild-to-moderate inflammatory HS or as systemic treatment | Reduce inflammatory activity | Usually given as a defined course and reviewed |
| Clindamycin + rifampicin | When tetracyclines have not worked adequately | Systemic anti-inflammatory/antimicrobial treatment | Drug interactions and side effects need consideration |
| Intralesional corticosteroid | Selected painful, inflamed individual lesions | Short-term reduction of inflammation and pain | Does not treat overall HS; local skin effects can occur |
| Adalimumab | Moderate-to-severe HS after inadequate response to conventional systemic treatment | Longer-term control of inflammatory disease | Infection screening and response monitoring required |
| Secukinumab | Moderate-to-severe HS in appropriate patients, including when adalimumab is unsuitable or unsuccessful | Targets IL-17A inflammatory signalling | Infection and inflammatory bowel disease considerations |
| Bimekizumab | Moderate-to-severe HS in appropriate adults | Targets IL-17A and IL-17F | Candida infection and inflammatory bowel disease considerations |
How Does Adalimumab Work for HS?
You may be offered adalimumab for moderate to severe HS when conventional treatment has not worked well enough. Adalimumab blocks TNF-alpha, an inflammatory messenger involved in HS, which may help reduce inflammation associated with painful nodules and abscesses.
You and your dermatologist can review your response at 12 weeks, looking at changes in inflammatory lumps, draining lesions and your overall symptoms. If you are not improving enough, your treatment plan may need to be reconsidered rather than continuing treatment without benefit.
What Is Secukinumab and When Is It Considered?
You may be offered secukinumab for moderate to severe HS when conventional systemic treatment has not worked well enough. You should know that it works differently from adalimumab by targeting IL-17A, a different inflammatory pathway involved in HS.
You and your dermatologist can review your response at 16 weeks to see whether your HS has improved enough. If you are not responding adequately, your treatment plan may need to be reviewed rather than continuing a medicine that is not helping you.
UK Guidance Note
For NHS treatment in England, your pathway depends on the biologic and your previous response. NICE recommends adalimumab after inadequate conventional systemic therapy, with your response assessed at 12 weeks. Secukinumab is recommended if adalimumab is unsuitable, did not work or stopped working, with your response assessed at 16 weeks. NICE currently has no recommendation on bimekizumab for HS because its appraisal was terminated.
Where Does Bimekizumab Fit Into HS Treatment?
You may be offered bimekizumab for moderate to severe HS when conventional systemic treatment has not worked well enough. You should know that it targets IL-17A and IL-17F; secukinumab targets IL-17A alone, while adalimumab targets TNF-alpha.
You and your dermatologist can discuss whether bimekizumab is suitable for you based on your symptoms, previous treatment, medical history and infection risk. You should also know that it can increase the risk of Candida infections, so your healthcare team can monitor you for possible side effects during treatment.
What Safety Checks Are Needed Before a Biologic?
Before starting a biologic for HS, your dermatologist may check your general health and infection risk. These checks help your healthcare team decide whether the treatment is suitable and whether you need any precautions.
- Infection screening: You may be checked for infections such as tuberculosis or hepatitis.
- Blood tests: Your dermatologist may recommend blood tests before treatment.
- Medical history: Tell your doctor about recurrent infections, bowel problems, liver conditions and previous tuberculosis exposure.
- Vaccination history: Your vaccination status may be reviewed before starting treatment.
Your dermatologist can use these checks alongside your HS history and other medicines to decide whether a biologic is appropriate for you. You may also need ongoing monitoring after treatment begins.
What Side Effects Can Medical HS Treatments Cause?
You should know that every HS treatment can have side effects, so your dermatologist will balance the potential benefits and risks for you. You may experience stomach problems with some antibiotics, while clindamycin can rarely cause serious bowel inflammation and rifampicin can interact with other medicines.
You may also notice local skin changes after corticosteroid injections, such as thinning or pigmentation changes. Biologics can increase your infection risk, with Candida infections particularly relevant to some IL-17 medicines, so you should tell your healthcare team about any significant or persistent infection symptoms.
How Does Your Dermatologist Decide Which Treatment to Use?
You should know that there is no single HS treatment plan that works the same way for everyone. You and your dermatologist can look at how often you develop painful lumps, whether you have tunnels or scarring, how much HS affects your daily life and how well previous treatments have worked.
You may also need to consider your other health conditions and your own preferences. You and your dermatologist can discuss factors such as infection risk, bowel conditions, injections, monitoring, pregnancy, travel or work before choosing a treatment that suits you.
Clinical Tip
Before your appointment, make a list of previous antibiotics and other HS treatments you have tried, how long you used them and whether they helped. Also note how often you have flares, which areas are affected, whether lesions drain and whether you have any other conditions such as inflammatory bowel disease. This can help your dermatologist understand your treatment history and discuss the next option more efficiently.
When Should You See a Dermatologist for Medical HS Treatment?
You should consider a specialist review if you keep developing painful HS lesions despite basic care or repeated antibiotic courses. You do not need to wait for extensive scarring or tunnels, and you may want assessment sooner if your flares are becoming more frequent, painful or difficult to control.
You can bring your previous treatment details and photos to your appointment, especially if your skin is clearer on the day. You and your dermatologist can then discuss whether antibiotics, a corticosteroid injection or a biologic may be suitable, with the aim of controlling your HS over the longer term.
Myth vs Fact
| Myth | Fact |
| HS is simply a bacterial infection. | HS is a chronic inflammatory skin disease, although bacteria and secondary infection may sometimes be relevant. |
| Every one of your HS flares needs antibiotics. | Antibiotics may be useful for selected patients, but repeated flares do not automatically mean another antibiotic course is needed. |
| Antibiotics can permanently cure your HS. | Antibiotics can reduce inflammatory activity and control flares, but HS can recur after treatment. |
| A steroid injection treats your whole HS. | An intralesional steroid is a targeted treatment for selected inflamed lesions and does not prevent new lesions elsewhere. |
| Biologics are only for people with the most severe HS. | Biologics may be considered for active moderate-to-severe HS when conventional systemic treatment has not worked adequately. |
| All biologics work in exactly the same way. | Adalimumab targets TNF, secukinumab targets IL-17A, and bimekizumab targets IL-17A and IL-17F. |
| Bimekizumab and secukinumab are suitable for everyone with HS. | Medical history, previous treatment and conditions such as inflammatory bowel disease can affect whether an IL-17 medicine is appropriate. |
| If one biologic does not work, there are no other options. | Your dermatologist can reassess the diagnosis, response, safety and available treatment options if a biologic is ineffective or loses effect. |
Key Takeaways
- If you have HS, it is a chronic inflammatory condition, not simply a bacterial infection.
- Antibiotics may be used for their anti-inflammatory effects as well as when secondary infection is suspected.
- Your dermatologist may use oral tetracyclines as a defined course, while clindamycin and rifampicin may be considered when tetracyclines have not worked adequately.
- Intralesional corticosteroid injections can provide short-term relief for selected painful, inflamed lesions but do not treat the overall disease.
- Adalimumab targets TNF-alpha, secukinumab targets IL-17A, and bimekizumab targets IL-17A and IL-17F; these medicines may be used for appropriate patients with moderate-to-severe HS.
- Your previous treatment response, other medical conditions, infection risk and treatment preferences can influence biologic choice.
- Response to biologic treatment should be assessed rather than continuing an ineffective medicine indefinitely.
- In the UK, NHS recommendations and funding arrangements differ between biologics, so the treatment pathway should be discussed with your dermatologist.
Frequently Asked Questions
1. Does an HS Flare Mean Your Treatment Has Stopped Working?
No. You can still have a flare while your overall treatment is helping. If your flares become more frequent, painful or draining, tell your dermatologist so you can review whether your treatment is still giving you enough control.
2. How Long Should You Stay on Antibiotics for HS?
Your antibiotic course should be reviewed rather than continued indefinitely. You should take it exactly as prescribed, and your dermatologist can assess whether your symptoms are improving and whether you need a different longer-term treatment plan.
3. What Should You Tell Your Doctor Before Taking Rifampicin?
Tell your doctor about every medicine and contraceptive you use before starting rifampicin because it can affect other medicines. Your healthcare team can check your interactions and explain what you should do if your medicines need adjusting.
4. Are Steroid Injections Useful for Every HS Lesion?
No. Your dermatologist may use them for selected painful, inflamed lesions. You should tell your dermatologist if you have signs of infection or deeper tunnels, because your lesion may need a different treatment approach.
5. How Do You Know Whether a Biologic Is Working?
You and your dermatologist can track your inflammatory nodules, abscesses, draining tunnels and symptoms over time. Your response should be formally reviewed at the relevant time point so you do not continue a biologic that is not helping you.
6. What Happens If Adalimumab Does Not Work for You?
If adalimumab is unsuitable, does not work or stops working, your dermatologist can review other options with you. In NHS practice, secukinumab may be available for you when you meet NICE criteria, while your wider treatment plan may include other medical or surgical approaches.
7. Can Biologic Medicines Increase Your Risk of Infection?
Yes. Your infection risk is one reason your dermatologist checks your health before treatment. You should report significant or persistent infection symptoms, and your healthcare team can advise you if your treatment needs to be paused.
8. Can You Have Vaccinations While Taking a Biologic?
Before vaccination, tell the clinician that you are receiving a biologic. Your dermatologist can advise which vaccines are appropriate for you, because live vaccines are generally avoided during biologic treatment and your vaccination status may be reviewed before you start.
9. Why Should You Mention Bowel Problems Before a Biologic?
Tell your dermatologist if you have inflammatory bowel disease or ongoing bowel symptoms before a biologic is chosen. Your medical history can affect which treatment is suitable for you, particularly with IL-17 medicines, so your treatment should be individualised.
10. Can Your HS Treatment Change Over Time?
Yes. Your HS pattern and treatment response can change, so your dermatologist may adjust your plan over time. You can help by tracking your flares, side effects and previous treatments so your next treatment decision reflects what is working for you.
Final Thoughts: Hidradenitis Suppurativa Treatment
Hidradenitis suppurativa treatment aims to control inflammation, reduce painful flares and prevent further disease progression rather than simply treating individual lumps. By considering your symptoms, disease severity, previous treatments and overall health, you and your dermatologist can choose a medical approach that is appropriate for your needs.
If you’re looking for a dermatologist in London, you can contact London Dermatology Centre for specialist assessment and advice.
References:
- Molinelli, E. et al. (2023) ‘Systemic antibiotic therapy in hidradenitis suppurativa: A review on treatment landscape and current issues’, Antibiotics, 12(6), article 978. Available at: https://www.mdpi.com/2079-6382/12/6/978
- Riis, P.T. et al. (2016) ‘Intralesional triamcinolone for flares of hidradenitis suppurativa (HS): A case series’, Journal of the American Academy of Dermatology, 75(6), pp. 1151–1155. Available at: https://pubmed.ncbi.nlm.nih.gov/27692735/
- Ghanian, S., Yamanaka-Takaichi, M., Naik, H.B. and Alavi, A. (2022) ‘Medical Management of Hidradenitis Suppurativa with Non-Biologic Therapy: What’s New?’, American Journal of Clinical Dermatology, 23(2), pp. 167–176. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9131893/
- Fonjungo, F.E., Barnes, L.A. and Aleshin, M.A. (2024) ‘Antibiotic, hormonal/metabolic, and retinoid therapies for hidradenitis suppurativa’, Journal of the American Academy of Dermatology, 91(6S), pp. S37–S41. Available at: https://www.sciencedirect.com/science/article/pii/S0190962224028639
- Ingram, J.R. et al. (2019) ‘British Association of Dermatologists guidelines for the management of hidradenitis suppurativa (acne inversa) 2018’, British Journal of Dermatology, 180(5), pp. 1009–1017. Available at: https://academic.oup.com/bjd/article/180/5/1009/6732702