Use of intravenous antibiotics in severe hidradenitis suppurativa: a multicentre retrospective study

Abstract Hidradenitis suppurativa (HS) is a chronic inflammatory condition, characterized by recurrent abscesses and sinus tracts in intertriginous areas. Intravenous (IV) antibiotics are used in cases of severe HS after the failure of conventional therapies, or to optimize patients prior to initiation of biologics or surgery. However, there is limited evidence on the efficacy of IV antibiotics [Join-Lambert O, Coignard-Biehler H, Jais J-P et al. Efficacy of ertapenem in severe hidradenitis suppurativa: a pilot study in a cohort of 30 consecutive patients. J Antimicrob Chemother 2016; 71:513–20; Ingram JR, Collier F, Brown D et al. British Association of Dermatologists guidelines for the management of hidradenitis suppurativa (acne inversa) 2018. Br J Dermatol 2019; 180:1009–17]. Our aim was to determine the immediate and long-term impact of IV antibiotics in severe HS and to develop a pre- and post-IV antibiotics assessment and care pathway. We conducted a multicentre retrospective review of patients with HS treated with IV antibiotics at two tertiary HS centres between 2013 and 2022. In total, we included 30 patients (14 females and 16 males), with a mean (SD) age of 42.6 (12.8) years (range 15–66) and a mean (SD) body mass index of 29.96 (7.31) kg m−2. All patients were classified as Hurley stage 3. The majority of patients received ertapenem (n = 24); other antibiotics included ceftriaxone (n = 5) and meropenem (n = 1). Patients had an average of 38.7 days on treatment (range 14–56). There were statistically significant improvements at the completion of antibiotics in biochemical and haematological parameters, including C-reactive protein −27.5 mg L−1 [95% confidence interval (CI) −11 to −57; P < 0.003], white cell counts −1.75 × 109 cells L−1 (95% CI −0.95 to −2.80; P < 0.001) and haemoglobin +7 g L−1 (95% CI 2.5–13; P < 0.005). Dermatology Life Quality Index (out of 30) also improved significantly at completion (−5, 95% CI −1 to −10; P < 0.008). These were all maintained 12 months postcompletion. Clinical severity of HS assessed through pain visual analogue score (VAS), discharge VAS, DERMVAS, overall VAS, and HS Physician Global Assessment showed improvement but did not reach statistical significance. Improvement in discharge VAS [out of 10; −2, 95% CI −1.5 to −4.5 (P < 0.066)] achieved borderline significance. To our knowledge, this is the largest analysis of the efficacy of IV antibiotics in patients with the most severe form of HS (i.e. Hurley stage 3), where we show improvement in clinical parameters and quality of life. The findings of this study should encourage a randomized controlled study to determine conclusive evidence to guide the evidence-based management of severe HS and have informed the development of a more formal assessment pathway.