Hidradenitis Suppurativa — SCE Dermatology MCQ

Correct answer: B — Combination of oral Clindamycin and Rifampicin

The correct answer is B, combination of oral Clindamycin and Rifampicin. This patient has classic features of hidradenitis suppurativa (HS): recurrent tender nodules, sinus tracts with purulent discharge, comedones and scarring affecting flexural sites (axillae, groin), consistent with Hurley stage II (moderate) disease. For moderate HS, UK dermatology guidance recommends combined oral clindamycin 300 mg twice daily plus rifampicin 300 mg twice daily for 10 to 12 weeks as the first-line systemic antimicrobial regimen, exploiting both antibacterial and anti-inflammatory effects on the follicular occlusion process that drives HS. Topical clindamycin alone is reserved for mild disease, while this oral combination is stepped up when disease is more extensive, before considering biologics such as adalimumab if it fails. Obesity (BMI 34) is a recognised aggravating factor and weight loss should be advised alongside treatment, but it does not change the systemic drug of choice. Why the other options are wrong: C. Oral Isotretinoin: unlike acne vulgaris, isotretinoin has poor and inconsistent efficacy in HS because the underlying pathology is follicular occlusion with secondary inflammation rather than primarily sebaceous gland dysfunction, so it is not recommended as first-line therapy. D. Oral Prednisolone: systemic corticosteroids may be used briefly for severe flares to dampen acute inflammation but are not a first-line or sustainable treatment for moderate HS due to lack of long-term disease control and steroid side effects. E. Oral Dapsone: dapsone has only weak, anecdotal evidence in HS and is used as a third-line or alternative option in refractory cases, not as first-line systemic therapy. A. Oral Flucloxacillin: this narrow-spectrum antistaphylococcal antibiotic lacks the anti-inflammatory action needed in HS and is not part of the standard combination regimen; it is more appropriate for simple staphylococcal skin infections rather than HS. Key point: For Hurley stage II (moderate) hidradenitis suppurativa, first-line systemic therapy is combined oral clindamycin plus rifampicin for 10 to 12 weeks, reserving biologics like adalimumab for treatment failure.

Reference: British Association of Dermatologists, Guidelines for the management of hidradenitis suppurativa, British Journal of Dermatology 2019; 180: 1009-1017 (bad.org.uk)