What is the treatment for hidradenitis suppurativa (HS) under the breast?

Treatment of Hidradenitis Suppurativa Under the Breast

For hidradenitis suppurativa (HS) under the breast, treatment should follow a stepwise approach based on disease severity, with topical clindamycin for mild cases, oral antibiotics for moderate cases, biologics for severe cases, and surgical intervention for persistent or scarring lesions.

Disease Assessment

Before initiating treatment, assess disease severity using:

• Hurley Classification:

  • Stage I: Localized abscess without sinus tracts or scarring
  • Stage II: Recurrent abscesses with sinus tract formation and scarring
  • Stage III: Diffuse involvement with multiple interconnected tracts and abscesses

• Hidradenitis Suppurativa Clinical Response (HiSCR): A validated tool that measures inflammatory lesion count 1

Treatment Algorithm Based on Severity

Mild Disease (Hurley I/mild Hurley II)

1. First-line: Topical clindamycin 1% solution applied twice daily for 3 months

   • Evidence shows efficacy in a double-blind, placebo-controlled trial 1
   • If no response after 3 months, proceed to next option

2. Alternative topical option: Topical resorcinol 15%

   • Recent evidence suggests it may be more effective than clindamycin with fewer concerns about antibiotic resistance 2

3. Systemic option: Tetracycline 500 mg twice daily for up to 4 months

   • Comparable efficacy to topical clindamycin in randomized controlled trials 1

Moderate Disease (Hurley II)

1. First-line: Clindamycin 300 mg twice daily + Rifampicin 600 mg once daily (or 300 mg twice daily)

   • Treatment duration: 8-12 weeks
   • Response rates of 71-93% reported in systematic reviews 1, 3
   • Can be repeated intermittently as needed

2. Second-line: Adalimumab (if unresponsive to antibiotics)

   • Loading dose: 160 mg at week 0,80 mg at week 2
   • Maintenance: 40 mg weekly starting at week 4
   • Evaluate response after 16 weeks 1, 4

Severe Disease (Hurley II/III)

1. First-line: Adalimumab (as dosed above)

   • Demonstrated efficacy in randomized, double-blind, placebo-controlled trials
   • Improves HiSCR, pain scores, and quality of life 1

2. Second-line: Infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter

   • Consider after adalimumab failure
   • Evaluate response after 12 weeks 1

3. Rescue therapy: Ertapenem 1 g IV daily for 6 weeks

   • Reserved for severe cases as bridge to surgery or other long-term therapy
   • High efficacy but concerns about antibiotic resistance limit long-term use 1

Surgical Options (for persistent or scarring lesions)

1. Radical surgical excision for recurrent or persistent lesions

   • Width of excision is more important than closure technique 1
   • Recurrence rates of 32-41% reported in long-term follow-up studies 1

2. Negative pressure wound therapy can accelerate healing after surgical excision 1

Special Considerations for Inframammary HS

1. Moisture control is essential for inframammary lesions

   • Use absorbent powders and moisture-wicking fabrics
   • Consider supportive bras to reduce friction

2. Weight management may improve outcomes, as high BMI correlates with poorer response to antibiotics 5

3. Smoking cessation is strongly recommended, as smoking pack-years correlate with disease severity and reduced treatment response 5

Monitoring and Follow-up

• Evaluate response to topical or oral antibiotics after 3-4 months
• Assess response to biologics using HiSCR at 12-16 weeks
• Monitor for side effects, particularly with long-term antibiotic use
• Consider surgical intervention if medical therapy fails to provide adequate relief

Pitfalls to Avoid

1. Misdiagnosis as simple boils or abscesses leading to inadequate treatment 6

2. Delayed treatment can lead to irreversible skin damage and sinus tract formation 7

3. Antibiotic resistance with prolonged antibiotic therapy; consider rotating regimens or combination therapy 2

4. Inadequate pain management can significantly impact quality of life; address pain specifically with appropriate analgesics

5. Failure to address comorbidities like metabolic syndrome, inflammatory arthritis, or inflammatory bowel disease 7

Remember that early intervention is crucial to prevent irreversible skin damage and improve long-term outcomes for patients with inframammary HS.