What are the treatment options for a 33-year-old female with recurrent hydradenitis after excision?

Treatment Options for Recurrent Hidradenitis Suppurativa After Excision

For a 33-year-old female with recurrent hidradenitis suppurativa after excision, a combination of medical therapy with adalimumab and consideration for more extensive surgical excision offers the most effective treatment approach for long-term disease control and improved quality of life.

Medical Treatment Options

First-Line Medical Therapy

• Adalimumab: The most evidence-supported treatment for recurrent HS
  • Dosing: 160 mg at week 0,80 mg at week 2, then 40 mg weekly thereafter 1
  • Highest level of evidence (LOE Ib, SOR A) among medical therapies 2
  • Positively influences pain reduction, quality of life, and work productivity 2
  • Continue as long as HS lesions are present if clinical response is achieved 2

Alternative Medical Options

• Clindamycin + Rifampicin combination:

  • Dosing: Both at 300 mg twice daily for 10-12 weeks 2, 1
  • Consider if adalimumab is contraindicated or unavailable
  • Improvement in approximately 80% of cases with remission in 50% 1

• Tetracycline antibiotics:

  • Dosing: 500 mg twice daily for 4 months 2
  • Less effective for recurrent disease after surgery
  • Better suited for mild, early disease 2

• Infliximab:

  • Second-line biologic option if adalimumab fails
  • Dosing: 5 mg/kg at weeks 0,2,6, and every 8 weeks thereafter 1
  • LOE IIa, SOR B 2

Adjunctive Therapies

• Intralesional corticosteroid injections:

  • Triamcinolone 10 mg/mL for acute inflammatory lesions 2, 1
  • Provides rapid reduction in pain, erythema, and edema 1

• Topical treatments:

  • Clindamycin 1% solution twice daily for mild lesions 2
  • Antiseptic washes (chlorhexidine, zinc pyrithione) 1
  • Resorcinol 15% cream for flares 2, 1

Surgical Management

Radical Surgical Excision

• Most effective for long-term control and preventing recurrence 1

• Especially important when:

  • Previous excision was inadequate (not removing all affected tissue)
  • Significant scar tissue is present
  • Medical treatments have failed 1

• Surgical approaches:

  • Wide excision with margins extending beyond visible disease 2
  • Complete removal of all affected tissue is crucial to prevent recurrence 1
  • Consider healing by secondary intention, skin grafting, or flap closure 2, 1

• Efficacy of radical excision:

  • Recurrence rates vary from 2.5% to 41% depending on technique and follow-up period 2
  • Width of excision (not wound closure technique) influences therapeutic outcome 2

Comprehensive Management Approach

For This Patient

1. Evaluate disease severity and extent:

   • Assess Hurley stage and inflammatory component
   • Determine extent of scarring and sinus tracts

2. Initiate adalimumab therapy for rapid control of inflammation

   • Follow recommended dosing schedule
   • Evaluate response after 16 weeks 2

3. Plan for surgical intervention:

   • Consider more extensive radical excision than previous surgery
   • Ensure complete removal of all affected tissue and sinus tracts
   • Select appropriate reconstruction method based on defect size and location

4. Adjunctive measures:

   • Pain management
   • Weight management if applicable
   • Smoking cessation if applicable
   • Appropriate wound care for draining lesions

Important Considerations

• Early initiation of biologics can prevent disease progression and further scarring 1
• Combining medical and surgical interventions yields better outcomes than either approach alone 1
• Recurrence after surgery often indicates incomplete removal of affected tissue 2
• Long-term maintenance therapy may be necessary even after successful surgical intervention 1
• Monitor for associated comorbidities (metabolic syndrome, inflammatory arthritis, inflammatory bowel disease) 3

The evidence strongly supports that for recurrent HS after excision, the combination of adalimumab therapy with consideration for more extensive surgical excision provides the best chance for disease control and improved quality of life.