What is the recommended treatment for a 33-year-old male patient presenting with a flare-up of hidradenitis suppurativa (HS) without signs of abscess or severe infection in the Emergency Department (ER)?

Management of Hidradenitis Suppurativa Flare-Up Without Abscess

For a 33-year-old male presenting with a hidradenitis suppurativa flare-up without erythematous abscess, oral tetracycline antibiotics (doxycycline 100 mg once or twice daily) for 12 weeks is the recommended first-line treatment. 1

Initial Assessment and Classification

When evaluating a hidradenitis suppurativa (HS) flare without obvious abscess formation or signs of infection requiring drainage:

1. Determine the Hurley stage:

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

2. Assess pain level using a visual analog scale (VAS) and treat pain if needed with NSAIDs 1

3. Document lesion count and number of flares in the past month

Treatment Algorithm

First-Line Treatment

• Oral tetracyclines (doxycycline 100 mg once or twice daily or lymecycline 408 mg daily) for 12 weeks 1
• Consider topical clindamycin 1% solution applied twice daily to affected areas 1, 2
• Provide appropriate dressings for any draining lesions 1

If Inadequate Response After 12 Weeks

• Progress to combination therapy with oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1, 2
• This combination has shown effectiveness in moderate HS that is unresponsive to tetracyclines 1

For Severe or Refractory Disease

• Consider referral to dermatology for consideration of biologics like adalimumab (FDA-approved for moderate to severe HS in patients ≥12 years) 3
• Adalimumab dosing: 160 mg initially (day 1), 80 mg at week 2, then 40 mg weekly 3

Additional Interventions

• Intralesional corticosteroid injections can be considered for carefully selected individual lesions during acute flares 1, 2
• Provide patient education about the chronic nature of the disease and importance of long-term management 1
• Address modifiable risk factors:
  • Smoking cessation referral if applicable 1, 2
  • Weight management referral if overweight 1, 2

Important Considerations

• Avoid incision and drainage (I&D) in the absence of a fluctuant abscess with signs of infection, as this can worsen scarring and disease progression in HS 2
• Screen for associated comorbidities including depression, anxiety, and cardiovascular risk factors 1
• Regular follow-up is essential to assess treatment response and adjust therapy as needed

Common Pitfalls to Avoid

1. Misdiagnosing HS flares as simple abscesses - HS is a chronic inflammatory condition requiring systemic therapy rather than just drainage
2. Inadequate duration of antibiotic therapy - Treatment typically requires 8-12 weeks for optimal response 2
3. Failure to address lifestyle factors - Smoking and obesity are significant exacerbating factors 2, 4
4. Treating only with topical therapies - Systemic treatment is usually necessary for effective management of flares 5

For this 33-year-old male patient without signs of abscess requiring drainage, oral tetracyclines for 12 weeks represent the most appropriate initial management strategy based on current guidelines.