What is the appropriate management for a 19-year-old patient with a past medical history (PMH) of Hidradenitis Suppurativa (HS) presenting with a painful exacerbation of HS without fever or systemic symptoms?

Management of Acute Hidradenitis Suppurativa Exacerbation in a 19-Year-Old Patient

For a 19-year-old patient with hidradenitis suppurativa experiencing a painful exacerbation without fever or systemic symptoms, intralesional corticosteroid injection is the recommended first-line treatment for immediate relief of the localized flare. 1

Assessment of Current Exacerbation

When evaluating this patient's HS exacerbation, focus on:

• Location and characteristics of the painful area
• Number of inflammatory lesions (nodules, abscesses, draining tunnels)
• Presence of scarring or sinus tracts
• Pain severity (using Visual Analog Scale)
• Previous treatments and response
• Impact on quality of life

Treatment Algorithm

Immediate Management for Acute Painful Lesion

1. Intralesional corticosteroid injection

   • Triamcinolone acetonide (5-10 mg/mL) directly into the inflamed nodule
   • Provides rapid pain relief and reduces inflammation
   • Consider appropriate pain management and distraction techniques during the procedure 1

2. Topical therapies

   • Antiseptic washes (chlorhexidine) 1, 2
   • Warm compresses to promote drainage and relieve pain
   • Topical clindamycin 1% solution twice daily for mild disease 2
   • Topical resorcinol 15% cream can be considered for pain relief 1

3. Pain management

   • Topical lidocaine for localized pain
   • Oral acetaminophen and/or NSAIDs for pain control 1
   • Avoid opioids unless absolutely necessary for severe pain unresponsive to other measures

Short-term Management (1-2 weeks)

If the acute flare doesn't respond to intralesional steroids:

1. Oral antibiotics

   • First-line: Doxycycline 100 mg twice daily (appropriate for 19-year-old) 1, 2
   • Alternative: Minocycline 100 mg twice daily if doxycycline is not tolerated 1
   • For moderate disease: Combination therapy with clindamycin 300 mg + rifampin 300 mg, both twice daily for 10-12 weeks 2

2. Procedural intervention

   • Incision and drainage for fluctuant abscesses that are causing significant pain
   • Deroofing procedure for recurrent lesions in the same location 1

Long-term Management Based on Disease Severity

For ongoing management after this acute flare resolves:

Mild Disease (Hurley Stage I)

• Topical clindamycin 1% solution twice daily
• Oral tetracyclines for 12 weeks
• Lifestyle modifications (weight management, smoking cessation)

Moderate Disease (Hurley Stage II)

• Clindamycin + rifampin combination for 10-12 weeks
• Consider adalimumab if inadequate response to antibiotics
• Targeted surgical interventions for persistent lesions

Severe Disease (Hurley Stage III)

• Adalimumab as first-line therapy (FDA approved for patients ≥12 years old) 3
• Dose: 160 mg initially (Day 1), 80 mg at week 2, then 40 mg weekly starting at week 4 3
• Consider extensive surgical excision for persistent areas

Important Considerations

• Avoid triggers: Advise the patient to avoid tight clothing, heat, humidity, and friction in affected areas
• Wound care: For draining lesions, use absorbent, non-adherent dressings
• Screening: Evaluate for associated comorbidities (depression, anxiety, metabolic syndrome) 1
• Monitoring: Regular assessment of inflammatory lesion count, pain levels, and quality of life measures 2

Pitfalls to Avoid

1. Repeated incision and drainage without definitive treatment - This provides only temporary relief and may worsen scarring 1

2. Prolonged continuous antibiotic use - Limit extended courses to prevent antimicrobial resistance 2

3. Delaying biologic therapy in moderate-to-severe disease that doesn't respond to conventional treatments 2

4. Overlooking pain management - Pain control is essential for improving quality of life in HS patients 4

5. Neglecting psychological impact - Screen for depression and anxiety, which are common comorbidities in HS patients 1

By following this structured approach, you can effectively manage this patient's acute HS exacerbation while developing an appropriate long-term treatment plan based on disease severity.