What is the treatment for hidradenitis suppurativa of the armpit?

Treatment for Hidradenitis Suppurativa of the Armpit

Treatment for hidradenitis suppurativa (HS) of the armpit should follow a staged approach based on disease severity, with tetracyclines as first-line therapy for mild disease, clindamycin plus rifampin for moderate disease, and adalimumab for severe disease. 1

Disease Assessment and Staging

Before initiating treatment, it's essential to determine disease severity using the Hurley staging system:

• Hurley Stage I (Mild): Single or multiple abscesses without sinus tracts or scarring
• Hurley Stage II (Moderate): Recurrent abscesses with sinus tract formation and scarring
• Hurley Stage III (Severe): Diffuse involvement with multiple interconnected sinus tracts and abscesses

Document baseline measurements including:

• Pain level using Visual Analog Scale (VAS)
• Quality of life using Dermatology Life Quality Index (DLQI)
• Lesion count and number of flares in the last month 1

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

1. First-line: Tetracyclines (particularly doxycycline) for 12 weeks 1

   • Dosage: 100 mg twice daily
   • Benefits: Anti-inflammatory properties beyond antimicrobial effects
   • Monitor for: Photosensitivity, gastrointestinal upset

2. Topical therapies (can be used concurrently):

   • Clindamycin 1% solution twice daily (reduces pustules but has limited effect on nodules) 2
   • Antiseptic washes: Chlorhexidine, benzoyl peroxide, or zinc pyrithione 2, 1
   • Resorcinol 15% cream (keratolytic and antiseptic) 2

3. For acute flares:

   • Intralesional triamcinolone (10 mg/mL, 0.2-2.0 mL) into inflamed lesions 2
   • Significant reduction in erythema, edema, suppuration, and pain within 1 day

4. Conservative measures:

   • Washing affected area three times daily with antibacterial soap
   • Application of warm compresses for 10 minutes
   • Avoidance of shaving during treatment 3

Moderate Disease (Hurley Stage II)

1. First-line: Clindamycin + Rifampin combination for 10-12 weeks 1

   • Typical dosage: Clindamycin 300 mg twice daily + Rifampin 300 mg twice daily
   • Response rates: 71-93% reported in systematic reviews
   • Monitor for: Severe diarrhea and C. difficile colitis with clindamycin; hepatotoxicity with rifampin

2. If inadequate response: Proceed to adalimumab 1

3. Surgical options to consider:

   • Deroofing procedure for recurrent lesions
   • Nd:YAG laser treatment 1

Severe Disease (Hurley Stage III)

1. First-line: Adalimumab 1, 4

   • Dosage: 160 mg initially, 80 mg at week 2, then 40 mg weekly starting at week 4
   • FDA-approved for moderate to severe HS in patients 12 years and older
   • Monitor for: Serious infections including tuberculosis (screen before initiating)

2. Alternative biologics if adalimumab fails:

   • Infliximab (5 mg/kg at weeks 0,2,6, then every 8 weeks) 1

3. Surgical intervention:

   • Extensive surgical excision with complete removal of all affected tissue 1

Treatment Response Assessment

Evaluate treatment response after 12 weeks using:

• Reduction in inflammatory lesion count
• Improvement in pain levels
• Quality of life measures

If inadequate response, escalate therapy according to the algorithm above 1

Important Considerations and Pitfalls

1. Avoid simple incision and drainage except for acute abscesses to relieve pain, as this approach alone leads to recurrence 1

2. Bacterial resistance risk with topical clindamycin can be reduced by combining with benzoyl peroxide 2

3. Lifestyle modifications are crucial adjuncts to treatment:

   • Smoking cessation
   • Weight management
   • Appropriate wound care based on drainage amount 1

4. Screen for comorbidities:

   • Depression and anxiety
   • Cardiovascular risk factors (diabetes, hypertension, hyperlipidemia)
   • Inflammatory bowel disease if gastrointestinal symptoms are present 1

5. Warning about adalimumab:

   • Serious infections risk including tuberculosis
   • Malignancy risk, particularly lymphoma
   • Perform TB testing before initiating therapy 4

The management of hidradenitis suppurativa requires persistence and often a combination of approaches. Early and appropriate treatment based on disease severity is essential to prevent disease progression, reduce scarring, and improve quality of life.