What topical cream can be used to treat hidradenitis suppurativa (HS) under the breast and under the arm?

Topical Treatment for Hidradenitis Suppurativa Under Breast and Underarm

For mild HS in the axillary and inframammary areas, apply topical clindamycin 1% solution or gel twice daily for 12 weeks as first-line therapy. 1, 2

Primary Topical Antibiotic Recommendation

• Clindamycin 1% topical solution or gel is the only topical antibiotic with randomized controlled trial evidence for HS, demonstrating reduced pustules and improved patient self-assessment in Hurley stage I or II disease over 12 weeks. 1

• The solution formulation may be preferable for intertriginous areas like the axilla and under the breast due to better penetration and less occlusion than creams. 3

• Important caveat: Topical clindamycin increases Staphylococcus aureus resistance rates in HS patients. 1, 2 To mitigate this risk, consider combining with benzoyl peroxide wash or leave-on product. 1, 2

Adjunctive Topical Cleansers

While no specific data exist for particular agents, expert opinion supports using antiseptic cleansers: 1

• Chlorhexidine wash 1, 2
• Benzoyl peroxide wash (also reduces antibiotic resistance risk) 1, 2
• Zinc pyrithione 1, 2

Alternative Topical Keratolytic Agent

• Resorcinol 15% cream can be applied twice daily during flares and once daily between flares, showing reduction in pain and abscess duration in Hurley stage I-II disease. 1, 2 However, irritant dermatitis is frequent, limiting tolerability in sensitive intertriginous areas. 1

Intralesional Option for Active Lesions

• For inflamed nodules or abscesses, intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) provides rapid pain relief within 1 day and significantly reduces erythema, edema, and suppuration. 1, 2 This is particularly useful for acute flares in the axilla and inframammary regions.

When Topical Therapy Is Insufficient

Critical limitation: Topical clindamycin showed no effect on inflammatory nodules and abscesses in clinical trials—only on pustules. 1 If disease progresses beyond superficial pustules to include nodules, abscesses, or sinus tracts (Hurley stage II or higher), escalate to systemic therapy with oral antibiotics (clindamycin 300 mg + rifampicin 600 mg daily for 10-12 weeks) or biologics for severe disease. 1, 2, 4, 5

Practical Application Algorithm

1. Mild disease (isolated pustules, no nodules/abscesses): Topical clindamycin 1% twice daily + antiseptic cleanser 1, 2
2. Acute inflamed lesions: Add intralesional triamcinolone 10 mg/mL 1, 2
3. Persistent or worsening despite 12 weeks: Transition to systemic antibiotics 1, 5
4. Consider benzoyl peroxide co-application throughout to reduce resistance 1, 2