What is the management approach for abscesses in hidradenitis suppurativa?

Management of Abscesses in Hidradenitis Suppurativa

For acute abscesses in hidradenitis suppurativa, incision and drainage should be avoided; instead, treat with intralesional triamcinolone 10 mg/mL for rapid symptom relief, combined with systemic antibiotics (clindamycin 300 mg plus rifampicin 300-600 mg twice daily for 10-12 weeks) for moderate disease, or escalate to adalimumab 160 mg initial dose followed by 80 mg at week 2, then 40 mg weekly for severe or refractory cases. 1, 2

Immediate Management of Active Abscesses

Intralesional Therapy

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL per lesion) provides rapid symptom relief within 1 day, showing significant reduction in erythema, edema, suppuration, and pain in prospective studies 1, 2
• This should be the first-line intervention for acutely inflamed nodules and abscesses, regardless of disease stage 1

Critical Pitfall: Avoid Incision and Drainage

• Traditional incision and drainage is not recommended as it does not address the underlying inflammatory pathology and may worsen scarring and sinus tract formation 1, 2

Systemic Treatment Based on Disease Severity

Mild Disease (Hurley Stage I - Isolated Abscesses Without Sinus Tracts)

• Topical clindamycin 1% solution/gel twice daily for 12 weeks is first-line therapy 1, 2
• Must be combined with benzoyl peroxide wash or chlorhexidine 4% wash daily to prevent Staphylococcus aureus resistance development 1, 3
• However, topical therapy has no effect on deep inflammatory nodules and abscesses—it only reduces superficial pustules 3
• If abscesses persist beyond 12 weeks, escalate to systemic therapy 2

Moderate Disease (Hurley Stage II - Recurrent Abscesses With Sinus Tracts)

• Clindamycin 300 mg twice daily plus rifampicin 300-600 mg twice daily for 10-12 weeks is the superior first-line choice 1, 2
• This combination demonstrates response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy 2
• Doxycycline 100 mg twice daily for up to 4 months is an alternative, but has minimal effect on deep inflammatory lesions and abscesses characteristic of Hurley Stage II 2
• Do not use doxycycline as first-line for Hurley Stage II with abscesses—it is not independently linked to better outcomes for this presentation 2

Severe or Refractory Disease (Hurley Stage III or Failed Antibiotics)

• Adalimumab is first-line biologic therapy: 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4 1, 2, 4
• In clinical trials, 42-59% of patients achieved HiSCR (≥50% reduction in abscesses and inflammatory nodules) at 12 weeks 4
• Critical dosing error to avoid: 40 mg every other week is insufficient and not recommended—weekly dosing is required 1
• If no clinical response after 16 weeks, consider infliximab 5 mg/kg at weeks 0,2,6, and every 2 months 1, 2

Adjunctive Wound Care for Draining Abscesses

• Appropriate wound dressings are essential for draining lesions to prevent secondary infection and improve quality of life 2, 5
• Daily antiseptic washes with chlorhexidine, benzoyl peroxide, or zinc pyrithione reduce bacterial colonization 1, 2
• Resorcinol 15% cream applied twice daily during flares and daily between flares can reduce pain and duration of abscesses, though irritant dermatitis is a common limiting side effect 1, 3

Treatment Assessment and Escalation Timeline

• Reassess at 12 weeks using pain Visual Analog Scale, inflammatory lesion count (including abscess count), and quality of life measures 1, 2
• If inadequate response after 12 weeks of systemic antibiotics, escalate to clindamycin-rifampicin combination or consider biologics 2
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance 2

Surgical Considerations for Recurrent Abscesses

• Radical surgical excision is recommended for extensive disease with recurrent abscesses, sinus tracts, and scarring unresponsive to medical therapy 1, 2
• Deroofing is appropriate for recurrent nodules and tunnels in localized areas 2
• Surgery is often necessary for lasting cure in advanced disease, as non-surgical methods rarely achieve permanent resolution 1, 2

Flare Management Protocol

• During acute flares with new abscesses, intralesional triamcinolone provides immediate relief while systemic therapy takes effect 1, 2
• Ertapenem 1g daily IV for 6 weeks can be considered as rescue therapy for severe flares requiring intravenous antibiotics 2
• NSAIDs for pain management during acute episodes 2
• In studies, 22% of patients experienced flare (≥25% increase in abscesses and inflammatory nodules) when adalimumab was withdrawn after initial response 4

Comorbidity Screening and Lifestyle Modifications

• Screen for depression/anxiety, diabetes, hypertension, and hyperlipidemia at baseline, as these significantly impact outcomes 1, 2
• Smoking cessation is critical—tobacco use is associated with worse outcomes and more severe disease 1, 2
• Weight loss should be encouraged for patients with obesity, as elevated BMI correlates with disease severity 1, 2