What is the treatment for frequent abscesses with excessive sweating?

Treatment of Frequent Abscesses with Excessive Sweating

The combination of frequent abscesses and excessive sweating strongly suggests hidradenitis suppurativa (HS), which requires incision and drainage of active abscesses plus consideration of adalimumab (HUMIRA) for disease control, along with management of the underlying hyperhidrosis. 1, 2

Immediate Recognition and Diagnosis

The pattern of recurrent abscesses combined with excessive sweating is pathognomonic for hidradenitis suppurativa, a chronic inflammatory condition affecting apocrine gland-bearing areas (axillae, groin, perianal region). 1 This is not simply recurrent simple abscesses—it represents a distinct disease entity requiring different management.

• Search for characteristic features: pilonidal cysts, involvement of intertriginous areas, comedones, and scarring from previous lesions 1
• Distinguish from simple recurrent abscesses: HS involves apocrine gland dysfunction triggered by follicular occlusion and exacerbated by sweating 1

Acute Abscess Management

Drainage Protocol

• Perform incision and drainage on all active abscesses regardless of size 3, 4
• Use multiple counter-incisions for large abscesses (>5 cm) rather than single long incisions to prevent step-off deformity 3
• Thoroughly evacuate pus and probe the cavity to break up loculations 3
• Culture the abscess early in the course to guide antibiotic selection 1

Antibiotic Decision Algorithm

For simple drained abscesses without systemic signs:

• No antibiotics needed if temperature <38.5°C, white blood cells <12,000 cells/µL, and pulse <100 beats/minute 3

Antibiotics ARE indicated when:

• SIRS criteria present: temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or white blood cells >12,000 or <400 cells/µL 1, 3
• Significant surrounding cellulitis present 3, 4
• Axillary location (mixed flora): use cefoxitin or ampicillin-sulbactam for 5-10 days 1, 3
• Patient is immunocompromised 3, 4

Long-Term Disease Control for Hidradenitis Suppurativa

Decolonization Regimen

Implement a 5-day decolonization protocol repeated as needed: 1

• Intranasal mupirocin twice daily
• Daily chlorhexidine body washes
• Daily laundering of towels, sheets, and clothing

Biologic Therapy

Adalimumab (HUMIRA) is FDA-approved specifically for hidradenitis suppurativa and should be strongly considered for patients with recurrent disease. 2 The safety profile is well-established, with the most common adverse reactions being injection site reactions and upper respiratory infections. 2 Weekly dosing is used for HS (different from other indications). 2

Critical warning: Approximately 22% of patients experience disease flare (≥25% increase in abscesses and inflammatory nodules with minimum 2 additional lesions) upon withdrawal of adalimumab, so discontinuation must be carefully managed. 2

Hyperhidrosis Management

The excessive sweating component requires separate targeted treatment, as it likely exacerbates the HS: 5, 6

First-Line Topical Treatment

• Aluminum chloride solution (20% or higher concentration) applied nightly to affected areas 5
• For craniofacial sweating specifically: topical glycopyrrolate 5

Second-Line Options if Topical Fails

• Botulinum toxin (onabotulinumtoxinA) injections for axillary, palmar, plantar, or craniofacial hyperhidrosis 5
• Iontophoresis for palms and soles 5, 6
• Oral anticholinergics (glycopyrronium) as adjunct in severe cases 5, 6

Advanced Interventions

• Microwave thermolysis for axillary hyperhidrosis refractory to other treatments 5
• Surgical excision or sympathectomy reserved for severe cases unresponsive to all medical therapies 5, 7

Critical Pitfalls to Avoid

• Do not treat this as simple recurrent abscesses—failure to recognize HS leads to inadequate management and continued disease progression 1
• Do not rely on antibiotics alone without drainage—this leads to treatment failure and antibiosis resistance 3, 4
• Do not ignore the hyperhidrosis component—untreated sweating perpetuates the cycle of follicular occlusion and abscess formation 5
• Do not perform needle aspiration—success rate is only 25% and <10% with MRSA infections 3
• Do not delay biologic therapy in moderate-to-severe HS—early disease control prevents scarring and improves quality of life 2

Evaluation for Underlying Immunodeficiency

If abscesses began in early childhood (not typical adult-onset HS), evaluate for neutrophil disorders. 1 Adult-onset disease does not require neutrophil function testing. 1