What is the treatment for axillary hidradenitis?

Treatment of Axillary Hidradenitis Suppurativa

For mild axillary disease (Hurley Stage I), initiate topical clindamycin 1% twice daily for 12 weeks; for moderate disease (Hurley Stage II), use clindamycin 300 mg plus rifampicin 300-600 mg orally twice daily for 10-12 weeks; for severe or refractory disease (Hurley Stage III), start adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly, with surgical excision and flap reconstruction reserved for extensive disease with sinus tracts and scarring. 1, 2

Disease Severity Assessment

• Determine Hurley stage by examining the axilla for isolated nodules (Stage I), recurrent abscesses with sinus tracts (Stage II), or diffuse involvement with multiple interconnected sinus tracts and scarring (Stage III). 1, 2
• Document baseline pain using Visual Analog Scale (VAS) and count inflammatory lesions (abscesses and nodules). 1
• Screen for comorbidities including depression, anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease, as these significantly impact outcomes. 1

Medical Treatment Algorithm

Mild Disease (Hurley Stage I)

• Apply topical clindamycin 1% solution or gel twice daily to all affected axillary areas for 12 weeks as first-line therapy. 1, 2
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk. 1, 2
• Consider intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) for acutely inflamed nodules, which provides rapid symptom relief within 1 day. 1

Moderate Disease (Hurley Stage II)

• Prescribe clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks as the preferred first-line regimen, achieving response rates of 71-93%. 1, 2, 3
• Alternative option: doxycycline 100 mg once or twice daily for 12 weeks if combination therapy is unavailable, though this is less effective for abscesses with only 30% reduction rates. 1
• Do not use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses, as it has minimal effect on these lesions. 1

Severe or Refractory Disease (Hurley Stage III)

• Initiate adalimumab with loading dose of 160 mg at week 0 (given in one day or split over two consecutive days), 80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2, 4
• This regimen achieves HiSCR response rates (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) of 42-59% at week 12. 1
• If adalimumab fails after 16 weeks, consider second-line biologics: infliximab 5 mg/kg at weeks 0,2,6, then every 2 months, or secukinumab (response rates 64.5-71.4% in adalimumab-failure patients). 1

Surgical Management

Indications for Surgery

• Radical surgical excision is necessary for extensive axillary disease with sinus tracts and scarring, as non-surgical methods rarely result in lasting cure for advanced disease. 1, 2
• Surgery combined with adalimumab results in greater clinical effectiveness than adalimumab monotherapy. 1

Surgical Technique

• Perform wide excision of all affected tissue in a rhomboid shape, removing all apocrine gland-bearing skin to prevent recurrence. 5, 6
• Immediate coverage with a Limberg transposition flap is the preferred reconstruction method, allowing primary closure of the donor site and achieving non-recurrence rates of 81.25%. 5, 6
• Alternative flap options include latissimus dorsi musculocutaneous flap for extensive defects or inner arm perforator flap (V-Y advancement or propeller design), both preserving shoulder mobility. 7, 8
• Avoid open granulation or split-skin grafting alone, as these result in prolonged hospitalization, higher morbidity, functional problems, and scar contracture. 5, 6

Postoperative Management

• Administer systemic antibiotics postoperatively. 5, 6
• Immobilize the arm for 2 weeks, then initiate physiotherapy to restore shoulder range of motion. 5, 6

Treatment Monitoring and Escalation

• Reassess at 12 weeks using pain VAS score, inflammatory lesion count, DLQI, and HiSCR (for biologic therapy). 1, 2
• If no clinical response after 12 weeks of clindamycin-rifampicin, escalate directly to adalimumab rather than continuing antibiotics. 1, 3
• Consider treatment breaks after antibiotic courses to assess need for ongoing therapy and limit antimicrobial resistance. 1

Essential Adjunctive Measures

• Refer for smoking cessation, as tobacco use worsens outcomes and increases recurrence risk. 1, 2
• Refer for weight management if BMI is elevated, as obesity is associated with worse disease severity. 1, 2
• Provide appropriate wound dressings for draining lesions. 1
• Prescribe NSAIDs for pain management and symptomatic relief. 1, 2
• Screen for and treat depression/anxiety, as these are common comorbidities. 1
• Measure blood pressure, lipids, and HbA1c to screen for cardiovascular risk factors, which are elevated in hidradenitis suppurativa patients. 1, 3

Critical Pitfalls to Avoid

• Do not perform inadequate surgical excision, as this is the leading cause of disease recurrence—excise all apocrine gland-bearing tissue, not just visibly affected skin. 5, 9
• Avoid long-term antibiotic use without treatment breaks, as this increases antimicrobial resistance risk without proven additional benefit. 1, 3
• Do not continue doxycycline beyond 4 months without reassessment. 1
• Ensure rifampicin dose is 300-600 mg daily (not lower doses) and clindamycin is 300 mg twice daily for systemic effect. 3
• Do not use topical clindamycin alone for prolonged periods without benzoyl peroxide, as this increases Staphylococcus aureus resistance rates. 1