What is the treatment for hidradenitis suppurativa with purulent drainage?

Treatment of Hidradenitis Suppurativa with Purulent Drainage

For hidradenitis suppurativa with purulent drainage, initiate oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks as first-line systemic therapy, combined with topical clindamycin 1% twice daily and appropriate wound care for draining lesions. 1, 2

Immediate Assessment and Staging

• Determine Hurley stage to guide treatment intensity: Stage I (isolated nodules/abscesses), Stage II (recurrent abscesses with sinus tracts and scarring), or Stage III (diffuse involvement with multiple interconnected sinus tracts). 2
• Document baseline pain using Visual Analog Scale (VAS) and count inflammatory lesions (abscesses, nodules, draining fistulas). 2, 3
• Assess quality of life using Dermatology Life Quality Index (DLQI) and number of flares in the last month. 2, 3

The presence of purulent drainage typically indicates at least moderate disease (Hurley Stage II) with active inflammation and possible secondary infection. 2

First-Line Systemic Antibiotic Therapy

The clindamycin-rifampicin combination achieves response rates of 71-93%, far superior to monotherapy options like doxycycline (which shows only 30% abscess reduction and minimal effect on deep inflammatory lesions). 1, 4

Dosing Regimen:

• Clindamycin 300 mg orally twice daily 1, 2, 3
• Rifampicin 300-600 mg orally once or twice daily 1, 2, 3
• Duration: 10-12 weeks initially 1, 2, 3

This combination can be repeated intermittently as needed, but always include treatment breaks to assess ongoing need and limit antimicrobial resistance risk. 1

Critical Evidence:

A retrospective study of 116 patients with severe HS demonstrated dramatic improvement in Sartorius scores (median 29 to 14.5, p<0.001) after 10 weeks of clindamycin-rifampicin therapy, with only 6.9% discontinuing due to side effects. 4 This represents the strongest evidence for antibiotic therapy in HS with purulent drainage.

Topical Therapy and Wound Care

• Apply topical clindamycin 1% solution or gel twice daily to all affected areas for 12 weeks. 1, 2
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk, as topical clindamycin monotherapy increases resistance rates. 1
• Use appropriate wound dressings for draining lesions to manage exudate and prevent secondary infection. 2, 3

Adjunctive Acute Interventions

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) can be injected into acutely inflamed nodules for rapid symptom relief within 1 day, showing significant reduction in erythema, edema, suppuration, and pain. 1
• NSAIDs for pain management provide symptomatic relief during acute flares. 2, 3

Treatment Monitoring and Escalation

Reassess at 12 weeks using the following objective measures: 1, 2

• Pain VAS score
• Inflammatory lesion count
• HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas)
• DLQI score

If No Response After 12 Weeks:

Escalate directly to adalimumab, the only FDA-approved biologic for moderate-to-severe HS in patients ≥12 years old: 1, 5

• Day 1: 160 mg (single dose or split over two consecutive days)
• Day 15: 80 mg
• Day 29 and ongoing: 40 mg weekly

Adalimumab achieves HiSCR response rates of 42-59% at week 12, with a number needed to treat (NNT) of 4. 3

Second-Line Biologic Options (if adalimumab fails):

• Infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1
• Secukinumab (response rates 64.5-71.4% in adalimumab-failure patients) 1
• Ustekinumab (alternative IL-12/23 pathway targeting) 1

Surgical Considerations

Refer to hidradenitis suppurativa surgical multidisciplinary team for: 2, 3

• Hurley Stage III disease
• Lack of response to medical therapy after 12 weeks
• Extensive sinus tracts and scarring

Surgical options include: 1, 2

• Deroofing for recurrent nodules and tunnels
• Radical surgical excision for extensive disease with sinus tracts and scarring
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1

Essential Adjunctive Measures

These interventions are critical for long-term disease control: 2, 3

• Smoking cessation referral (tobacco use predicts poor antibiotic response and worse outcomes)
• Weight management referral if BMI elevated (obesity strongly associated with disease severity)
• Screen for comorbidities: depression/anxiety, cardiovascular risk factors (BP, lipids, HbA1c), inflammatory bowel disease, metabolic syndrome

Critical Pitfalls to Avoid

• Do not use doxycycline as first-line for purulent drainage or Hurley Stage II disease, as it has minimal effect on deep inflammatory lesions, abscesses, and sinus tracts characteristic of moderate-to-severe HS. 1, 2
• Do not continue ineffective antibiotics beyond 12 weeks without reassessment, as this increases antimicrobial resistance risk without proven benefit. 2, 3
• Do not use tetracyclines as first-line for severe flares with purulent drainage, as they are ineffective for the deep inflammatory lesions and sinus tracts that produce drainage. 2
• Be aware of high antibiotic resistance rates: bacterial cultures from HS patients show resistance to clindamycin (65.7%), rifampicin (69.3%), and tetracycline (84.7%), though the clindamycin-rifampicin combination remains clinically effective. 6

Special Considerations for Adolescents

For adolescents 12 years and older with moderate-to-severe disease requiring biologics: 1, 5

Weight-based adalimumab dosing:

• 30-60 kg: Day 1: 80 mg; Day 8 and ongoing: 40 mg every other week
• ≥60 kg: Adult dosing (160 mg → 80 mg → 40 mg weekly)