What are the first and second line treatments for a patient with hidradenitis suppurativa (HS) who has multiple scarred abscesses and current abscesses in the axilla and between the thighs?

First and Second Line Treatment for Hidradenitis Suppurativa with Active Axillary and Inguinal Abscesses

For this patient with Hurley Stage II hidradenitis suppurativa (multiple scarred abscesses plus current active abscesses in axilla and thighs), first-line treatment is clindamycin 300 mg orally twice daily plus rifampicin 300-600 mg orally once or twice daily for 10-12 weeks, combined with intralesional triamcinolone 10 mg/mL for acutely inflamed nodules. 1, 2, 3 If no clinical response after 12 weeks, second-line treatment is adalimumab 160 mg at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2, 4

Disease Severity Assessment

This patient has Hurley Stage II disease, characterized by recurrent abscesses with sinus tract formation and scarring, affecting multiple anatomical sites (axilla and inguinal/thigh regions). 1, 2 The presence of both active inflammation and established scarring indicates moderate-to-severe disease requiring aggressive systemic therapy beyond topical agents. 1, 2

First-Line Treatment Protocol

Systemic Antibiotic Combination Therapy

• Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks is the superior first-line choice for Hurley Stage II disease with abscesses and inflammatory nodules. 1, 2, 3
• This combination achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy (30% abscess reduction). 1, 2
• The combination provides both bactericidal action and reduces rifampicin resistance development. 3
• Treatment typically lasts 8-12 weeks and can be repeated intermittently as needed. 1, 2

Acute Lesion Management

• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) injected directly into inflamed nodules and abscesses provides rapid symptom relief within 1 day. 1, 5, 2
• This demonstrates significant reductions in erythema, edema, suppuration, lesion size, and pain VAS scores. 1, 5
• Use this for immediate control of the current axillary and thigh abscesses while systemic antibiotics take effect. 2

Adjunctive Topical Therapy

• Topical clindamycin 1% solution applied twice daily to all affected areas can be added, though its efficacy is limited to superficial pustules, not deep abscesses. 1, 5, 2
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk from topical clindamycin. 5, 2
• Antiseptic washes (chlorhexidine, benzoyl peroxide, or zinc pyrithione) should be used daily on all intertriginous areas. 1, 5

Treatment Assessment at 12 Weeks

Reassess using objective measures: 2, 3

• Pain VAS score reduction
• Inflammatory lesion count (abscesses and nodules)
• Quality of life measures (DLQI)
• HiSCR response (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas) 2, 4

If inadequate response after 12 weeks of clindamycin-rifampicin, escalate immediately to second-line biologic therapy. 2, 3

Second-Line Treatment: Biologic Therapy

Adalimumab (First-Line Biologic)

• Adalimumab dosing: 160 mg subcutaneous at week 0,80 mg at week 2, then 40 mg weekly starting at week 4. 1, 2, 4
• This is FDA-approved for moderate-to-severe HS in patients ≥12 years old. 2, 4
• HiSCR response rates of 42-59% at week 12 in placebo-controlled trials. 2, 4
• In Study HS-II (which allowed concomitant oral antibiotics), 59% achieved HiSCR at week 12 versus 28% with placebo. 4
• Assess response at 16 weeks; if no clinical response, consider alternative biologics. 2

Alternative Second-Line Biologics (After Adalimumab Failure)

• Infliximab 5 mg/kg IV at weeks 0,2,6, then every 2 months for patients who fail adalimumab. 1, 2
• Secukinumab demonstrates response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks. 2
• Ustekinumab is an alternative targeting different cytokine pathways (IL-12/23 versus TNF-alpha). 2

Critical Pitfalls to Avoid

• Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses—these have minimal effect on deep inflammatory lesions and abscesses, showing only 30% abscess reduction. 1, 2
• Do NOT use topical clindamycin alone for this patient—it only reduces superficial pustules, not inflammatory nodules or abscesses. 1, 5
• Ensure rifampicin dose is 300-600 mg daily (not lower doses) and clindamycin must be 300 mg twice daily for systemic effect. 3
• Avoid long-term antibiotics without treatment breaks to reduce antimicrobial resistance risk. 2, 3
• Do NOT delay biologic therapy if antibiotics fail at 12 weeks—chronic inflammation leads to irreversible skin damage with tunnel formation and morbid scarring. 6

Surgical Considerations

Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy for extensive disease with sinus tracts and scarring. 2 Given this patient's established scarring, consider:

• Deroofing for recurrent nodules and tunnels as an adjunct to medical therapy. 2
• Radical surgical excision may be necessary for extensive disease with sinus tracts and scarring that fails medical management. 1, 2, 7
• Surgery is often necessary for lasting cure, especially in advanced disease. 2, 7

Essential Adjunctive Measures

Regardless of treatment choice, address: 2, 3

• Smoking cessation referral—tobacco use worsens outcomes. 2
• Weight management referral if BMI elevated—obesity is associated with worse disease. 2
• Pain management with NSAIDs for symptomatic relief. 2, 3
• Appropriate wound dressings for draining lesions. 2, 3
• Screen for depression/anxiety—HS has profound negative effects on quality of life. 2, 6
• Screen for cardiovascular risk factors (BP, lipids, HbA1c)—HS patients have increased cardiovascular mortality. 2, 3

Third-Line Options (If Second-Line Fails)

If no response to adalimumab after 16 weeks: 2, 3

• Triple antibiotic therapy: moxifloxacin + metronidazole + rifampin as rescue therapy. 2, 3
• Ertapenem 1g IV daily for 6 weeks can be considered as rescue therapy or during surgical planning for severe disease. 2
• Alternative biologics (infliximab, secukinumab, ustekinumab) targeting different inflammatory pathways. 2
• Surgical deroofing or radical excision concurrently with medical therapy. 2, 7