What to do for hidradenitis suppurativa on the groin?

Treatment of Hidradenitis Suppurativa in the Groin

For groin hidradenitis suppurativa, start with topical clindamycin 1% twice daily for mild disease (isolated nodules without sinus tracts), escalate to oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks for moderate disease (recurrent abscesses), and advance to adalimumab for severe or refractory cases with sinus tracts and scarring. 1, 2

Initial Disease Severity Assessment

Determine Hurley stage by examining the groin area for:

• Hurley Stage I: Isolated nodules and abscesses without sinus tracts or scarring 2
• Hurley Stage II: Recurrent abscesses with limited sinus tracts and scarring 2
• Hurley Stage III: Diffuse involvement with multiple interconnected sinus tracts and extensive scarring 2

Document baseline pain using Visual Analog Scale (0-10) and count inflammatory nodules/abscesses 2

Treatment Algorithm by Disease Severity

Mild Disease (Hurley Stage I)

First-line therapy: Topical clindamycin 1% solution or gel applied twice daily to all affected groin areas for 12 weeks 1, 2, 3

Critical addition: Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk, as topical clindamycin monotherapy significantly increases antibiotic resistance 2, 3

Adjunctive measures for acute flares: Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) injected directly into inflamed nodules provides rapid symptom relief within 1 day, with significant reductions in pain, erythema, edema, and suppuration 1, 2, 3

Important limitation: Topical clindamycin only reduces superficial pustules and has no effect on inflammatory nodules or abscesses 3

Moderate Disease (Hurley Stage II)

First-line therapy: Clindamycin 300 mg orally twice daily PLUS rifampicin 300-600 mg orally once or twice daily for 10-12 weeks 1, 2, 4

This combination achieves response rates of 71-93% in systematic reviews, far superior to tetracycline monotherapy (30% abscess reduction) 2, 4

Alternative first-line option (if combination unavailable): Doxycycline 100 mg once or twice daily for 12 weeks, though this is generally less effective for acute abscesses 2, 4

Critical pitfall to avoid: Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses, as these have minimal effect on deep inflammatory lesions 2

Reassess at 12 weeks using:

• Pain VAS score reduction 2
• ≥50% reduction in abscess/nodule count (HiSCR criteria) 2
• Quality of life improvement (DLQI) 2

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

First-line biologic therapy: Adalimumab 1, 2, 5

• Week 0: 160 mg subcutaneous (single dose or split over two consecutive days)
• Week 2: 80 mg subcutaneous
• Week 4 onward: 40 mg subcutaneous weekly

This achieves HiSCR response rates of 42-59% at week 12 2

Second-line biologic options (if adalimumab fails after 16 weeks):

• Infliximab: 5 mg/kg IV at weeks 0,2,6, then every 2 months 1, 2
• Secukinumab: Response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 1, 2
• Ustekinumab: Alternative targeting different cytokine pathways 2

Surgical intervention: Radical surgical excision is necessary for extensive disease with sinus tracts and scarring that fails medical management, with options including deroofing for recurrent nodules or wide excision with healing by secondary intention, skin grafts, or flaps 1, 2

Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 2

Essential Adjunctive Measures (All Severity Levels)

• Smoking cessation referral: Tobacco use worsens outcomes 2, 6
• Weight management referral if BMI elevated: Obesity is a major risk factor 2, 6
• Pain management: NSAIDs for symptomatic relief 2
• Appropriate wound dressings for draining lesions 2
• Screen for depression/anxiety: Quality of life is profoundly affected 2, 6
• Screen for cardiovascular risk factors: Measure blood pressure, lipids, HbA1c 2
• Screen for comorbidities: Diabetes mellitus, Crohn's disease, inflammatory bowel disease 2, 7

Treatment Duration and Monitoring

For antibiotic courses: Treat for 10-12 weeks initially, then consider treatment break to assess need for ongoing therapy and limit antimicrobial resistance 1, 2, 4

For biologics: If no clinical response after 16 weeks of adalimumab, escalate to alternative biologic or consider surgical intervention 2

Avoid long-term antibiotics without treatment breaks to reduce antimicrobial resistance risk 2, 4

Critical Pitfalls to Avoid

• Do NOT use topical clindamycin alone for Hurley Stage II with abscesses, as it only reduces superficial pustules 2
• Do NOT use doxycycline as first-line for Hurley Stage II with deep inflammatory lesions or abscesses 2
• Ensure rifampicin dose is 300-600 mg daily (not lower doses) when using combination therapy 4
• Always combine topical clindamycin with benzoyl peroxide to prevent antibiotic resistance 2, 3

Special Population Considerations

For adolescents 12 years and older: Adalimumab is FDA-approved with weight-based dosing for moderate to severe disease 2, 5

For pregnant patients: Adalimumab is recommended if biologics are required, with counseling about use during pregnancy 1

For breastfeeding patients: Biologics are likely safe based on pharmacokinetics, as these large proteins are not well-absorbed by the GI tract 1