What is the management for a patient presenting with small bumps in the armpit?

Management of Small Bumps in the Armpit

The management of small bumps in the armpit depends critically on the underlying diagnosis, with hidradenitis suppurativa being the most likely condition requiring specific treatment algorithms based on disease severity.

Initial Diagnostic Approach

The first priority is determining the etiology of the axillary bumps, as management differs dramatically between conditions:

• Hidradenitis suppurativa (HS) presents as painful nodules, abscesses, and draining lesions in apocrine gland-bearing areas like the axillae 1
• Infectious processes (folliculitis, abscesses) require bacterial culture and targeted antimicrobial therapy 1
• Soft-tissue masses require systematic evaluation to distinguish benign from malignant lesions 2
• Lymphedema may present as swelling associated with chronic inflammatory conditions 3

Management Algorithm for Hidradenitis Suppurativa (Most Common Cause)

Acute Lesions (All Stages)

For immediate symptomatic relief of inflamed lesions:

• Warm compresses applied to affected areas 1
• Antiseptic washes (chlorhexidine, zinc pyrithione) to reduce bacterial colonization 1
• Intralesional corticosteroids for individual inflamed nodules provide short-term control of acute flares 1
• Incision and drainage for fluctuant abscesses, though recurrence is common 1, 4

Mild Disease (Hurley Stage I)

First-line treatment consists of topical clindamycin applied twice daily to affected areas, though this carries high risk of bacterial resistance 1. Alternative options include:

• Resorcinol 15% cream is recommended but may induce contact dermatitis 1
• Tetracyclines (doxycycline 100 mg twice daily OR minocycline 50 mg twice daily) for 12-week course or long-term maintenance 1
• Antiseptic body washes with chlorhexidine or zinc pyrithione daily 1

Moderate Disease (Hurley Stage II)

Combination antibiotic therapy with clindamycin and rifampin is effective as second-line treatment or first-line in more severe presentations 1:

• Clindamycin 300 mg twice daily PLUS rifampin 300 mg twice daily 1
• Duration typically 10-12 weeks 1
• Monitor for antibiotic resistance and balance benefit against risk 1

Severe Disease (Hurley Stage III)

For extensive disease with multiple interconnected tracts and scarring:

• Triple antibiotic therapy: moxifloxacin, metronidazole, and rifampin as second- or third-line treatment 1
• IV ertapenem as rescue therapy or bridge to surgery 1
• Surgical intervention including deroofing or wide excision for definitive management 1, 4

Adjunctive Measures

Hormonal Therapy (Female Patients)

Hormonal agents should be considered in appropriate female patients, either as monotherapy for mild-to-moderate disease or in combination with other agents 1:

• Combined oral contraceptives containing estrogen 1
• Spironolactone 1
• Avoid progestogen-only contraceptives as anecdotal data suggest they may worsen HS 1

General Skincare

• Avoid skin irritants including over-the-counter anti-acne medications, solvents, and disinfectants 1
• Minimize friction from tight clothing 1
• Weight reduction in obese patients may reduce disease burden 4
• Smoking cessation is strongly recommended as smoking exacerbates HS 1

When to Escalate Care

Refer to dermatology or surgery when:

• Disease fails to respond to first-line antibiotics within 4-6 weeks 1
• Progression to Hurley Stage II or III despite medical management 1
• Development of extensive scarring, sinus tracts, or lymphedema 1, 3
• Recurrent abscesses requiring repeated incision and drainage 4

Critical Pitfalls to Avoid

• Do not perform repeated incision and drainage alone without addressing underlying inflammation, as this never provides lasting results and may worsen scarring 4
• Do not use topical clindamycin as monotherapy long-term due to high bacterial resistance risk 1
• Do not delay surgical referral in patients with extensive disease, as medical therapy alone is insufficient for advanced HS 1, 4
• Ensure adequate debridement if surgical intervention is pursued, as incomplete removal of affected tissue leads to high recurrence rates 4