What is the management for a 45-year-old female patient with painful lesions on both axillae, a history of flares, and a diagnosis consistent with hidradenitis suppurativa?

Management of Hidradenitis Suppurativa in a 45-Year-Old Female with Bilateral Axillary Involvement

For this patient with bilateral axillary hidradenitis suppurativa and recurrent flares, initiate clindamycin 300 mg orally twice daily plus rifampicin 600 mg orally once daily for 10-12 weeks as first-line therapy, combined with intralesional triamcinolone 10 mg/mL for acutely inflamed nodules. 1, 2

Initial Assessment

Before initiating treatment, determine the Hurley stage by examining both axillae for:

• Hurley Stage I: Recurrent nodules and abscesses with minimal scarring 3, 4
• Hurley Stage II: One or limited number of sinus tracts and/or scarring within the region 3, 4
• Hurley Stage III: Multiple or extensive sinus tracts and/or scarring 3, 4

Document baseline pain using Visual Analog Scale (VAS), count inflammatory nodules and abscesses, and assess quality of life with DLQI score 3, 1. Screen for comorbidities including depression/anxiety, diabetes, hypertension, hyperlipidemia, and inflammatory bowel disease 1, 2.

First-Line Treatment for Moderate Disease (Hurley Stage II)

The clindamycin-rifampicin combination achieves response rates of 71-93%, far superior to tetracycline monotherapy which shows only 30% abscess reduction. 1, 2 This regimen specifically targets the deep inflammatory lesions and abscesses characteristic of bilateral axillary involvement 1.

Dosing Regimen:

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

Adjunctive Intralesional Therapy:

• 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 erythema, edema, suppuration, and pain 1, 2

Critical Pitfall to Avoid

Do NOT use doxycycline or tetracycline monotherapy as first-line for this patient. These agents have minimal effect on deep inflammatory lesions and abscesses, showing only 30% abscess reduction compared to the 71-93% response rate with clindamycin-rifampicin 1. Doxycycline is only appropriate for widespread mild disease (Hurley Stage I) without abscesses 1.

Mandatory Adjunctive Measures

Implement these interventions concurrently with antibiotic therapy:

• Smoking cessation referral (tobacco use worsens outcomes) 1, 2
• Weight management referral if BMI elevated 1, 2
• Pain management with NSAIDs for symptomatic relief 1, 2
• Appropriate wound dressings for draining lesions 1, 2
• Screen for depression/anxiety and cardiovascular risk factors (BP, lipids, HbA1c) 1, 2

Reassessment at 12 Weeks

Evaluate treatment response using:

• Pain VAS score 1
• Inflammatory lesion count (abscesses and nodules) 1
• Number of flares 1
• DLQI score 1

Treatment Escalation if Inadequate Response

If no clinical response after 12 weeks of clindamycin-rifampicin, escalate directly to adalimumab. 1, 2

Adalimumab Dosing (FDA-Approved for HS):

• Week 0: 160 mg subcutaneous (single dose or split over two consecutive days) 5
• Week 2: 80 mg subcutaneous 5
• Week 4 onward: 40 mg subcutaneous weekly 5

Adalimumab achieves HiSCR response rates of 42-59% at week 12 in patients with moderate-to-severe HS 1, 2. The FDA label specifically indicates adalimumab for moderate to severe hidradenitis suppurativa in patients 12 years of age and older. 5

Assessment of Biologic Response:

Use HiSCR (Hidradenitis Suppurativa Clinical Response): ≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas 1. If no clinical response after 16 weeks of adalimumab, consider second-line biologics including infliximab, secukinumab, or ustekinumab 1.

Surgical Considerations

If extensive sinus tracts and scarring develop (Hurley Stage III), surgical intervention becomes necessary for lasting cure. 1, 2 Options include:

• Deroofing for recurrent nodules and tunnels 1
• Radical surgical excision for extensive disease 1, 2
• Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy 1

Treatment Break Strategy

After completing the 10-12 week antibiotic course, take a treatment break to assess need for ongoing therapy and limit antimicrobial resistance. 1 This regimen can be repeated intermittently for flares 1.

Special Considerations for This Patient

Given the bilateral axillary involvement and history of recurrent flares, this patient likely has at least Hurley Stage II disease. The clindamycin-rifampicin combination is the superior first-line choice for this presentation, with documented response rates of 71-93%. 1, 2 Topical clindamycin alone is insufficient for bilateral disease with recurrent flares, as it only reduces superficial pustules, not inflammatory nodules or abscesses 1.