What is the best course of treatment for a 29-year-old male with hidradenitis suppurativa (HS) or an abscess of the right axilla?

Treatment of Hidradenitis Suppurativa or Axillary Abscess in a 29-Year-Old Male

For a 29-year-old male with hidradenitis suppurativa (HS) or axillary abscess, start with oral clindamycin 300 mg twice daily plus rifampicin 300-600 mg daily for 10-12 weeks, combined with intralesional triamcinolone 10 mg/mL for acutely inflamed nodules. 1, 2, 3

Initial Assessment and Diagnosis

First, determine whether this is HS versus a simple bacterial abscess by looking for: 1

• Recurrent nodules or abscesses in the axilla (HS requires recurrence as a diagnostic criterion) 1
• Comedones (double-headed blackheads pathognomonic for HS) 1
• Sinus tracts or tunneling under the skin 1
• Scarring from previous episodes 1

If this is the first isolated abscess without recurrence, comedones, or scarring, treat as a simple bacterial abscess with incision and drainage plus oral antibiotics. 4 However, given the patient's age (peak HS incidence is third-fourth decade) and axillary location (classic HS site), strongly suspect HS. 1

Determine Hurley stage to guide treatment intensity: 1, 2

• Stage I: Isolated nodules/abscesses without sinus tracts or scarring
• Stage II: Recurrent nodules with limited sinus tracts and scarring (most likely for this patient if HS)
• Stage III: Multiple/extensive sinus tracts and scarring across the region

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

Oral clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg once or twice daily for 10-12 weeks achieves response rates of 71-93%, far superior to tetracycline monotherapy (30% abscess reduction). 1, 2, 3 This combination is the preferred first-line regimen for moderate HS with active abscesses. 1, 2

Add intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) injected directly into inflamed nodules and abscesses for rapid symptom relief within 1 day, with significant reductions in erythema, edema, suppuration, and pain. 1, 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, showing only 30% abscess reduction. 1, 2
• Do NOT use topical clindamycin alone for Hurley Stage II—it only reduces superficial pustules, not inflammatory nodules or abscesses. 1, 2
• Do NOT perform simple incision and drainage for HS lesions, as this leads to high recurrence rates and worsening scarring. 4, 5

Treatment for Mild Disease (Hurley Stage I)

If this is truly isolated nodules without recurrence or sinus tracts (Hurley Stage I): 2, 3

• Topical clindamycin 1% solution/gel applied twice daily to all affected areas for 12 weeks 1, 2, 3
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 1, 2
• Intralesional triamcinolone 10 mg/mL for individual inflamed lesions 1, 2

Reassessment at 12 Weeks

Evaluate treatment response using: 2, 6

• Pain Visual Analog Scale (VAS) score 2, 6
• Inflammatory lesion count (abscesses and nodules) 2, 6
• Number of flares since treatment initiation 2
• Dermatology Life Quality Index (DLQI) 2, 6

If inadequate response after 12 weeks of clindamycin-rifampicin, escalate to adalimumab. 1, 2

Biologic Therapy for Severe or Refractory Disease

Adalimumab is the only FDA-approved biologic for moderate-to-severe HS in patients ≥12 years old. 7 Dosing: 1, 2, 3, 7

• 160 mg subcutaneous at week 0 (single dose or split over two consecutive days)
• 80 mg at week 2
• 40 mg weekly starting at week 4 (NOT every other week—the every-other-week dosing is ineffective) 1, 2

HiSCR response rates are 42-59% at week 12. 2, 3 If no clinical response after 16 weeks, consider second-line biologics: 1, 2

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

Surgical Considerations

Radical surgical excision is recommended for extensive disease with sinus tracts and scarring when conventional systemic treatments have failed. 1, 2, 3, 8 Non-recurrence rates after wide excision are 81.25%. 3, 8

Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy. 2 Consider surgery concurrently with medical therapy for Hurley Stage II-III disease with established sinus tracts. 2, 3

Wound closure options include secondary intention healing, TDAP (thoracodorsal artery perforator) flap for axillary wounds, or skin grafts. 1, 2, 3

Mandatory Adjunctive Measures for All Patients

Regardless of disease severity, address: 2, 3, 6

• Smoking cessation referral (tobacco use worsens outcomes) 2, 3, 6
• Weight management referral if BMI elevated (obesity worsens outcomes) 2, 3, 6
• Pain management with NSAIDs for symptomatic relief 2, 3, 6
• Appropriate wound dressings for draining lesions 2, 3, 6
• Screen for depression/anxiety (HS significantly reduces quality of life) 2, 6
• Screen for cardiovascular risk factors (measure BP, lipids, HbA1c) 2, 6

Treatment Duration and Antimicrobial Resistance

Consider treatment breaks after completing the 10-12 week antibiotic course to assess need for ongoing therapy and limit antimicrobial resistance risk. 2 Avoid long-term continuous antibiotic use without reassessment. 1, 2