How should I evaluate and initially manage a 28-year-old man with suspected hidradenitis suppurativa of the groin?

Evaluation and Initial Management of Suspected Hidradenitis Suppurativa in a 28-Year-Old Male with Groin Involvement

For a 28-year-old male with suspected hidradenitis suppurativa of the groin, confirm the diagnosis by identifying recurrent painful nodules or abscesses with comedones, sinus tracts, or scarring in the inguinal region, then determine Hurley stage and initiate topical clindamycin 1% twice daily for 12 weeks if Stage I, or oral clindamycin 300 mg plus rifampicin 300-600 mg twice daily for 10-12 weeks if Stage II or greater. 1, 2

Diagnostic Confirmation

The diagnosis of HS is clinical, based on characteristic features rather than laboratory testing 1, 3:

• Look for recurrent painful nodules or abscesses in the groin (inguinal region), which is the second most common site after axillae 4, 3, 5
• Identify double-headed comedones (blackheads with two or more openings), which are pathognomonic for HS 3
• Examine for sinus tracts or tunneling beneath the skin surface, which indicates more advanced disease 1, 3
• Assess for scarring, including ropelike fibrotic subcutaneous bands that may cause contractures 3
• Confirm recurrent nature - HS requires at least two episodes in 6 months or chronic persistence 1

Do not order bacterial cultures unless signs of secondary infection (surrounding cellulitis, fever) are present, as mixed normal flora is typical and does not guide treatment 1. Do not order genetic or biomarker testing, as there is no current role for these in diagnosis 1.

Hurley Staging Assessment

Determine Hurley stage by examining all intertriginous areas (both groins, axillae, buttocks, perianal region) 1, 6:

• Hurley Stage I: Isolated nodules and abscesses with minimal or no scarring, no sinus tracts 1, 6
• Hurley Stage II: Recurrent nodules with one or limited sinus tracts and scarring within the groin region 1, 6
• Hurley Stage III: Multiple or extensive sinus tracts and scarring affecting the entire groin/genital region 1, 6

Document baseline pain using Visual Analog Scale (VAS) and inflammatory lesion count (number of nodules and abscesses) to track treatment response 1, 2.

Mandatory Comorbidity Screening

Screen for the following conditions at initial evaluation 1:

• Smoking status - 70-75% of HS patients smoke; document pack-years and refer to cessation services 1
• Diabetes screening - check HbA1c or fasting glucose, as HS patients have 1.5-3 fold increased risk with prevalence up to 30% 1
• Metabolic syndrome components - measure blood pressure, lipid panel, BMI 1, 2
• Depression and anxiety screening - use validated tools, as psychiatric comorbidity is common 1
• Inflammatory bowel disease symptoms - thorough review of GI symptoms 1

Examine chronic lesions on perineum and buttocks carefully for signs of squamous cell carcinoma, which is most common in these locations 1.

Initial Treatment Based on Hurley Stage

For Hurley Stage I (Mild Disease)

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

• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk 2
• Intralesional triamcinolone 10 mg/mL (0.2-2.0 mL) can be injected into acutely inflamed nodules for rapid relief within 1 day 2

For Hurley Stage II (Moderate Disease)

Oral clindamycin 300 mg twice daily PLUS rifampicin 300-600 mg once or twice daily for 10-12 weeks is the superior first-line regimen, achieving response rates of 71-93% 1, 2:

• This combination is far superior to tetracycline monotherapy (30% abscess reduction) 2
• Add intralesional triamcinolone 10 mg/mL for acutely inflamed nodules 2
• Do NOT use doxycycline monotherapy as first-line for Stage II with abscesses, as it has minimal effect on deep inflammatory lesions 2

For Hurley Stage III (Severe Disease)

Immediate referral to dermatology is mandatory 2, 7:

• Initiate clindamycin 300 mg plus rifampicin 300 mg twice daily while awaiting specialist evaluation 2, 7
• Definitive treatment requires adalimumab (160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4) or surgical intervention 1, 2

Essential Adjunctive Measures for All Patients

Implement these interventions regardless of disease severity 1, 2:

• Smoking cessation referral - smoking is associated with worse outcomes and treatment failure 1
• Weight management referral if BMI elevated - obesity prevalence exceeds 75% in HS patients 1
• Pain management with NSAIDs for symptomatic relief 2
• Appropriate wound dressings for draining lesions - choice based on drainage amount and location 6, 7

Reassessment at 12 Weeks

Evaluate treatment response using 1, 2:

• Pain VAS score reduction
• Inflammatory lesion count (abscesses and nodules)
• Number of flares
• Dermatology Life Quality Index (DLQI)
• HiSCR (≥50% reduction in abscess/nodule count with no increase in abscesses or draining fistulas)

If no clinical response after 12 weeks of first-line therapy, escalate to clindamycin-rifampicin combination (if not already used) or adalimumab for severe/refractory disease 1, 2.

Critical Pitfalls to Avoid

• Do NOT interpret purulent drainage as solely bacterial infection requiring only antimicrobial therapy - the drainage reflects chronic inflammation, not just infection 6
• Do NOT use doxycycline or tetracycline monotherapy for Hurley Stage II with abscesses or deep nodules 2
• Do NOT continue antibiotics indefinitely - take treatment breaks after 10-12 weeks to assess ongoing need and limit antimicrobial resistance 1
• Do NOT delay surgical referral for extensive disease (Stage III), as non-surgical methods rarely achieve lasting cure in advanced disease 2, 7