In a patient with a 15‑year history of recurrent tender pustules of varying size, some forming nidular clusters, and a single firm painful nodular cyst on the right upper scalp causing alopecia, should I refer to a dermatologist or start antibiotic therapy?

Refer to Dermatology Immediately—This is Likely Hidradenitis Suppurativa

This patient requires specialist evaluation by a dermatologist before initiating antibiotics, as the clinical presentation—recurrent tender pustules and nodules with a 15-year history, nodular cyst formation, and scarring alopecia—strongly suggests hidradenitis suppurativa (HS) rather than simple recurrent boils. 1

Why Dermatology Referral Takes Priority

• Diagnosis must be established by a dermatologist or healthcare professional with expert knowledge in HS, as recommended by the European Dermatology Forum guidelines 1
• The 15-year chronic relapsing course with varied-sized pustules (1-4mm), nodular formations, and scarring (alopecia) is pathognomonic for HS, not simple furunculosis 1
• HS requires disease severity staging (Hurley staging, Physician Global Assessment) before treatment decisions, which should be performed by specialists 1
• Empiric antibiotic therapy without proper diagnosis risks undertreating a progressive inflammatory condition that may require biologics or surgical intervention 1

Key Distinguishing Features Supporting HS Diagnosis

• Recurrent painful nodules and pustules in characteristic distribution (scalp involvement occurs in HS) 1
• Nodular cyst formation with scarring (causing alopecia)—this indicates progression beyond simple infection 1
• 15-year chronic relapsing pattern—simple recurrent boils would typically respond to decolonization strategies, whereas HS is a chronic inflammatory disease 1, 2
• "Nidular" (clustered) formation—suggests sinus tract development, a hallmark of HS 1

Why Antibiotics Alone Are Inadequate

• HS is a chronic inflammatory disease of hair follicles, not primarily an infectious process, though secondary infection occurs 1
• Treatment must address both inflammatory components and scarring, requiring evidence-based medical and surgical approaches 1
• For mild HS, topical clindamycin 1% twice daily for 12 weeks is first-line, not systemic antibiotics 1
• For moderate-to-severe disease, combination therapy (clindamycin 300mg + rifampicin 600mg for 10 weeks) or biologics (adalimumab) may be required 1
• Surgical evaluation is essential for all HS patients to assess scarring extent and need for definitive excision 1

Critical Pitfalls to Avoid

• Do not treat this as recurrent furunculosis—the chronicity, scarring, and nodular formations distinguish HS from simple S. aureus infections 1, 2
• Do not prescribe antibiotics without specialist input—inappropriate antibiotic selection or duration may worsen outcomes in HS 1
• The scalp alopecia indicates permanent scarring, suggesting advanced disease requiring aggressive management 1
• HS patients require adjuvant therapy (pain management, weight loss counseling, tobacco cessation) that primary care alone cannot adequately coordinate 1

Immediate Actions Before Referral

• Document disease severity: photograph lesions, count active pustules/nodules, measure scarred areas 1
• Assess pain using Visual Analogue Scale and quality of life impact (DLQI)—these patient-reported outcomes are strongly recommended for HS management 1
• Screen for obesity and tobacco use, as both worsen HS prognosis 1
• Provide temporary pain management if needed, but defer definitive treatment to dermatology 1

Alternative Diagnosis Considerations

While less likely given the chronic course, the differential includes:

• Dissecting cellulitis of the scalp (perifolliculitis capitis abscedens et suffodiens)—but this typically presents with boggy scalp nodules rather than widespread pustules 1
• Severe nodulocystic acne—but 15-year duration without response to typical acne measures argues against this 3
• Infected epidermal cysts—but multiple recurrent lesions with nodular clustering suggests systemic inflammatory disease 4

The dermatologist will perform definitive staging, initiate evidence-based therapy, coordinate surgical evaluation, and establish long-term management including potential biologic therapy if first-line treatments fail. 1