Management of Suppurative Dermatitis
Immediate Treatment Depends on Accurate Diagnosis
The term "suppurative dermatitis" is non-specific and requires clarification before treatment can begin. If this refers to hidradenitis suppurativa (HS) with active suppurative lesions, initiate oral clindamycin 300 mg twice daily plus rifampicin 300–600 mg daily for 10–12 weeks combined with intralesional triamcinolone 10 mg/mL into inflamed nodules for rapid symptom relief. 1 If this refers to a simple bacterial skin infection (e.g., impetigo, folliculitis, or abscess), management differs substantially and depends on whether the infection is simple or complicated. 2
If This Is Hidradenitis Suppurativa (HS)
Step 1: Confirm the Diagnosis Clinically
- Look for recurrent painful nodules or abscesses in intertriginous areas (axillae, groin, perineum, inframammary folds) with at least two episodes within six months. 1
- Identify paired comedones, sinus tracts, tunneling beneath the skin, or scarring—these features distinguish HS from simple bacterial abscesses. 1
- Do not order bacterial cultures unless there are clear signs of secondary infection (cellulitis, fever), because mixed normal flora does not guide therapy. 1
Step 2: Determine Hurley Stage to Guide Treatment Intensity
- Hurley Stage I (isolated nodules/abscesses, no sinus tracts): Topical clindamycin 1% twice daily for 12 weeks. 1
- Hurley Stage II (recurrent nodules with limited sinus tracts and scarring): Oral clindamycin 300 mg twice daily plus rifampicin 300–600 mg daily for 10–12 weeks, achieving response rates of 71–93%. 1
- Hurley Stage III (multiple/extensive sinus tracts and scarring): Initiate clindamycin-rifampicin while awaiting specialist evaluation; definitive therapy is adalimumab (160 mg week 0,80 mg week 2, then 40 mg weekly from week 4) or surgical excision. 1
Step 3: Add Intralesional Triamcinolone for Acute Inflamed Nodules
- Inject triamcinolone 10 mg/mL (0.2–2.0 mL) directly into each inflamed nodule or abscess to achieve significant reductions in erythema, edema, suppuration, and pain within 24 hours. 1, 3
Step 4: Implement Mandatory Adjunctive Measures
- Smoking cessation referral: 70–75% of HS patients are smokers; nicotine worsens disease. 1
- Weight management referral: >75% of HS patients are obese; obesity increases mechanical friction and pro-inflammatory cytokines. 1
- Pain management with NSAIDs for symptomatic relief. 1
- Appropriate wound dressings for draining lesions. 1
- Screen for depression/anxiety using validated tools, as these conditions are highly prevalent in HS. 1
- Screen for cardiovascular risk factors (blood pressure, lipid profile, HbA1c), as HS patients have nearly doubled cardiovascular mortality risk. 1
Step 5: Reassess at 12 Weeks and Escalate if Needed
- Measure pain using a Visual Analog Scale (VAS), count inflammatory lesions (nodules + abscesses), and assess HiSCR (≥50% reduction in abscess/nodule count without new abscesses or draining fistulas). 1
- If no clinical response after 12 weeks of clindamycin-rifampicin, escalate directly to adalimumab (160 mg week 0,80 mg week 2, then 40 mg weekly starting week 4). 1
- If adalimumab fails after 16 weeks, consider second-line biologics: infliximab 5 mg/kg at weeks 0,2,6, then every 2 months; secukinumab (response rates 64.5–71.4% in adalimumab-failure patients); or ustekinumab. 1
Step 6: Consider Surgery for Extensive Disease
- Radical surgical excision is recommended for Hurley Stage III with extensive sinus tracts and scarring when medical therapy fails, achieving non-recurrence rates of ~81% after wide excision. 1
- Wound closure options include secondary intention healing, split-thickness skin grafts, or local flaps. 1
If This Is a Simple Bacterial Skin Infection (Not HS)
Step 1: Classify the Infection
- Simple (uncomplicated) infections are monomicrobial, present with localized findings (erythema, warmth, tenderness), and lack systemic signs. 2
- Complicated infections may be polymicrobial, present with systemic inflammatory response syndrome (fever, tachycardia, hypotension), or involve deeper structures (necrotizing fasciitis). 2
Step 2: Treat Simple Infections
- Superficial abscesses: Incision and drainage alone; antibiotics are seldom required. 2
- Impetigo or folliculitis: Topical mupirocin or fusidic acid for localized lesions; oral antibiotics (e.g., cephalexin, dicloxacillin) if extensive. 2
- Empiric coverage should target Staphylococcus aureus (including MRSA) and beta-hemolytic Streptococcus: Use trimethoprim-sulfamethoxazole, doxycycline, or clindamycin for MRSA coverage in community-acquired infections. 2
Step 3: Treat Complicated Infections
- Admit for inpatient treatment if systemic signs are present, if necrotizing fasciitis is suspected, or if the patient is immunocompromised. 2
- Empiric polymicrobial antibiotic coverage: Vancomycin plus piperacillin-tazobactam or a carbapenem. 2
- Urgent surgical consultation for debridement if necrotizing fasciitis or gangrene is suspected. 2
Critical Pitfalls to Avoid
- Do not use doxycycline or tetracycline monotherapy for HS with abscesses or deep inflammatory nodules; these agents show only 30% abscess reduction and are ineffective for Hurley Stage II disease. 1
- Do not prescribe adalimumab 40 mg every other week for moderate-to-severe HS; weekly dosing (40 mg) is required for efficacy. 1
- Do not extend antibiotic therapy beyond 10–12 weeks without reassessment, as prolonged use increases antimicrobial resistance without demonstrated additional benefit. 1
- Do not use topical clindamycin alone for HS with abscesses or inflammatory nodules; it only reduces superficial pustules, not deep lesions. 3
- Always combine topical clindamycin with benzoyl peroxide to reduce the risk of Staphylococcus aureus resistance. 3