What is the recommended management for hidradenitis suppurativa affecting the groin in an adult?

Management of Hidradenitis Suppurativa in the Groin

For groin hidradenitis suppurativa, initiate oral clindamycin 300 mg twice daily plus rifampicin 300–600 mg daily for 10–12 weeks combined with intralesional triamcinolone 10 mg/mL injected into inflamed nodules for rapid symptom relief, achieving response rates of 71–93%. 1

Initial Assessment and Staging

• Confirm the diagnosis by identifying recurrent painful nodules, abscesses, or sinus tracts in the inguinal region with at least two episodes within six months. 2
• Examine all intertriginous areas (axillae, perineum, inframammary folds) to determine total disease burden, not just the groin. 1, 2
• Document Hurley stage: Stage I (isolated nodules without sinus tracts), Stage II (recurrent nodules with limited sinus tracts and scarring), or Stage III (extensive sinus tracts and scarring throughout the region). 1
• Record baseline pain using a Visual Analog Scale (0–10) and count inflammatory lesions (nodules + abscesses) to monitor treatment response. 1

Mandatory Comorbidity Screening

• Screen for smoking (70–75% of HS patients smoke; odds ratio 36) and refer immediately for cessation services, as smoking worsens outcomes and increases treatment failure. 1, 3
• Measure BMI and refer for weight management if elevated (>75% of HS patients are obese; odds ratio 33), as weight loss >15% can achieve complete remission in nearly half of patients. 1, 3
• Check blood pressure, lipid profile, and HbA1c, as HS patients have nearly doubled cardiovascular mortality risk and increased prevalence of diabetes (up to 30%). 1, 3
• Screen for depression and anxiety using validated tools, as these conditions are highly prevalent and significantly impact quality of life. 1, 2

Treatment Algorithm by Disease Severity

Hurley Stage I (Mild Disease)

• Apply topical clindamycin 1% solution or gel twice daily to all affected groin areas for 12 weeks as first-line therapy. 1, 2
• Combine with benzoyl peroxide wash or chlorhexidine 4% wash daily to reduce Staphylococcus aureus resistance risk. 1
• Inject intralesional triamcinolone 10 mg/mL (0.2–2.0 mL) into acutely inflamed nodules for rapid relief within 24 hours. 1

Hurley Stage II (Moderate Disease)

• Prescribe oral clindamycin 300 mg twice daily PLUS rifampicin 300–600 mg once or twice daily for 10–12 weeks, which achieves response rates of 71–93% in systematic reviews. 1, 2
• Add intralesional triamcinolone 10 mg/mL to inflamed nodules for immediate symptom control while antibiotics take effect. 1
• Do NOT use doxycycline or tetracycline monotherapy as first-line for Hurley Stage II with abscesses, as these show only 30% abscess reduction and minimal effect on deep inflammatory lesions. 1

Hurley Stage III (Severe Disease)

• Initiate adalimumab with loading dose of 160 mg subcutaneously at week 0,80 mg at week 2, then 40 mg weekly (not every other week) starting at week 4, achieving HiSCR response rates of 42–59% at week 12. 1, 2
• While awaiting biologic approval or specialist evaluation, bridge with clindamycin 300 mg + rifampicin 300 mg twice daily. 1
• Refer to surgery for radical excision if extensive sinus tracts and scarring are present, as combining adalimumab with surgery yields greater effectiveness than adalimumab alone. 1

Reassessment at 12 Weeks

• Measure pain VAS score, count inflammatory lesions, and assess HiSCR (≥50% reduction in abscess/nodule count without increase in draining fistulas). 1, 2
• Evaluate quality of life using Dermatology Life Quality Index (DLQI). 1
• If no clinical response after 12 weeks of clindamycin-rifampicin, escalate directly to adalimumab. 1
• Consider a treatment break after completing the 10–12 week antibiotic course to assess need for ongoing therapy and limit antimicrobial resistance. 1

Second-Line Biologic Options After Adalimumab Failure

• Prescribe infliximab 5 mg/kg at weeks 0,2,6, then every 2 months, which improved DLQI by 8.4 points after eight weeks in one study. 4, 1
• Consider secukinumab, which demonstrates response rates of 64.5–71.4% in adalimumab-failure patients at 16–52 weeks. 1
• Ustekinumab is an alternative option with conditional strength and moderate quality evidence. 1

Essential Adjunctive Measures for All Stages

• Provide NSAIDs for pain management and symptomatic relief. 1, 2
• Apply appropriate wound dressings to draining lesions to manage exudate. 1, 3
• Refer for smoking cessation immediately, as tobacco use is associated with worse outcomes and treatment failure. 1, 3
• Refer for weight management if BMI is elevated, as substantial weight loss can lead to complete remission. 1, 3

Critical Pitfalls to Avoid

• Do NOT prescribe adalimumab 40 mg every other week for moderate-to-severe HS, as this dosing is ineffective; weekly dosing (40 mg) is required. 1
• Do NOT use topical clindamycin alone for Hurley Stage II disease, as it only reduces superficial pustules, not inflammatory nodules or abscesses. 1
• Do NOT extend antibiotic therapy beyond 12 weeks without formal reassessment, as prolonged use increases antimicrobial resistance without demonstrated additional benefit. 1
• Do NOT use doxycycline or tetracycline as first-line for Hurley Stage II with abscesses, as these have minimal effect on deep inflammatory lesions. 1
• Avoid long-term antibiotic use without treatment breaks to reduce antimicrobial resistance risk. 4, 1