How should I manage a draining, splitting, and bleeding intergluteal sinus in a hidradenitis suppurativa patient on weekly adalimumab (Simlandi) who is currently using normal saline irrigation, clindamycin 1% topical, vaseline and wound patch, with collagen and extra vaseline ineffective?

Management of Refractory Intergluteal HS Lesion on Adalimumab

Your current wound care regimen is inadequate for this draining, splitting intergluteal sinus tract; you need to escalate to combination systemic therapy with clindamycin 300 mg plus rifampicin 300–600 mg twice daily for 10–12 weeks while continuing adalimumab, and consider intralesional triamcinolone 10 mg/mL injection directly into the lesion for rapid symptom control. 1

Immediate Pharmacologic Escalation

• Add oral clindamycin 300 mg twice daily PLUS rifampicin 300–600 mg twice daily for 10–12 weeks while maintaining your weekly adalimumab (Simlandi). This combination achieves response rates of 71–93% in moderate-to-severe HS and can be safely administered alongside biologic therapy. 1, 2

• Inject intralesional triamcinolone 10 mg/mL (0.2–2.0 mL) directly into the draining, inflamed intergluteal lesion to achieve rapid symptom relief within 24 hours, with significant reductions in erythema, edema, suppuration, and pain. 1

• The 2025 North American guidelines explicitly endorse concurrent clindamycin-rifampicin with adalimumab as standard therapy for patients with moderate HS who have persistent active lesions despite biologic treatment. 1

Wound Care Optimization

• Replace your current vaseline-based dressing with absorptive foam dressings or hydrofiber dressings (Aquacel) for this draining intergluteal sinus. Simple foam dressings are appropriate for most HS wounds, while advanced hydrofiber or silver alginate dressings improve patient satisfaction in complex draining lesions. 3

• Continue normal saline irrigation but discontinue collagen application, as a 200-patient RCT found no difference in recurrence rates at three months between gentamicin-collagen sponge and standard wound care (RR 0.96,95% CI 0.68–1.34). 3

• Discontinue topical clindamycin 1% to this specific lesion, as it only reduces superficial pustules and has minimal effect on deep inflammatory lesions, sinus tracts, or draining fistulas. 1

Adalimumab Dose Optimization

• Consider increasing adalimumab to 80 mg weekly if no improvement occurs after 12 weeks of combination antibiotic therapy. A 2025 retrospective series demonstrated that 43.8% of patients who escalated to 80 mg weekly achieved clinical improvement versus 33.3% who remained at 40 mg weekly, with significantly higher serum adalimumab concentrations (P < 0.001). 4

• Higher serum adalimumab concentration is associated with lower disease activity (P = 0.043), and normal-weight patients achieve significantly higher concentrations than overweight patients (P = 0.011). 4

• Standard-dose adalimumab 40 mg every other week is ineffective for moderate-to-severe HS; weekly dosing (40 mg) is required. 3, 1

Reassessment Timeline

• Evaluate treatment response at 12 weeks using pain VAS score, inflammatory lesion count, and HiSCR (≥50% reduction in abscess/nodule count without increase in abscesses or draining fistulas). 1

• If no clinical response after 12 weeks of clindamycin-rifampicin combination, escalate adalimumab to 80 mg weekly or consider second-line biologics (infliximab 5 mg/kg at weeks 0,2,6, then every 2 months; secukinumab; or ustekinumab). 1

Surgical Consideration for This Specific Lesion

• Refer for surgical deroofing or limited excision of the intergluteal sinus tract if medical therapy fails after 12 weeks. Deroofing is specifically recommended for recurrent nodules and sinus-tract tunnels, and combining adalimumab with surgery produces greater clinical effectiveness than adalimumab monotherapy. 1

• Wide excision with secondary intention healing achieves non-recurrence rates of 81.25% for extensive disease, but deroofing is more appropriate for this isolated intergluteal lesion. 1

Critical Pitfalls to Avoid

• Do not continue topical clindamycin alone for this Hurley Stage II lesion with sinus tract, as it is ineffective for deep inflammatory lesions. 1

• Do not extend antibiotic therapy beyond 12 weeks without formal reassessment, as prolonged use increases antimicrobial resistance without proven additional benefit. 1

• Do not use collagen-based products, as RCT evidence shows no benefit over standard wound care for HS surgical wounds. 3

• Do not assume adalimumab failure until you have optimized the dose to 80 mg weekly and added combination antibiotics, as 40% of initial non-responders achieve response with continued treatment. 5