Please write a SOAP note for a 28-year-old obese (BMI ≈ 32 kg/m²) patient with moderate-to-severe hidradenitis suppurativa (Hurley stage II) involving the bilateral axillae and left inguinal region, who has a 10‑year history of smoking (1 pack/day) and prior intermittent courses of oral antibiotics with limited benefit.

SOAP Note for Hidradenitis Suppurativa (Hurley Stage II)

Subjective

Chief Complaint:

• 28-year-old patient presenting with painful, recurrent nodules and abscesses in bilateral axillae and left inguinal region 1

History of Present Illness:

• 10-year history of recurrent inflammatory nodules, abscesses, and draining lesions in flexural areas 1
• Prior intermittent courses of oral antibiotics with limited benefit 1
• Document frequency of flares in the last month 1
• Assess pain severity using Visual Analogue Scale (VAS) 1
• Evaluate impact on quality of life using Dermatology Life Quality Index (DLQI) 1

Risk Factors:

• Current smoker: 1 pack per day for 10 years 1
• Obesity: BMI approximately 32 kg/m² 1

Review of Systems:

• Screen for depression and anxiety symptoms 1
• Assess for gastrointestinal symptoms (inflammatory bowel disease screening) 1
• Evaluate for joint pain or stiffness (spondyloarthritis) 1
• Inquire about sexual dysfunction 1

Objective

Physical Examination:

• Hurley Stage: Document as Stage II (moderate) for worst-affected regions 1
• Lesion Count: Document number of inflammatory nodules and abscesses 1
• Distribution: Bilateral axillae and left inguinal region 1
• Lesion Characteristics: Presence of inflamed nodules, open comedones, sinus tracts, and bridging scars 1

Vital Signs:

• Blood pressure measurement (screen for hypertension) 1
• BMI: 32 kg/m² 2

Laboratory/Screening:

• Lipid panel (dyslipidemia screening) 1
• HbA1c (diabetes screening) 1
• Depression/anxiety screening tools 1

Assessment

Primary Diagnosis:

• Hidradenitis Suppurativa, Hurley Stage II (moderate-to-severe) involving bilateral axillae and left inguinal region 1

Contributing Factors:

• Active tobacco use (1 pack/day) - associated with disease severity 1, 2
• Obesity (BMI 32 kg/m²) - associated with progression to Hurley Stage III 2
• Male sex - associated with more severe disease 2
• Prior antibiotic failure indicating need for escalation 1

Comorbidity Risk:

• High risk for cardiovascular disease, metabolic syndrome, depression, and anxiety 1

Plan

Immediate Medical Management

Since this patient has failed oral tetracyclines and has moderate-to-severe (Hurley Stage II) disease, escalate directly to combination antibiotic therapy:

1. Clindamycin 300 mg PO twice daily + Rifampicin 300 mg PO twice daily for 10-12 weeks 1

   • This is the appropriate next step after tetracycline failure 1
   • Consider treatment break after 10-12 weeks to assess need for ongoing therapy and limit antimicrobial resistance 1

2. Topical Clindamycin 1% solution/gel twice daily to affected skin regions 1

   • Continue as adjunctive therapy 1

If No Response to Clindamycin/Rifampicin at 12 Weeks:

Initiate Adalimumab (first-line biologic):

• Loading dose: 160 mg subcutaneously at week 0 1
• Second dose: 80 mg subcutaneously at week 2 1
• Maintenance: 40 mg subcutaneously weekly 1
• This is the only FDA-approved biologic for HS with Level Ib evidence 1
• Continue as long as HS lesions are present if improvement occurs 1

Alternative Options if Adalimumab Fails:

• Consider Infliximab 5 mg/kg IV every 8 weeks 1
• Consider Acitretin 0.3-0.5 mg/kg/day (male patient, appropriate candidate) 1
• Consider Dapsone 1

Adjunctive Management (Critical Components)

1. Pain Management:

   • NSAIDs as needed 1
   • Measure pain using VAS at each visit 1

2. Wound Care:

   • Provide appropriate dressings for pus-producing lesions 1

3. Smoking Cessation (ESSENTIAL):

   • Immediate referral to smoking cessation services 1
   • Smoking is associated with disease severity, particularly in mild-to-moderate cases 2

4. Weight Management (ESSENTIAL):

   • Immediate referral to weight management services 1
   • Elevated BMI is strongly associated with progression to Hurley Stage III 2

Comorbidity Screening and Management

Screen for the following at baseline and monitor:

• Depression and anxiety (use validated screening tools) 1
• Cardiovascular risk factors: hypertension, diabetes, dyslipidemia 1
• Inflammatory bowel disease (if GI symptoms present) 1
• Spondyloarthritis (if joint symptoms) 1
• Sexual dysfunction 1

Monitoring and Follow-Up

1. Assess response at 12 weeks:

   • Pain VAS 1
   • Quality of life (DLQI) 1
   • Lesion count 1
   • Number of flares in the last month 1

2. For patients on adalimumab:

   • Use HiSCR (Hidradenitis Suppurativa Clinical Response) as primary endpoint 1
   • Monitor inflammatory lesion count 1

3. Long-term monitoring:

   • Screen for cutaneous squamous cell carcinoma in long-standing disease 1
   • Monitor for fistulating gastrointestinal disease 1
   • Screen for genital lymphoedema 1
   • Monitor for anemia 1

Surgical Consultation

Consider referral to HS surgical multidisciplinary team if:

• Lack of response to medical therapy (including biologics) 1
• Presence of extensive scarring or sinus tracts 1
• Anatomical or functional impairment 1
• Surgical excision with healing by secondary intention or TDAP flap may be curative in refractory cases 1, 3

Patient Education

• Provide patient information leaflet (www.bad.org.uk/leaflets) 1
• Counsel on chronic nature of disease and need for long-term management 1
• Discuss importance of smoking cessation and weight loss as disease modifiers 1, 2
• Educate on proper wound care and hygiene 1

Critical Pitfalls to Avoid

• Do not continue ineffective oral tetracyclines - this patient has already failed them 1
• Do not delay smoking cessation and weight loss interventions - these directly impact disease severity 1, 2
• Do not miss comorbidity screening - HS is associated with significant systemic disease burden 1
• Do not use monotherapy with clindamycin or rifampicin alone - combination therapy is required 1
• Do not delay biologic therapy if combination antibiotics fail - adalimumab has the strongest evidence base 1