A 40-Year-Old Man With Painful, Rupturing Lesions

Elizabeth K. Satter, MD, MPH


July 27, 2021

Treatment of hidradenitis suppurativa is often challenging. Despite the introduction of new therapeutic options, large clinical trials are few. Early diagnosis and treatment is essential because more effective control can be achieved in early disease, with the goal of treatment being to reduce disease burden; prevent development of new lesions; and avoid, or at least limit, scarring. Unfortunately, patients typically do not seek medical attention when they have early limited disease or are misdiagnosed with suppurative folliculitis, carbuncles, or inflamed epidermal or pilonidal cysts and treated with incision and drainage.

Several comprehensive reviews have evaluated different treatment options based on clinical stage; however, no treatment gained US Food and Drug Administration (FDA) approval for hidradenitis suppurativa until May 2015, when the FDA granted adalimumab orphan status for treatment of patients with Hurley stage II or III disease.[11,12] First-line medical therapy for patients with Hurley stage I or II disease should include topical antimicrobials (eg, benzoyl peroxide washes, bleach baths, bleach soaks) and clindamycin lotion, along with short courses of oral doxycycline, minocycline, or the combination of clindamycin and rifampin for acute flares. Dapsone has also been used; however, studies are limited and have shown variable results.[11,12] Antibiotics are believed to be beneficial, not just for their bactericidal properties but also their anti-inflammatory and immunomodulatory effects. However, similar to acne treatment, long-term antibiotic therapy is not recommended owing to development of bacterial resistance.

Although hidradenitis suppurativa resembles nodular acne, oral retinoids have had limited success. Antiandrogen therapy may be beneficial for females with hidradenitis suppurativa, especially those who experience flares of their symptoms with menstruation.[11,12] Methotrexate, metformin, and various biologic agents (adalimumab, anakinra, etanercept, infliximab, and ustekinumab) are typically reserved for patients in whom other approaches have been tried and failed.[11,12,13]

Surgical options depend on the stage of disease. Incision and drainage is not recommended because recurrence is almost universal. For limited stage I and II disease, a "deroofing" procedure with curettage of the base is a good treatment option and is associated with a lower likelihood of recurrence.[14] For patients with Hurley stage III or refractory hidradenitis suppurativa, surgery is the best option. Patients with more extensive disease require wide excision, followed by split-thickness skin grafts or local fasciocutaneous flaps; the latter often provide better functional results.[15] Lasers designed to help with hair reduction have also been used with some success.

In conclusion, hidradenitis suppurativa remains a challenging, chronic debilitating condition; therefore, patient education and support groups are essential. Treatment often consists of a combination of lifestyle modifications (eg, weight loss, avoidance of tight-fitting clothes and skin trauma, keeping skin cool, warm compresses), topical therapies, laser hair reduction, systemic agents, or surgery.

The patient in this case was classified as having Hurley stage III hidradenitis suppurativa. Because he experienced recurrence and contractures, after local excision and grafting, he was referred for wide excision followed by closure of the defect with a local fasciocutaneous advancement flap.


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