Related Therapeutic strategies

Herpes simplex virus (HSV) occurs in 2 common locations: orofacial (usually due to HSV-1) and genital (usually due to HSV-2).

Read more

Seborrheic dermatitis can be limited to the scalp, but it also can involve the face and any hairy or intertriginous area and rarely can even progress to a generalized erythroderma.

Read more


Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

The diagnosis of chancroid is usually clinical, although improved culture techniques allow isolation of the causative organism H. ducreyi. The therapeutic strategy is to eliminate the pathogenic microorganism.

Read more

Case Note

Case Note 25: Painful Cysts on the Body


A 21-year-old male presents for management of painful cysts and plaques with purulent drainage in the bilateral axilla and groin-buttock area.

Initial evaluation

  • Obese young male, but otherwise healthy
  • No significant past medical history and takes no medications
  • Presents for management of indurated plaques with scattered nodules, cysts, and sinus tracts with moderate erythema in the bilateral axillae, inguinal folds, buttocks, perianal area, and infra-abdominal pannus
  • Denies gastrointestinal symptoms
  • Image 1
    Image 1

Enter your diagnosis


  • A diagnosis of hidradenitis suppurativa is rendered

Initial Treatment

  • No skin biopsy required
  • Treatment options discussed; patient opts for systemic infliximab
    • Patient to start infliximab at 5 mg/kg dose on Weeks 0, 2, 6, 10, 16, and every 6 weeks thereafter
  • Pre-treatment labs:
    • Complete blood count (CBC) with differential, liver and kidney function tests, hepatitis viral serologies and purified protein derivative (PPD)
    • Test dose of methotrexate 2.5 mg once a week is given with normal follow-up CBC
      • Dose is escalated to 5 mg per week
  • Intralesional triamcinolone 5 mg/cc injection administered to active cysts
  • Follow up in 1 month

Follow-up evaluation strategy

Follow-up evaluation:

  • The skin lesions are much improved
    • Less significant (but still occasional) purulent drainage and no new lesions
  • Infliximab and methotrexate are continued, with complete resolution of symptoms within 3 months
  • Follow up in 3 months

Further recommendations:

  • Encourage obese patients with disease in the intertriginous areas to lose weight
  • Culture draining sinus tracts or abscesses for aerobic and anaerobic bacteria
  • Give full-dose oral antibiotics effective against the isolated organisms for 1 month
    • Tetracycline (500 mg three times daily), amoxicillin (500 mg twice daily), cephalosporins (such as cephalexin 500 mg twice daily), and clindamycin (300 mg twice daily) have all been used with variable results
      • The combination of clindamycin with rifampin (both 300 mg twice daily) may have slightly increased efficacy over use of a single antimicrobial agent alone
  • For mild disease, prescribe topical clindamycin solution to be applied to the affected areas twice daily
    • Combination with a benzoyl peroxide containing gel or wash can help to prevent development of antibiotic-resistant bacterial colonization
  • For severe disease, anti-tumor necrosis factor (TNF) alpha inhibitors can be highly effective and is supported by evidence. However, as was prescribed in this Case Note, infliximab (5-8 mg/kg given Weeks 0, 2, 6, 10, then every 6 to 8 weeks) is superior in its efficacy and should be combined with low-dose methotrexate (5-7.5 mg/week) in order to avoid the production of infliximab neutralizing antibodies
  • Minor surgical procedures:
    • Incise and drain fluctuant abscesses
    • Inject triamcinolone acetonide 5-10 mg/cc into all non-fluctuant inflammatory areas. This may be repeated at intervals of 2-4 weeks
    • Local areas may be totally excised, if small, with good results

Subsequent treatment steps:

  • If patients demonstrates an initial positive response, continue oral antibiotics and taper them slowly over 3-6 months
    • If the disease recurs, reculture and repeat initial management
  • Patients demonstrating an initial positive response may also be offered extensive surgery (as detailed below) due to the persistence of and relapse associated with hidradenitis suppurativa
  • For severe cases of hidradenitis suppurativa, a limited course of systemic corticosteroids (prednisone 0.5-1 mg/kg/day) for 1-2 weeks will significantly reduce inflammation
    • When combined with appropriate antibiotics, corticosteroids may also allow the disease to be controlled
  • Extensive surgical procedures usually offer the only hope for the severely affected
    • For axillary disease, total excision of the affected axillary areas is of only moderate morbidity and gives excellent results. After their recovery, patients are in general quite satisfied with the long-term, usually permanent remission
    • Genitocrural hidradenitis can also be totally excised, but often extensive grafting or prolonged healing is required owing to the large areas of involvement. Despite this, after recovery most patients are satisfied

General discussion

Hidradenitis suppurativa is a chronic inflammatory process that affects skin bearing apocrine glands, typically involving the groin, axillae, and inframammary areas. Areas affected by hidradenitis suppurativa are characteristically marked by heterogeneous skin lesions, ranging from cysts, nodules, sinus tracts, and inflamed abscesses. In rare cases, lesions of pyoderma gangrenosum can occur concurrently within areas of hidradenitis suppurativa or at distant sites.

Women are typically more commonly affected than males and the axilla is the most common site of involvement. A family history of hidradenitis suppurativa is not unusual, and in one small patient cohort, mutations in the gamma secretase complex were identified. Risk factors for disease include obesity, smoking, and Crohn's disease. Additional cutaneous associations include acne, pilonidal cyst, acne conglobata, and dissecting cellulitis of the scalp (also known as the follicular occlusion tetrad). Lesions of hidradenitis suppurativa must be monitored for development of squamous cell carcinoma, which evolve at sites of chronic inflammation (Marjolin's ulcer), and in hidradenitis suppurativa typically occur on the buttocks.

Progression is often relentless and defies medical management. Early surgery for local and widespread lesions is sometimes the best alternative. Hidradenitis suppurativa has a profound impact on patient quality of life. The medical management should be tailored towards the severity and distribution of the disease. Local, mild disease may be managed with topical antibiotics or intralesional corticosteroid injections alone. More severe, extensive disease may require systemic therapy, including short courses of systemic antibiotics and anti-androgen therapy for female patients. Systemic retinoids have not been found to be helpful in this disease. For severe cases of hidradenitis suppurativa, especially with concurrent lesions of pyoderma gangrenosum, systemic immunosuppression with anti-TNF inhibitors may be the best option, though data is limited. To date, the evidence best supports use of antibiotics and TNF-blockade; the use of anti-androgens is only recommended for women with mild to moderate hidradenitis suppurativa who have previously failed antibiotics or have evidence of hyperandrogenism.

Further reading

Jemec G. Clinical practice: Hidradenitis suppurativa. N Engl J Med 2012;366:158-64.

Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review (CME). JAAD 2009;60:539-61.

Machet M,et al.Systemic review of the efficacy and adverse events associated with infliximab treatment of hidradenitis suppurativa in patients with coexistent inflammatory diseases. JAAD 2013;69:649-50.

Alhusayen R, Shear NJ. Pharmacologic intervention for hidradenitis suppurativa: what does the evidence say? Amer J Clin Derm 2012;13:283-91.


Disclaimer: The material above has been adapted from Therapeutic Strategies prepared by It has not been reviewed by the DermQuest Editorial Board for its accuracy or reliability. Reference to any products, service, or other information does not constitute or imply endorsement, sponsorship, or recommendation by members of the Editorial Board.