Richard P. Usatine, MD
Professor, University of Texas Health San Antonio
Founding Director, Skin Clinic, University Health System

Case Study:

A 37-year-old woman presents with a number of recurring painful sores in her armpits. She is overweight and smokes one pack per day.

On physical exam, she had inflamed nodules and abscesses in both axillae. The abscesses were just enlarged nodules, and they were not very fluctuant. There were no draining tunnels (sinus tracts), but there was scarring from previous episodes of inflammatory lesions. She did not have any active lesions elsewhere; but on history, she has had a few in the inguinal area, which left some scarring.

What is the diagnosis?

Diagnosis and treatment

The diagnosis is hidradenitis suppurativa, Hurley stage 2. The diagnosis is based on the recurring nodules and abscesses in the axillae and the groin. Stage 2 is defined as more than one lesion or area but with limited tunneling.

What is the treatment?

Initially, it is important to explain the disease to the patient, as this is the first time she has been given this diagnosis. This includes letting her know that this is a chronic disease with no cure, which can be managed with a number of lifestyle changes and medications. This patient has the two most common risk factors, smoking and obesity, so these should be addressed.

The patient is in pain, so it is good to offer her intralesional injections of steroids into the most painful nodules and abscesses. This is usually more effective and less painful than a traditional incision and drainage, unless an abscess is very large and fluctuant. The patient is willing to try to quit smoking and lose weight, and she would like the injections today. Triamcinolone acetonide 10 mg/mL is drawn up to be injected with a 27-gauge needle into the five most painful areas (2.5 mL total, based on an estimate of 0.5 mL per injected site).

The physician prescribed doxycycline 100 mg twice daily for the coming month after determining that the patient did not have an allergy to this antibiotic. A follow-up was set for 1 month to determine the effectiveness of the treatments and to map out additional treatments for the future.

On follow-up, the patient states that the injections worked within 1 day to diminish her pain and swelling and that the oral antibiotic has helped her lesions to become smaller and less active.