Clinical Challenge: Underarm Pain, Swelling, and Drainage - MPR

Clinical Challenge: Underarm Pain, Swelling, and Drainage

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A 28-year-old obese Hispanic female complains of pain, swelling and drainage about her left underarm. The condition has been increasing in severity over the past several days. This is a recurrent problem that intermittently affects her axillae, groin and abdominal folds. Examination reveals erythema and induration of the affected area which on palpation elicits tenderness and expresses pus. Sinus tracks and hyperpigmentation are noted at other sites.

Hidradenitis suppurativa (HS) is a chronic, recurrent inflammatory disorder that affects apocrine gland bearing skin such as that found in the axillae and groin. The condition is characterized by painful purulent abscesses which frequently lead to sinus tracts and variable...

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Hidradenitis suppurativa (HS) is a chronic, recurrent inflammatory disorder that affects apocrine gland bearing skin such as that found in the axillae and groin. The condition is characterized by painful purulent abscesses which frequently lead to sinus tracts and variable degrees of scarring. HS typically arises after puberty and during the second and third decades. The underlying pathogenesis is uncertain although follicular occlusion appears to be the inciting event1. Contributing factors include obesity and cigarette smoking2.  

Treatment of HS is challenging. Recommended lifestyle modifications include the wearing of loose-fitting clothing, weight loss for obese patients, and smoking cessation. Topical and oral antibiotics are considered first line therapies3 and the combination of clindamycin and rifampin is a well-established regimen4. Isotretinoin may induce remission in less severe cases but results overall are disappointing5. Surgical options include incision and drainage, deroofing and marsupialization, full excision, and laser ablation although most are associated with high recurrence rates6,7.

Biologics including adalimumab, infliximab and ustekinumab have demonstrated efficacy as therapy.8 and an in situ study with adalimumab revealed inhibition of inflammatory cytokines in HS skin9. In 2015 the FDA approved adalimumab for the treatment of moderate to severe HS.

References: 

    1. Boer, J. and Weltevreden, E.F. Hidradenitis suppurativa or acne inversa. A clinicopathological study of early lesions. Br J Dermatol. 1996; 135: 721-725

    2. Alikhan, A., Lynch, P.J., and Eisen, D.B. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009; 60: 539-561

    3. Lee, R.A., Yoon, A., and Kist, J. Hidradenitis suppurativa: an update. Adv Dermatol.2007; 23: 289-306

    4. Lamb, R and Desai, N. Clindamycin and rifampicin dosing in hidradenitis suppurativa. J Am Acad Dermatol. 2015; 72: Supplement 1, Page AB42.

    5. Boer, J. and van Gemert, M.J. Long-term results of isotretinoin in the treatment of 68 patients with hidradenitis suppurativa. J Am Acad Dermatol. 1999; 40: 73-76

    6. Mehdizadeh, A, Hazen P.G. et al. Recurrence of hidradenitis suppurativa after surgical management: A systematic review and meta-analysis. J Am Acad Dermatol. 2015; 73:  S70-S77

    7. Hamzavi IH, Griffith JL, et al. Laser and light-based treatment options for hidradenitis suppurativa. J Am Acad Dermatol. 2015 Nov;73(5 Suppl 1):S78-81.

    8. Lee, R.A. and Eisen, D.B. Treatment of hidradenitis suppurativa with biologic medications. J Am Acad Dermatol. 2015; 73: Suppl 1, pp. S82 – S88.

    9. van der Zee HH, Laman JD, de Ruiter L, Dik WA, Prens EP. Adalimumab (antitumour necrosis factor-α) treatment of hidradenitis suppurativa ameliorates skin inflammation: an in situ and ex vivo study. Br J Dermatol. 2012;166(2):298-305

Stephen Schleicher, MD is an associate professor of medicine at the Commonwealth Medical College in Scranton, Pennsylvania, and an adjunct assistant professor of dermatology at the University of Pennsylvania in Philadelphia. He directs the DermDox Center for Dermatology (www.dermdox.org) in Hazleton, Pennsylvania.

No conflicts of interest.