Left Axillary Pain and Malaise in a 29-Year-Old Woman

Jennifer Gregory, MD

Case Report

A 29-year-old African American female with a history of axillary hidradenitis suppurativa (HS) on oral clindamycin and doxycycline suppressive therapy presented to a forward deployed clinic in an austere, hot, and humid environment for increasing pain in her left axilla. She was diagnosed with a left axillary abscess and treated with incision and drainage. Five days later, she returned to the clinic with worsening left axillary pain and general malaise. Physical examination revealed temperature of 103.2˚ F, heart rate of 144 beats/min, blood pressure of 118/78 mmHg, and respiratory rate of 14 breaths/min. Laboratory testing revealed a white blood cell count of 22.4 x103 cells/µL with 95.7% granulocytes. Complete physical exam and review of systems was negative for any other source of infection. Diagnosed with sepsis due to left axillary soft tissue infection, she was admitted to the intensive care unit and treated with intravenous fluid resuscitation and intravenous clindamycin. Repeat incision and drainage of the left axillary abscess produced purulent material, and the wound was subsequently packed.

Due to persistently elevated heart rate and temperature, intravenous antibiotic treatment was changed to vancomycin and ampicillin/sulbactam. No further abscess was appreciated on surgical exploration with wide excision. She was stabilized and medically evacuated to a higher level of intensive care at a regional medical center. While admitted, she received intravenous linezolid, underwent a delayed flap closure of her left axillary wound, and was discharged on oral cefuroxime. Wound cultures grew pan-sensitive Staphylococcus aureus and Escherichia coli.

Discussion

HS is a chronic inflammatory condition characterized by painful, deep-seated nodules, abscesses, and sinus tracts. Clinical diagnosis is made upon the presence of typical lesions in intertriginous regions with apocrine glands (i.e., axillary, inframammary, inguinal, gluteal, and perineal). Though previously thought to be caused by dysfunctional apocrine glands, HS is now included in the follicular occlusion tetrad, which includes acne conglobata, dissecting cellulitis of the scalp, and pilonidal cysts. Follicular infundibular occlusion is likely the inciting event, followed by follicular rupture and local inflammatory changes.1 However, the exact pathogenesis remains uncertain.

HS is more common than previously considered; a French community study revealed a point prevalence at 1 year of 1%.2 Patients often develop HS during their 20’s, and women are more commonly affected than men, with a 3:1 ratio.3,4 Men tend to have more severe disease with lesions in the gluteal, perianal and atypical regions, while women more often have lesions in the inguinal, axillary and mammary regions.4 A chronic, recurrent disease often accompanied by malodorous, painful and disfiguring lesions, HS has a significant negative impact on patients’ quality of life.5

Recent studies have sought to identify disease associations, factors portending increased severity, and prognostic indicators. HS severity has been directly correlated with smoking and obesity.2 Factors related to greater severity include obesity, smoking pack-years, male gender, disease duration, and lesions in the axillary, perianal, and mammary regions.4,6 Patients who smoke are less likely to respond to first-line therapy.7 Furthermore, obese patients had a higher rate of recurrence after CO2 laser excision treatment.8

Medical Management

In the absence of formal HS management guidelines, treatment methods have been based primarily on anecdotal clinical experience. However, recent clinical studies have sought to establish evidence-based medical and surgical treatments. Optimal HS management consists of a multidisciplinary approach based on clinical severity, often categorized by Hurley stage (Table).

Hurley stage I (mild) disease is best treated with daily topical clindamycin therapy.9 Acutely inflamed nodules or abscesses respond well to intralesional triamcinolone (10 mg/ml).10 Patient education is vital early in the disease course, as lifestyle modifications may prevent disease progression. These include smoking cessation, weight loss, and reduction of friction and moisture.

In addition to intralesional triamcinolone for acute lesions and lifestyle modifications, oral antibiotics are the mainstay of treatment for stage II (moderate) HS disease. This typically entails three to six month courses of daily doxycycline, clindamycin, or a combination of clindamycin and rifampin.9,11,12 Antibiotics are effective against HS most likely due to both antibacterial and anti-inflammatory properties. While HS is not inherently an infectious disease, lesions are often colonized with bacteria. Unfortunately, most patients experience recurrence following completion of an antibiotic course. Randomized controlled trials to guide antibiotic selection, dosing, and duration are lacking. Due to the recurrent nature of HS, repeat bouts of systemic antibiotics raise concern for resistance development, as demonstrated by a study of antimicrobial resistance in HS lesions.13 Along with oral antibiotics, select patients may benefit from hormonal therapy in the form of combined oral contraceptive pills for women and finasteride for men and postmenopausal women.1,3

Stage III (severe) HS disease often requires systemic immunosuppressant therapy. Historically, this has been achieved with prednisone or cyclosporine. However, adalimumab, a TNF-α inhibitor, was recently FDA-approved for moderate to severe HS treatment. In two phase-3 trials, a course of adalimumab 40mg weekly for twelve weeks resulted in clinically significant improvement compared to placebo.14 Clinical response was defined as a 50% decrease or more from baseline of the total abscess and inflammatory nodule count without increase in abscess or draining fistula counts, either with or without antibiotic treatment.

Surgical Management

Surgical management is not recommended as first-line treatment for stage I HS, as these lesions often respond well to local therapy. However, stages II and III disease usually require a combined medical and surgical approach. Incision and drainage is not recommended, due to the subsequent high recurrence rate.15 While an acute nodule may appear to be an infected abscess, incision and drainage generally does not produce much, if any, purulent material.

The goal in surgical management is removal of the dysfunctional skin and its follicular units in order to limit disease progression and prevent recurrence. Multiple methods exist based on the extent of disease. Deroofing is a minimally-invasive, tissue-saving surgical technique in which the overlying skin of an abscess, cyst, or sinus tract is electro-surgically removed.16 This is an outpatient procedure recommended for mild to moderate lesions. CO2 laser excision is another minimally-invasive procedure effective for recurrent fibrotic HS lesions or sinus tracts.8 Therapy with the neodymium-doped yttrium aluminium garnet (Nd:YAG) laser has been demonstrated to decrease HS lesion counts, possibly owing to hair epilation and follicular de-occlusion effects.17

A large retrospective study of 590 patients concluded that surgical excision and unroofing procedures were effective treatments for advanced disease with good long-term control.18 Local excisions may be closed primarily or secondarily. Wide excisions closed by skin flaps or grafts result in decreased recurrence compared to minimally-invasive techniques.19 However, the benefits must be weighed against the risks of delayed wound healing, infection, pain, and decreased mobility of the affected intertriginous regions.

Patient Outcome

The patient was transferred back to the United States for continued medical care. One month after discharge, Dermatology evaluation revealed scarred sinus tracts in bilateral axillae without active inflammation or infection. Her current treatment regimen consists of daily oral doxycycline, benzoyl peroxide, and silver sulfadiazine as needed on active lesions. Future treatment considerations include laser hair removal and adalimumab. 

This case emphasizes the importance of recognizing characteristic HS lesions and combined medical and surgical management in moderate to severe cases. Additionally, incision and drainage is not recommended for HS treatment in the absence of a secondarily infected abscess. This patient’s initial presentation of left axillary nodule recurrence was possibly an acute HS flare, which would likely have responded well to intralesional triamcinolone. The initial incision and drainage may have placed the patient at increased risk for secondary skin infection and subsequent sepsis. 

This case also highlights the need for education and review of HS diagnosis and treatment recommendations for primary care providers, who are most likely to treat HS patients acutely. Early diagnosis is essential to administering appropriate therapy and avoiding risks of unnecessary procedures. Providers must emphasize lifestyle management at all stages of severity, specifically addressing smoking cessation and weight loss for overweight patients. Future randomized clinical trials are needed to clarify effective antibiotic regimens, compare systemic antibiotic therapy to immunosuppressants or biologics, and compare surgical techniques with various wound healing methods.

Jennifer F. Gregory, MD, is a Naval Flight Surgeon at Carrier Air Wing THREE in NAS Oceana, Virginia.

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