A 32-year-old woman with obesity and a 15 pack-year smoking history presents with a 9-year history of painful, malodorous abscesses in the axillae and inframammary folds. Examination reveals confluent, interconnected sinus tracts, double-ended comedones, thick hypertrophic scarring, and multiple draining abscesses across the entire axillary and inframammary regions, as shown in the diagram marked **A**. She has failed multiple courses of antibiotics and incision-and-drainage procedures. Her DLQI is 27, indicating severe quality-of-life impairment. Which of the following is the most appropriate next step in management for this stage of hidradenitis suppurativa?

Question

Accepted Answer

D. Adalimumab or other anti-TNF biologic therapy with consideration of wide local excision. ## Why Adalimumab or other anti-TNF biologic therapy with consideration of wide local excision is right

The diagram marked **A** depicts Hurley Stage III hidradenitis suppurativa — diffuse, interconnected sinus tracts, scarring, and abscesses across an entire anatomic area. According to Bolognia Dermatology 5e and BAD Guidelines 2019, Stage III disease or moderate-to-severe HS requires systemic biologic therapy as first-line treatment. Adalimumab (TNF-alpha inhibitor) is FDA-approved for HS and addresses the dysregulated TNF-alpha, IL-17, IL-1, and IL-23 axes that drive chronic inflammation. Wide local excision with healing by secondary intention, skin grafting, or flap reconstruction is the most definitive surgical option for established Stage III disease in defined anatomic areas. This patient's failure of antibiotics and drainage, combined with severe quality-of-life impairment (DLQI 27) and diffuse involvement, mandates escalation to biologic therapy and consideration of definitive surgical management.

## Why each distractor is wrong

- **Intralesional triamcinolone and topical clindamycin**: These are appropriate for Hurley Stage I disease (single or multiple isolated abscesses without sinus tracts). This patient has Stage III with diffuse involvement and has already failed conservative measures; topical and intralesional approaches are insufficient.
- **Clindamycin-rifampin combination with hormonal therapy**: This is the standard approach for Hurley Stage II disease (recurrent abscesses with sinus tracts but widely separated lesions). This patient has Stage III with confluent, interconnected involvement across the entire anatomic area, requiring escalation to biologic therapy.
- **Repeat incision and drainage with extended oral tetracycline course**: Repeated drainage without addressing the underlying autoinflammatory pathology has already failed in this patient over 9 years. Tetracyclines are adjunctive for early-stage disease but are inadequate monotherapy for Stage III with severe systemic inflammation.

**High-Yield:** Hurley Stage III HS = diffuse interconnected sinus tracts and abscesses across an entire anatomic area → requires anti-TNF biologic (adalimumab) ± wide local excision; earlier stages use antibiotics and drainage alone.

[cite: Bolognia Dermatology 5e Ch 38; Saunte JAMA 2017; Zouboulis BAD Guidelines 2019]

Answer

A. Intralesional triamcinolone and topical clindamycin

Answer

B. Repeat incision and drainage with extended oral tetracycline course

Answer

C. Clindamycin-rifampin combination with hormonal therapy

Explanation

Why Adalimumab or other anti-TNF biologic therapy with consideration of wide local excision is right

Why each distractor is wrong

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