I've had to manage several cases chronically (one of the
disadvantages of being both a primary care physician as well as an EM
guy is that you tend to wind up with the tough long-term cases because
most of the other primary care providers in the community have generally
given up on the people who bounce into your lap in the ED). I've
generally found that incision and drainage may certainly be required
acutely to address an axial abscess that is clearly "pointing." The
problem then is *autoinnoculation* of other apocrine glands in the
I've dressed these wounds (after I&D) with Bactroban (mupirocin
2% topical ointment) despite the fact that I'm reluctant to apply a
petrolatum vehicle to skin that gets saturated with perspiration.
Bactroban requires TID changing, however, and that seems to mitigate
against the development of maceration. Though only indicated for
impetigo, Bactroban is capable of eradicating MRSA (there's a Bactroban
Nasal formulation specifically marketed for wiping out MRSA nasal
colonization in institutional settings) and penicillin-resistant
Streptococcus, and I suspect that it's about your best option for
preventing the spread of infection to neighboring apocrine glands.
The key to further management consists in reducing the
irritation and insult that caused the infections to develop in the first
place. No more depilatories, no more axial shaving, no more perfumed
and irritating deoderant/antiperspirants (I've found that of the widely
available products in the United States, the Almay brand is about the
best to recommend as a replacement; because many of the products are
scent-neutral, they can readily be used by men).
To the best of my knowledge, the definitive surgical attack on
hidradenitis suppurativa is a sort of flensing of the afflicted axilla,
with healing by secondary intention, and I've always skeeved at sending
my patients to be (literally) skinned alive. While my personal
experience may be narrow, I've been uniformly successful in getting
these ladies (all were female) comfortably resolved without more than
occasional further incision and drainage procedures.
The principle reason why we got the job done (and I mean *we*)
was that each patient was willing to learn how to beat this damned
condition, and each was willing to work with me. In each case, we wound
up with some pretty ugly little knots of scar tissue in the afflicted
axilla, but that certainly beat all hell out of the proposed surgical
Necessarily, however, and henceforth, said axilla was a *hairy*
axilla, and to hell with wearing sleeveless dresses. I've never even
*considered* permanent depilation (via electrolysis), for much the same
reason that you don't strike a match in a grain elevator.
You've got to treat the patient as your partner, and *both* of
you have to be persistent. This is definitely a "long-haul" disorder
with no genuine quick fix.
-- Richard Bartucci, D.O.
> From: Lorraine Gari
> Sent: Thursday, August 13, 1998 2:44 PM
> To: Multiple recipients of list PED-EM-L
> Subject: Management of hidadrenitis suppurativa
> Just curious. Would you incise and drain the above yourself or refer
> surgery to do this or manage medically until the surgeons could see
> it? Teen
> came in with this in the middle of the night and the surgeon deferred
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is: