A patient presents with tender, draining sinuses and abscesses in the axillae and groin bilaterally, with ropelike scarring from prior episodes. He has smoked for 15 years. Hurley stage III is assigned. What is the mechanism underlying this condition and the best treatment for Hurley stage III?

• A Staphylococcal superinfection of sweat glands — treat with prolonged antibiotics
• B Follicular occlusion with secondary rupture and sinus tract formation — adalimumab for moderate-severe, surgical wide excision for Hurley III ✓
• C Autoimmune destruction of apocrine glands — treat with methotrexate
• D Sebaceous gland hyperplasia — treat with isotretinoin alone

Explanation

Hidradenitis suppurativa (HS) is a chronic inflammatory follicular disease, not a primary sweat gland infection. The pathogenesis involves follicular hyperkeratosis and occlusion, follicular rupture, secondary inflammation and infection, sinus tract formation, and scarring — apocrine glands are secondarily involved. Hurley stage III is the most severe: widespread, interconnected sinus tracts and abscesses with diffuse scarring, requiring wide surgical excision as definitive treatment. Adalimumab (anti-TNF biologic) is the only FDA-approved systemic therapy for moderate-severe HS (Hurley II–III) when medical therapy fails.

Reference: Neena Khanna Illustrated Synopsis of Dermatology & STD, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.