A 29-year-old man comes to the physician with nodules under his arm. He reports a 6-month history of slowly enlarging nodules in his right axilla associated with mild discomfort. He has a history of chronic obesity but is otherwise healthy. The patient has a 10-pack-year smoking history and does not drink alcohol. Skin examination shows swollen, nodular lesions in his right axilla with moderate scarring and mild tenderness to palpation. He has no other significant skin lesions. Which of the following is the best next step in management of this patient?

Question

A 29-year-old man comes to the physician with nodules under his arm.  He reports a 6-month history of slowly enlarging nodules in his right axilla associated with mild discomfort.  He has a history of chronic obesity but is otherwise healthy.  The patient has a 10-pack-year smoking history and does not drink alcohol.  Skin examination shows swollen, nodular lesions in his right axilla with moderate scarring and mild tenderness to palpation.  He has no other significant skin lesions.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be77_ded7_8f63_9fdc3b740cdd_MD0005_00 This patient's presentation is consistent with hidradenitis suppurativa (HS) (also known as acne inversa), a chronic inflammatory disorder characterized by occlusion of skin follicles. It is most commonly seen in intertriginous skin areas (eg, axillary, inguinal, genital, perianal, perineal), but can occur in any part of the skin that contains hair follicles. Risk factors for HS include family history of HS, smoking, obesity, and mechanical stress on the skin (eg, friction, patient manipulation). Patients typically develop an initial solitary and painful inflamed nodule in an intertriginous area that can last for several days to months before progressing to an abscess with purulent or serosanguineous drainage. The nodules and pain typically improve after drainage. Multiple recurrent nodules can lead to sinus tracts, comedones, and significant scarring. General measures for all patients include weight loss, smoking cessation, and daily skin cleansing of the affected area. Mild disease (Hurley stage I) typically responds to topical clindamycin, but some patients may require intralesional steroids or oral antibiotics during flare-ups. Moderate disease (Hurley stage II) presents with inflammatory nodules, sinus tracts, and scarring (as seen in this patient). These patients require oral antibiotics (tetracyclines preferred) for several weeks to reduce inflammation and improve the infection. Severe and refractory disease (Hurley stage III) usually requires medical therapy with biologic TNF-alpha inhibitors (eg, infliximab) and/or oral retinoids (eg, acitretin) and occasionally surgical excision (Choice C). (Choice A) Incision and drainage of nodules in HS may provide pain relief for very painful abscesses. However, incision and drainage provides only short-term relief and is generally avoided as it does not prevent recurrent lesions. (Choice D) Topical nystatin powder is a treatment option for intertrigo, which typically presents as well-defined erythematous plaques with satellite vesicles or pustules in intertriginous and occluded skin areas (eg, axilla, groin, skin folds). intertrigo (Choice E) Warm compresses may be effective for mild skin inflammation (eg, superficial thrombophlebitis) or small boils, but they do not effectively treat HS. Educational objective: Hidradenitis suppurativa (acne inversa) is an inflammatory disorder of the skin most commonly involving the intertriginous areas (eg, axillae, groin, medial thigh, perineal area). Mild cases can be managed with topical antibiotics (eg, clindamycin). Moderate cases with sinus tracts and scar formation require oral antibiotics (tetracyclines preferred). More severe cases with diffuse involvement and extensive sinus tract formation may require biologic TNF-alpha inhibitors (eg, infliximab) and wide surgical excision. References: Hidradenitis suppurativa: A practical review of possible medical treatments based on over 350 hidradenitis patients. (http://www.ncbi.nlm.nih.gov/pubmed/24021361)

A 29-Year-Old Man Comes to the Physician with Nodules Under