A 36-year-old man comes to the office due to pain and drainage under his right arm for the past week. For the past 5 years, the patient has had similar symptoms in both axillae. He initially had painful nodules that regressed spontaneously within 1-2 weeks. However, the lesions eventually progressed to thickened scars and openings that intermittently drained malodorous, seropurulent material. Medical history is unremarkable, and the patient takes no medications. Vital signs are normal. BMI is 36 kg/m². Examination is shown in the exhibit. There is no fluctuance or lymphadenopathy to palpation. Which of the following is the most appropriate next step in management of this patient?

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11ec25c8_d8b3_5189_bc81_7f1831157507_MD0003_00 This patient has hidradenitis suppurativa (HS), a chronic occlusion folliculitis involving folliculopilosebaceous units. Mechanical friction in intertriginous areas and other factors (eg, relative androgen excess, nicotine) are thought to induce inflammation, leading to the formation of painful, inflamed nodules, subcutaneous abscesses, and scarring. Sinus tracts may form, intermittently draining seropurulent material, as in this patient. Risk factors include smoking, obesity, and type 2 diabetes mellitus. folliculopilosebaceous units The diagnosis of HS is based primarily on the typical location, appearance, and recurring course. Initial lesions are typically sterile but may later become colonized or infected with a broad range of bacteria; antibiotics are the preferred therapy for reducing the bacterial load and providing additional anti-inflammatory effects. Prolonged treatment with topical (eg, clindamycin) or oral (eg, tetracycline) antibiotics is often required. Severe or refractory disease may require tumor necrosis factor-alpha inhibitors (eg, adalimumab), oral retinoids (eg, acitretin), or wide local excision. Additional measures include weight loss and smoking cessation; loose-fitting clothing is advised to reduce friction and occlusion. (Choice A) Antifungal therapy is used to treat candida intertrigo, which manifests in intertriginous areas (eg, axilla, inframammary area) as bright red patches or plaques with satellite macules or papules. Painful nodules and sinus tracts with drainage are not consistent with this diagnosis. candida intertrigo (Choice B) Fine-needle aspiration is used to quickly sample a mass for malignant cells (ie, cytopathology). HS is a clinical diagnosis, and tissue sampling is not needed. In addition, this patient's bilateral symptoms and relapsing/recurring course make malignancy less likely. (Choice D) Wide excision is used to treat severe HS that has failed medical management. However, the procedure carries significant risks, including long recovery times and permanent disfigurement. Educational objective: Hidradenitis suppurativa is a chronic, relapsing condition characterized by inflamed nodules, subcutaneous abscesses, scarring, and sinus tract formation in intertriginous areas. Treatment includes a prolonged course of topical or systemic antibiotics. References: Hidradenitis suppurativa: rapid evidence review. (http://www.ncbi.nlm.nih.gov/pubmed/31674740)

A 36-Year-Old Man Comes to the Office Due to Pain