A Recalcitrant Case of Hidradenitis Suppurativa: Successful Combination of Biologic, Antibiotic, and Surgical Therapy.

Introduction: Hidradenitis suppurativa (HS), or acne inversa, is a chronic inflammatory skin disease that leads to painful nodules, abscesses, and fistulas.

Case presentation: This case describes the treatment of a 49-year-old male patient with progressive and massively inflamed HS for 20 years who also suffered from heart failure (NYHA II-III, EF 35-40%) and hypochromic microcytic anaemia (Hb 7.8 g/dL). Upon presentation, he was suffering from fatigue and severe pain (8-9/10, NRS). Due to prolonged immobility, knee and hip joint contractures with extension deficits were present. At the initial presentation, communicating, and purulent sinus tracts were observed bilaterally from the gluteal to femoral region and perianal area. Hurley score III, HS-PGA score: very severe, Dermatology Life Quality Index (DLQI) score: 19, ISH4 score: severe (16). Under adalimumab s.c. 40 mg/week combined with clindamycin (300 mg bd), the condition had worsened. The patient was admitted to the hospital for i.v. administration of ertapenem 1 g/day for 14 days in preparation for sinus tract resection. With an Hb level of 7.8 g/dL, the patient received iron carboxymaltose and erythropoietin. After a significant reduction in inflammatory markers (leukocytes 17.11/nL to 7.42/nL), a large excision of the sinus tracts was performed bilaterally in the gluteal region and left femoral area. Following 4 weeks of wound granulation, split-thickness skin grafting was performed. The knee and hip joint contractures improved with intensive physiotherapy. After surgery, the patient received antibiotic therapy with clindamycin, rifampicin, and metronidazole (clindamycin 600 mg, rifampicin 300 mg, metronidazole 500 mg, each p.o. 2×/day). In parallel, anti-inflammatory therapy with secukinumab 300 mg s.c. twice a month was initiated. Over the following 3 months, no progression or recurrence occurred. Quality of life and pain levels improved significantly under the therapy (DLQI from 19 to 10, pain from 8 to 9 to 3/10 NRS).

Conclusion: In extensive cases of HS, a combination of surgical and conservative therapy is necessary. We demonstrate that severe cases can be successfully treated with a combination of antibiotic, anti-inflammatory, and surgical therapy.