Hidradenitis Suppurativa in Emergency Medicine Medication

Tetracycline and erythromycin may be helpful on a long-term basis, and cephalosporins often will help in acute cellulitis. On a short-term basis in the emergency department, dicloxacillin is considered a good choice. However, consideration must be given to using a sulfonamide or clindamycin antibiotic because of the growing presence of methicillin-resistant Staphylococcus aureus (MRSA) for both short-term and long-term treatment. A 2012 clinical practice article from the New England Journal of Medicine recommended using both clindamycin 300 mg twice daily along with rifampin 300 mg twice daily.^[6] Topical products, such as benzoyl peroxide, may be helpful. Topical and intralesional injections of corticosteroids are sometimes helpful.

Topical clindamycin cream has also been used with some success. Retin-A has rarely been found to be helpful in some patients. Systemic retinoids (Accutane) can reduce the severity of attacks in some patients but is not a reliable cure for hidradenitis suppurativa. Accutane cannot be prescribed in the emergency department due to requirements set forth by the pharmaceutical company. Hormonal manipulation (eg, certain oral contraceptives) has been useful for some patients but is unlikely to be prescribed from the emergency department.

Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting. In recurrent disease, antibiotics may be administered for 2 or more months.

Tetracycline (Sumycin)

Treats susceptible bacterial infections of both gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections.

Minocycline (Minocin, Dynacin)

For the treatment of infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Rickettsia, Chlamydia, and Mycoplasma.

Dicloxacillin (Dynapen, Dycill)

Binds to one or more penicillin-binding proteins, which, in turn, inhibit synthesis of bacterial cell walls. For treatment of infections caused by penicillinase-producing staphylococci. May use to initiate therapy when staphylococcal infection is suspected.

Resistance to this drug results from alterations in penicillin-binding proteins.

Trimethoprim/sulfamethoxazole (Bactrim DS, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Erythromycin (E-Mycin, Ery-Tab, E.E.S.)

Recommended dosing schedule of erythromycin may result in GI upset, causing one to prescribe an alternative macrolide or change to tid dosing. Covers most potential etiologic agents, including Mycoplasma species.

Erythromycin is less active against H influenzae. Although 10 d seems to be a standard course of treatment, treating until the patient has been afebrile for 3-5 d seems a more rational approach. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.

Has the added advantage of being a good anti-inflammatory agent by inhibiting migration of polymorphonuclear leukocytes.

Clindamycin (Cleocin)

Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by liver and kidneys.

Used for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci).

Rifampin (Rifadin, Rimactane)

Rifampin inhibits RNA synthesis in bacteria by binding to the beta subunit of DNA-dependent RNA polymerase, which, in turn, blocks RNA transcription.

Class Summary

These agents inhibit sebaceous gland function and keratinization.

Isotretinoin (Accutane)

Decreases sebaceous gland size and sebum production; may also inhibit sebaceous gland differentiation and abnormal keratinization.

Class Summary

These agents modify the body's immune response to a variety of stimuli. Intralesional injections have been used in addition to the cream.

Triamcinolone topical (Aristocort)

Treats inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.