Recurrent Neck Boils in Young Male - Diagnostic Challenge

Case at a Glance

A 29-year-old male presents with a 3-week history of recurrent, painful boils on the neck that drain spontaneously and recur in nearby locations despite antibiotic treatment.

Patient's Story

The patient reports cyclical formation of painful lesions on his neck over the past three weeks. Each lesion follows a predictable pattern: beginning as erythematous areas that become progressively swollen and painful, eventually developing purulent centers that drain either spontaneously or with minimal manipulation. After drainage, the affected areas become indurated for several days before resolving, only to have new lesions appear in adjacent locations. The patient denies fever, systemic symptoms, or similar lesions in household contacts. He has no known diabetes, immunocompromising conditions, or other chronic medical conditions.

Initial Assessment

Physical examination revealed multiple stages of follicular lesions on the neck area - some in early inflammatory stages, others with purulent heads, and several in post-drainage healing phases with induration. The patient appeared systemically well with normal vital signs. No lymphadenopathy was noted.

The Diagnostic Journey

Initial treatment was initiated for presumed bacterial folliculitis with topical fusidic acid cream twice daily, oral ampicillin-cloxacillin combination 500mg three times daily, and antiseptic borax solution for local cleansing. Despite three weeks of appropriate antibiotic therapy, the lesions continued to recur in a cyclical pattern, raising concerns for either chronic bacterial colonization, treatment-resistant organisms, or an underlying inflammatory condition such as hidradenitis suppurativa.

Final Diagnosis

Working diagnosis of recurrent furunculosis versus early hidradenitis suppurativa. The cyclical nature, location, and treatment resistance suggested the need for bacterial culture and sensitivity testing to guide targeted therapy or consideration of hidradenitis suppurativa as an inflammatory rather than purely infectious process.

Treatment Plan

Bacterial culture and sensitivity testing recommended to identify causative organisms and guide antibiotic selection. Consider oral clindamycin therapy, with or without rifampin, based on culture results. If bacterial causes are ruled out or treatment continues to fail, approach as potential hidradenitis suppurativa with anti-inflammatory treatments. Maintain local hygiene measures and antiseptic cleansing.

Outcome and Follow-up

Patient advised to obtain bacterial culture before antibiotic modification. Follow-up scheduled for culture results review and potential treatment adjustment. Long-term monitoring planned to assess for chronic recurrence patterns that might indicate hidradenitis suppurativa requiring specialized dermatologic management.