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Hidradenitis suppurativa

What's new

The European Academy of Dermatology and Venereology (EADV) has published an updated guideline for the management of hidradenitis suppurativa (HS). For mild-to-moderate HS, recommended options include topical clindamycin, resorcinol peel, oral tetracyclines for up to 3 months per course, intralesional corticosteroids, isotretinoin, complement inhibitors, botulinum toxin B, metformin, oral zinc, and photodynamic therapy. For moderate-to-severe HS, adalimumab is recommended as first-line treatment, with other biologics such as infliximab, brodalumab, anakinra, ustekinumab, povorcitinib, upadacitinib, and spesolimab reserved as second-line options. .

Background

Overview

Definition
HS is a chronic inflammatory skin condition characterized by painful, suppurative lesions in apocrine gland-bearing areas.
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Pathophysiology
HS is caused by immune dysregulation in the terminal follicular epithelium and is thought to occur due to a combination of genetic predisposition and environmental factors.
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Epidemiology
Estimates of the prevalence of HS globally range from 0.03% to 4%. The incidence of HS in the US is 8.6 per 100,000 population/year.
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Disease course
The dysregulated innate and adaptive immune response leads to perifollicular inflammation, hyperkeratosis, and occlusion of hair follicles in apocrine gland-bearing areas. Spillage of sebum and debris occurs due to rupture of dilated hair follicles, triggering an inflammatory response and the development of painful, inflamed nodules, abscesses, fistulas, and sinus tracts.
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Prognosis and risk of recurrence
HS is associated with increased all-cause mortality (incidence rate ratio 1.35, 95% CI, 1.15-1.59). Recurrence rates vary according to treatment, with rates of 13%, 22%, and 27% reported following wide excision, local excision, and deroofing, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of hidradenitis suppurativa are prepared by our editorial team based on guidelines from the European Academy of Dermatology and Venereology (EADV 2024), the British Association of Dermatologists (BAD 2019), and the United States Hidradenitis Suppurativa Foundation (USHSF/CHSF 2019).
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Classification and risk stratification

Severity grading: as per EADV 2024 guidelines, use validated scoring systems for the evaluation of draining tunnels:
IHS4, IHS4-55 based on a 55% reduction of the IHS4 score
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hiSCR, HS-IgA
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HASI-R, SAHS
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Diagnostic investigations

Laboratory tests
As per CHSF/USHSF 2019 guidelines:
Do not obtain routine microbiologic testing unless signs of secondary infection such as surrounding cellulitis or fever are present. Recognize that a negative culture may support a diagnosis of HS based on consensus-derived diagnostic criteria.
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Do not obtain biomarker or genetic testing in patients with HS.
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  • Screening for comorbidities

Medical management

General principles
As per BAD 2019 guidelines:
Manage patients with HS via a multidisciplinary team approach, particularly when considering surgical interventions.
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Consider referring patients with Hurley stage III (severe) disease immediately to dermatology secondary care.
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  • Antibiotics (systemic)

  • Antibiotics (topical)

  • Antiandrogen therapy

  • Retinoids

  • Corticosteroids

  • Other immunosuppressants

  • Biologic agents

  • Therapies with no evidence for benefit

  • Agents with no evidence for benefit

  • Pain management

Nonpharmacologic interventions

Lifestyle modifications: as per EADV 2024 guidelines, consider offering weight loss in overweight patients with HS, particularly because of general health benefits and potential improvement of HS-associated conditions, such as T2DM, hypertension, metabolic syndrome, dyslipidemia, and CVD.
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  • Zinc

  • Psychological support

Therapeutic procedures

Intralesional corticosteroids: as per BAD 2019 guidelines, consider administering intralesional corticosteroid injections in carefully selected HS lesions during the acute phase.
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  • Laser and light therapies

  • Botulinum toxin injection

  • Therapies with no evidence for benefit

Perioperative care

Perioperative medical therapy: as per EADV 2024 guidelines, offer medical therapy before surgical intervention to achieve control of inflammation.
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Surgical interventions

Surgery: as per EADV 2024 guidelines, offer surgical approaches after anti-inflammatory treatment or when only solitary draining tunnels are present.
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  • Wound care

Specific circumstances

Pregnant patients
As per CHSF/USHSF 2019 guidelines:
Offer topical treatments, procedures, and safe systemic agents in pregnant patients with HS.
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Avoid using retinoids, hormonal agents, most systemic antibiotics, and most immunosuppressive medications in pregnant patients with HS.
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Patient education

General counseling: as per BAD 2019 guidelines, provide a patient information leaflet in all patients with HS.
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Follow-up and surveillance

Assessment of treatment response: as per BAD 2019 guidelines, measure treatment response using recognized instruments for pain and QoL, including an inflammatory lesion count for patients on adalimumab therapy.
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