A practical guide to hidradenitis suppurativa
Early diagnosis and treatment of hidradenitis suppurativa is key to avoiding severe disease and minimizing its negative psychological impact.
PRACTICE RECOMMENDATIONS
› Screen patients with hidradenitis suppurativa (HS) for depression, anxiety, history of smoking, metabolic syndrome, and type 2 diabetes. A
› Look into early surgical and dermatology referrals for patients with mild diffused, moderate, and severe disease. B
› Consider biopsy to rule out skin cancer in patients with severe and longstanding HS refractory to treatment. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
These tools can help you to stage hidradenitis suppurativa
Multiple tools are available to assess the severity of HS.53 We will describe the Hurley staging system and the International Hidradenitis Suppurativa Severity Score System (IHS4). Other diagnostic tools, such as the Sartorius score and the Hidradenitis Suppurativa Physician’s Global Assessment Scale (HS-PGA), can be time-consuming and challenging to interpret, limiting their use in the clinical setting.2,54
Hurley staging system (available at www.hsdiseasesource.com/hs-disease-staging) considers the presence of nodules, abscesses, sinus tracts, and scarring affecting an entire anatomical area.13,55 This system is most useful as a rapid classification tool for patients with HS in the clinical setting but should not be used to assess clinical response.2,13,56
The IHS4 (available at https://online library.wiley.com/doi/10.1111/bjd.15748) is a validated and easy-to-use tool for assessing HS and guiding the therapeutic strategy in clinical practice.54 With IHS4, the clinician must calculate the following:
- total number of nodules > 10 mm in diameter
- total number of abscesses multiplied by 2, and
- total number of draining tunnels (fistulae/sinuses) multiplied by 4.
Mild HS is defined as a score ≤ 3 points; moderate HS, 4 to 10 points; and severe HS, ≥ 11 points.54
No diagnostic tests, but ultrasound may be helpful
There are currently no established biological markers or specific tests for diagnosing HS.15 Ultrasound is emerging as a tool to assess dermal thickness, hair follicle morphology, and number and extent of fluid collections. Two recent studies showed that pairing clinical assessment with ultrasound findings improves accuracy of scoring in 84% of cases.57,58 For patients with severe HS, skin biopsy can be considered to rule out squamous cell carcinoma. Cultures, however, have limited utility except for suspected superimposed bacterial infection.2
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