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Hidradenitis suppurativa guidelines encourage individualized care

Experts from the United States and Canadian Hidradenitis Suppurativa Foundations have issued guidelines to assist clinicians in the diagnosis, evaluation and management of the condition, with an emphasis on an individualized approach to standard of care.

“HS management is often complex and requires balancing medical and surgical treatment options in addition to addressing associated pain, psychiatric and medical comorbidities,” Ali Alikhan, MD, co-chair of the report and dermatologist at Sutter Health in Sacramento, California, and colleagues wrote.

Part I of the guidelines summarizes the available data and is not meant to set a standard of care.

New research into hidradenitis suppurativa (HS) suggests genetic susceptibility and dysregulation in the innate and adaptive immune pathways, according to the researchers. Treatment is evolving, they wrote, and combines both medical and surgical approaches.

Severity measurements typically include lesion counts of inflammatory nodules, noninflammatory nodules, sinuses/fistulas, scarring and surface area affected. The experts recommend Hurley staging in the clinical setting, which is categorized in stages of severity from I to III.

To assess treatment response, the Hidradenitis Suppurativa Clinical Response is the most validated dynamic physical measure, they wrote. Additionally, a multinational effort to create a core outcome set in HS clinical trials is ongoing.

Biofilms in diagnostic testing may offer a therapeutic target for HS in the future; however, their role in pathogenesis is not yet understood. While cohort studies are exploring biomarkers in HS, there is no current role for genetic or biomarker testing in diagnosis.

Regular screening for smoking, diabetes, metabolic syndrome, depression/anxiety, follicular occlusion tetrad and squamous cell carcinoma is recommended. Previous studies suggested up to a threefold risk for type 2 diabetes in patients with HS, according to the researchers. Those with physical signs of diabetes, hypertension, obesity or hyperlipidemia are at highest risk and should be screened. Moreover, patients who experience menstrual irregularity or physical signs of androgen excess should undergo evaluation for polycystic ovarian syndrome.

Previous large-scale studies demonstrate an association of HS with acne, inflammatory arthropathies, sexual dysfunction, psychiatric conditions, lymphoma, thyroid disease, substance abuse, Down syndrome, pyoderma gangrenosum, inflammatory bowel disease and autoinflammatory syndromes.

Among the findings regarding patients’ lifestyles:

• The experts recommend smoking cessation.
• Being overweight or obese may be more prevalent in patients with HS.
• The clinical effects of specific dietary restrictions are unclear.
• The evidence is also unclear to support the use of vitamin D or zinc supplementation.

Researchers have proposed that friction may stimulate epidermal hyperplasia, leading to the development of HS lesions, but this evidence is limited.

Surgical management recommendations of acute HS lesions rely on low-quality, uncontrolled retrospective reports, they wrote. Incision and drainage procedures are associated with recurrence rates nearing 100%. Deroofing small lesions using a punch tool or by other methods is preferred to simple drainage. For large recurrent abscesses, the experts recommend incision and drainage to provide acute relief while allowing for a smaller procedure to be performed in the future.

“In a series of 590 patients with excision, deroofing or drainage, drainage was associated with the highest recurrence, whereas deroofing and wide excision were about equal in effectiveness,” Alikhan and colleagues wrote.

Surgery alone will not alter disease biology, and clinicians should understand the trade-offs regarding extent of excision, surgical morbidity and reducing the risk for future lesions.

Reconstruction methods may speed healing time but may be associated with higher recurrence rates. Typically, surgical intervention is reserved for disease that is uncontrolled by pharmacologic care.

Pain is an important contributor to quality of life, and reducing inflammation improves pain. For acute pain, the researchers recommend topical analgesics, oral acetaminophen and oral NSAIDs. For chronic pain, they recommend a multidisciplinary approach with pain specialists.

As for wound care, there are no data favoring a specific type of absorptive dressing. Negative pressure wound therapy may shorten the duration between excision and delayed closure or grafting, but comparisons of various approaches are limited, according to the researchers.

The Nd:YAG laser has the largest number of controlled trials and case reports with consistent results in those with mostly Hurley stage II or III disease. CO₂ lasers for excision, marsupialization and vaporization were the first to be utilized in HS, and patients with Hurley stage II or III disease show consistently positive outcomes. Photodynamic therapy has been evaluated, but variations in outcomes measures and other factors make interpreting the results challenging.

To direct future research, the experts described the need for stronger evidence in areas highlighted by the guidelines. – by Abigail Sutton

Disclosures: Alikhan reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.