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Overview and Comparison of Hidradenitis Suppurativa Management Guidelines
Introduction
Long considered an orphan disease until recent years, hidradenitis suppurativa (HS) is rapidly gaining attention in the healthcare field with a growing spotlight on investigating HS pathogenesis, epidemiology, and treatment options. To better navigate the expanding therapeutic options available, a number of HS management guidelines have been published by international expert organizations from North America, South America, and Europe between 2015 and July 2020 ( Fig. 14.1 ). These groups include the British Association of Dermatologists, U.S. and Canadian HS Foundations, HS ALLIANCE, Canadian Dermatology Association, European HS Foundation, European Academy of Dermatology and Venereology, Swiss Consensus Group, and Brazilian Society of Dermatology. These guidelines encompass therapeutic modalities ranging from lifestyle modifications and topical therapies to systemic medications and procedural interventions. While significant overlap exists between the therapeutic ladders proposed by each set of guidelines, there are also abundant variations in recommendations across organizations. International recommendations and practice guidelines have been collated and compared in recent summaries, allowing for review and discussion of practices with the best evidence and efficacy in HS treatment.
The management of HS often requires a comprehensive approach comprised of lifestyle modifications, mental healthcare, and depending on disease severity, topical antimicrobials, systemic antibiotics, hormonal and immune modulators, light-based therapies, and procedural interventions. In this chapter, which is modified from our recent publication, we compare the similarities and differences among the nine published guidelines and highlight knowledge and practice gaps that remain to be addressed. Specific management modalities are discussed in detail in Section 3: Clinician’s Corner, Chapters 13 to 28.
General Guideline Comparison
International guidelines emphasize a multidisciplinary approach to HS management, including primary care providers, dermatologists, surgeons, pain management, and mental health specialists. All nine guidelines propose lifestyle modifications (such as weight loss and smoking cessation) and topical antimicrobials as first-line medical therapy, followed by systemic antibiotics, then systemic immunomodulators (such as adalimumab) for severe widespread disease. All guidelines include procedural modalities, such as intralesional corticosteroids recommended for isolated inflammatory lesions and light-based procedures (including laser hair reduction) as second- or third-line therapeutic considerations. Guideline recommendations vary in the order of use for systemic retinoids and hormonal agents. The North American guideline presents a broader discussion on classification criteria, biomarker and genetic testing, comorbidities screening, and procedural interventions than European and Brazilian groups. Additionally, while other guidelines utilize a therapeutic ladder approach, the North American and HS ALLIANCE guidelines display treatment modalities according to level of evidence. The North American guidelines also incorporate a more in-depth discussion of complementary and alternative medicine treatment modalities.
Detailed Comparison by HS Treatment Modality
Non-Pharmacological Approaches
Several lifestyle modifications are recommended as components of a comprehensive HS treatment plan. Universally supported lifestyle approaches include smoking cessation and weight reduction. While existing data is inconsistent in characterizing the relationship between tobacco use and HS severity, the prevalence of HS is higher among individuals who smoke compared to those who do not, and tobacco cessation should be encouraged for general health benefits. Similarly, there is limited evidence to support an association between higher body mass index and more severe HS, but proposed contributing factors include proinflammatory cytokines from adipose tissue and increased friction and inflammation in intertriginous areas. Tobacco cessation and weight loss counseling should be incorporated in routine HS management where relevant. Additionally, mental health is recognized in all guidelines as a critical factor in treatment of HS due to the psychological impact of chronic pain, skin disfigurement, and variable efficacy of treatment. All expert guidelines support screening for depression and anxiety in routine clinical visits with referral to psychiatric care as appropriate, further emphasizing the importance of a multidisciplinary healthcare team in managing HS.
Pain Management
The pain burden of HS remains a challenging aspect of disease management. Most guidelines recommend assessing pain severity using validated patient-reported outcome tools such as a pain visual analogue scale or numeric rating scale. Guidance regarding selection of analgesic agents is limited, but those guidelines that do address specific agents recommend topical analgesics and nonsteroidal antiinflammatories as first-line treatment, with opioids reserved only for severe pain refractory to first-line agents and to be used under the supervision of pain management specialists.
Topical Analgesics
The North American and Canadian consensus guidelines cite topical lidocaine as a first-line option for HS pain management, with diclofenac gel suggested as an alternative in the Canadian consensus guidelines.
Non-Steroidal Antiinflammatory Drugs (NSAIDs)
North American, Canadian consensus, and European S1 guidelines discuss nonsteroidal antiinflammatory drug (NSAIDs) as first-line systemic pain management in HS. NSAID use should be reviewed regularly during clinical visits with special dosing consideration or use of alternate agents in patients with impaired hepatic or renal function.
Neuropathic Pain Agents
Gabapentin and pregabalin are mentioned in the North American and Canadian consensus guidelines as therapeutic options for neuropathic pain associated with HS.
Tramadol
The opioid-like analgesic tramadol is cited in the North American guidelines as an agent for HS-associated pain that does not respond to topical analgesics or NSAIDs, although specific dosing is not discussed.
Opioids
Opioid use in selected patients (those with severe pain unresponsive to first-line agents) is discussed in the North American, Canadian consensus, and European S1 guidelines. These three guidelines underscore the importance of judicious opioid prescribing and recommend involvement of pain specialists in managing HS patients who are candidates for opioid use. However, the Canadian consensus and European S1 guidelines highlight the lack of evidence for opioid use in treating HS.
Topical Modalities
The nine guidelines recommend topical therapies for use in mild HS, localized disease, or as an adjunct to systemic therapies. Recommendations for these modalities are summarized in Table 14.1 .
Table 14.1
Topical and Intralesional Therapy for HS—International Guideline Recommendations
From Hendricks AJ, Hsiao JL, Lowes MA, Shi VY. A comparison of international management guidelines for hidradenitis suppurativa. Dermatol . 2021;237(1):81–96. doi:10.1159/000503605.
| Modality | Recommendations per guideline | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| British Association of Dermatologists | North American (US and Canadian HS Foundations) | HS ALLIANCE | Canadian Dermatology Association | Canadian Consensus Group | European HS Foundation | European S1 | Swiss Consensus Group | Brazilian Society of Dermatology | |
| Topical Therapies (Further discussed in Chapter 15 ) | |||||||||
| Resorcinol 15% cream | -- | Recommended (may induce contact dermatitis) | -- | 2nd line | Resolve/prevent follicular blockage in mild HS | 2nd line | For recurrent lesions in Hurley stage I/II HS a BID application during flares |
-- | Can be useful to shorten mean duration of painful nodule or abscess |
| Antiseptics | -- | Chlorhexidine, benzoyl peroxide zinc pyrithione supported by expert opinion | -- | -- | -- | -- | -- | Triclosan, ammonium bituminosulfate for all Hurley stages a | Advise on adequate local hygiene; no need for soaps with high concentrations of chlorhexidine |
| Clindamycin 1% solution | Consider in patients with HS | May reduce pustules; carries risk of bacterial resistance | Recommended BID × ≤ 3 months in Hurley I/II a with localized lesions, especially without deep inflammatory lesions | 1st line tx for mild HS; 1% lotion applied BID × 12 weeks | Use as topical antiinflammatory agent and to prevent secondary infection b | Recommended BID × 3 months as 1st line tx in Hurley stage I/mild stage II, a especially without deep inflammatory lesions b | BID × 3 months in localized Hurley stage I or mild stage II a ; can be prolonged if clinically indicated b | Recommended in Hurley I/II a HS to avoid bacterial superinfection and reduce inflammation | Recommended for Hurley stage I a or in cases of superficial lesions during exacerbation |
BID, Twice daily ; HS, hidradenitis suppurativa ; tx, treatment ,
–Not specifically mentioned
-
Hurley stage I—single or multiple abscesses without scarring
-
Hurley stage II—limited scarring and/or sinus tracts
-
Hurley stage III—extensive scarring and/or sinus tracts
b Recommendation based on randomized controlled trial(s) in HS
Topical Keratolytics
Keratolytics aim to reduce follicular plugging thought to exacerbate the cycle of follicular occlusion and inflammation in HS. Resorcinol 15% cream is a keratolytic with antiseptic properties mentioned in six of the nine guidelines, and recommended as second-line therapy in the European HS Foundation and Canadian Dermatology Association guidelines. While more readily available in Europe, resorcinol cream requires compounding by a specialty pharmacy in the United States.
Topical Antiseptics
Topical antiseptics are used to inhibit bacterial colonization and resulting cutaneous inflammation. Recommendations for various antiseptic agents are included in the North American, Swiss, and Brazilian guidelines, although the North American guideline cites a lack of evidence to support specific formulations. Recommended topical antiseptics include chlorhexidine, benzoyl peroxide, zinc pyrithione, triclosan, and ammonium bituminosulfonate (ichthammol). Availability of these agents varies by region, as triclosan was removed from the U.S. market in 2018 due to lack of efficacy and safety data. Ichthammol is available over the counter as a cream or ointment formulation in the United States but is more frequently recommended and used for dermatologic purposes in Europe.
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