Evidence‐Based and Consensus‐Based Approach to the Treatment of Hidradenitis Suppurativa: Based on the Updated European SK2 Guidelines for the Treatment of Hidradenitis Suppurativa/Acne Inversa

Hidradenitis suppurativa/acne inversa (HS) is a chronic inflammatory skin disease characterized by painful recurrent nodules, abscesses that rupture and can lead to tunnels and scarring. An initial evidence-based therapeutic approach was published by Gulliver et al. in 2015 [1]. The European HS Guidelines are updated and, although comprehensive, did not provide an approach to patients with HS. I propose an evidence and consensus-based approach to treatment of hidradenitis suppurativa/acne inversa based on the updated European SK2 guidelines for the treatment of HS [2]. This algorithm (Figure 1) was developed by combining the consensus recommendation (CR) and the published evidence for each therapy in the updated European HS guidelines [2]. The guidelines used the Delphi methodology based on published evidence to determine the CR. The Grade methodology [3] was applied to the published evidence for each therapy within these guidelines to determine Category of Evidence (COE) and Strength of Recommendation (Table 1). The diagnosis of HS should be made by a dermatologist or other healthcare professional with expert knowledge in HS. All patients should be offered adjuvant therapy as needed including tobacco cessation, pain management, weight loss management and application of appropriate dressings. Dietary restrictions are not recommended (see Table 1 and Figure 1). The treating physician should be familiar with disease severity score, especially Hurley staging, international hidradenitis suppurativa 4 (IHS4) score, dermatology life quality index (DLQI) and pain assessment scores using visual analogue scale (VAS). The need for surgical intervention should be assessed in all patients and depending upon the type and extent of lesions, tunnels and scarring an evidence-based surgical approach should be implemented (see Table 1). For patients with draining tunnels, Bimekizumab or surgery may be considered as first line. Evidence-based medical treatment (COE, SOR, CR) for mild disease consists of topical clindamycin 1% gel BID for 12 weeks (IIB, B, 59%), resorcinol 15% peel (IV, D, 59%) or oral tetracyclines (IIA, B, 74%). If in mild HS (HIS4 SCORE 1−3), the patient's lesions fail to exhibit response or an IHS4 score of moderate (4−10), a combination of clindamycin 300 mg PO BID/rifampin 600 mg PO OD for 10 weeks (IIA, B, 79%). If the patient is not improved, then adalimumab 160 mg at Week 0, 80 mg at Week 2, then 40 mg subcutaneous weekly should be considered (IB, A, 100%). Similar evidence is present for adalimumab in paediatric patients. Adalimumab biosimilars may be used (III, C, 100%). Other approved biologics include Secukinumab 300 mg SubQ every 2 weeks for 12 weeks, then every 4 weeks (IB, A, 91%) or Bimekizumab 320 mg SubQ every 2 weeks for 12 weeks, then every 4 weeks (IB, A, 91%). Again, for patients with draining tunnels, Bimekizumab (IB, A, 100%) or surgery may be considered as first line. If improvement occurs, then therapy should be maintained as long as HS lesions are present. If complete remission is obtained treatment should be continued and may be discontinued only as a joint decision between the patient and physician. If the patient fails to exhibit response, then consideration of second and third-line therapy will be required (see Table 1, Figure 1). The growing body of evidence has been published on the treatment of HS including multiple guidelines both European and North American [4]. HS therapy should be based upon the evaluation of the inflammatory components (IHS4) as well as the scarring (Hurley stage). Treatment should be directed by evidence-based guidelines. Treatment must include both surgery and medical treatments after diagnosis is established by a dermatologist or other healthcare professional with expert knowledge in HS. Adjuvant therapy including smoking cessation, pain and weight loss management, along with appropriate wound care should be implemented. These treatments should be based upon the best evidence and guidelines as to produce the best outcome for our patients. The work was conducted solely by the author. The author has nothing to report. The author has nothing to report. The author declares no conflicts of interest. All data is in the Public domain and found in reference [2].

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