Hidradenitis Suppurativa: Determining Severity



Hidradenitis suppurativa is a chronic skin disease associated with severe symptoms and complications. Early diagnosis and treatment can improve disease control and overall quality of life. Robert G. Micheletti, MD, discusses the impact of the disease and provides insight on its optimal management.

Robert G. Micheletti, MD: There are a number of staging systems out there and scoring systems that have been used in research for the purposes of determining efficacy for particular drugs. I think for the community physician or the practicing dermatologist, the most useful of these is the Hurley staging system. This is not really extremely detailed. It’s easy to use, and it breaks patients down into mild, moderate, severe, and then helps you dictate basically what therapies to employ.

So, a Hurley stage I patient—and this is about two-thirds of patients with hidradenitis—a Hurley stage I patient is going to have inflammatory acneiform nodules or boils, but they’re separated from one another. There’s no scarring or sinus tract formation. The Hurley stage II patient, which is probably about 27% of hidradenitis patients, that individual is going to have these recurring boils, but now you’re getting scar formation and sinus tract formation, where you’re seeing aggregate long-term damage beginning to build up. And then the most severe category, Hurley stage III, it only accounts for say 4%, 7%, somewhere in that range. These are patients in whom the entire anatomic area is involved. Say the entire axilla is nothing, but these inflammatory cystic nodules, boils, sinus tracts, scarring, and so it’s really much more severe.

And when you are able to sort of categorize patients in that way, it helps you know right off the bat which of the therapies that we have might be most appropriate for those patients. You might not even want to try one of the, say, less efficacious or less strong agents in a patient who is a Hurley stage III and vice versa. A relatively mild Hurley stage I patient may not be appropriate for a TNF inhibitor. Having some general sense of the spectrum of disease does help us with our therapeutic options.

I mentioned before that often hidradenitis suppurativa (HS) goes undiagnosed. Physicians and patients don’t necessarily know what it is. Patients may be embarrassed to mention if they have, say, disease in the groin area, and so it goes undiagnosed. I’ve also observed that even patients that come with a diagnosis of hidradenitis, they’re often not on appropriate therapy and that may be because physicians fail to think about the severity of the disease and match up a therapy in an appropriate way. My bias is that even patients with mild hidradenitis, they deserve treatment. They should be on some form of therapy even with Hurley stage I or fairly mild disease because, as I mentioned, we do see the disease progressing. That scar formation is aggregate, and so, over time, you have additive problems that patients are experiencing with this, not to mention the fact that even mild HS is painful, and smelly, and messy, and all of those other things that truly affect quality of life. It is important to have an accurate sense of how severe this is and how severe it is for the patient. Even mild disease is severe for the patient.

I think one important thing about making a diagnosis of hidradenitis, in addition to speaking with the patient about what it is, why is it happening, is giving them a sense of empowerment. This is something that’s not a hygiene issue, it’s not their fault. It’s something that is a disease that needs to be treated, and it is empowering to be able to say to them that here’s some things you can do. Smoking cessation, weight loss, some dietary modifications, as well, can be helpful for this. I do think at the same time that it’s important to recognize that it’s not easy. If you had painful boils in the groin, it’s hard to get out and exercise. I often tell patients I have a job and they have a job. My job is to help their hidradenitis get better medically so that they are less depressed, less anxious, and have less discomfort. Then I find that once I’ve done my job, they're able to exercise, lose weight, stop smoking, those kinds of things.

Anytime you’re dealing with a chronic condition and you’re telling a patient, “Hey, I’m going to put you on a therapy that, in many cases, we’re going to keep going for the foreseeable future,” they want to know where’s the light at the end of the tunnel and ask, “Am I going to be able to come off of this medication? What can I expect?” Being able to tell them that I’m going to keep working on this, we have many options. We’re going to get to a point where we can make, hopefully, this better or at least take it from the flaring up here to flaring down here and less frequently that then they can implement some of these lifestyle changes. I can back them off of the medications, and hopefully in the future, it will be much less of an issue for them and maybe I won’t even need some of these therapies. I think sometimes it’s important to acknowledge all of that, and lay that out for the patient, so they have a sense of, “Hey, there’s something I can do here. The doctor is going to help me. I can help myself.” And we can go from there.

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