HS Draining Tunnels: Severity Markers, Scarring, and Unmet Needs

This episode, "HS Draining Tunnels: Severity Markers, Scarring, and Unmet Needs," features the dermatology panel examining what draining tunnels mean for severity and prognosis.

The panel is asked what a draining tunnel means for disease severity, the potential for progression, and how difficult these patients are to treat. The panel describes draining tunnels as a fire alarm. The amount of inflammation in these areas signals that the disease is progressing, and progressing quickly, so clinicians can often upstage severity once tunnels appear. The panel argues that this inflammation needs to be recognized, managed, and treated aggressively. Tunnels push patients into the moderate-to-severe range on every severity metric available. The goal is to reach patients before that point, because skin that has tunneled will never be normal again. Where there is a tunnel, there will be a scar, usually a rope-like scar that constricts mobility.

The panel illustrates this with a patient who wanted only to throw a ball for his children but had about 20 degrees of shoulder movement when treatment began. After treatment he regained full range of motion and could play with his children. The panel cites this as further support for treating earlier and more aggressively, and notes that frozen shoulder has been shown to increase with HS severity.

Asked about the most significant unmet needs, the panel highlights understanding why tunnels form and how to address them earlier. Education is a second priority, both for colleagues learning to recognize draining tunnels and for patients, who need to feel comfortable and safe presenting to the office. The panel also welcomes the move away from rigid adherence to early staging. Hurley staging was designed as a surgical tool rather than a guide to medical treatment, and it is static, so patients could be upstaged but not downstaged. Clinicians now need to discern moderate-to-severe disease and better appreciate its dynamic nature.

In "HS Biologic Therapy: Selecting, Starting, and Monitoring Response," the panel will review the approved biologics, comorbidity-guided selection, and how to judge response.