What is the management approach for Hidradenitis suppurativa (HS) Hurley stage 3?

Management of Hidradenitis Suppurativa Hurley Stage 3

For Hurley stage III (severe) hidradenitis suppurativa, immediate referral to dermatology secondary care and a multidisciplinary team approach with combination medical and surgical therapy is strongly recommended. 1

Initial Assessment and Management

Immediate Steps

• Document Hurley stage III classification (characterized by diffuse involvement with multiple interconnected sinus tracts and abscesses)
• Measure pain using Visual Analogue Scale (VAS) and treat if needed (e.g., NSAIDs)
• Measure quality of life (e.g., DLQI) and lesion count
• Provide appropriate dressings for pus-producing lesions
• Screen for associated comorbidities:
  • Depression and anxiety
  • Cardiovascular risk factors (diabetes, hypertension, hyperlipidemia)
  • Inflammatory bowel disease (if gastrointestinal symptoms present)
  • Inflammatory arthropathy

Lifestyle Interventions

• Offer smoking cessation referral if applicable
• Offer weight management referral if applicable

Medical Management

First-Line Therapy

• Consider immediate combination therapy with oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10-12 weeks 1
• Topical clindamycin 1% solution can be used concurrently for affected skin regions 1

Second-Line Therapy (If Inadequate Response)

• For males and non-fertile females: Acitretin 0.3-0.5 mg/kg/day 1
• Alternative: Dapsone 1

Third-Line Therapy (Biologics)

• Adalimumab 40 mg weekly (after initial loading dose of 160 mg at week 0,80 mg at week 2) is the most strongly recommended biologic therapy for moderate-to-severe HS unresponsive to conventional systemic therapy 1, 2

  • Clinical trials demonstrated significant improvement with 42-59% of patients achieving Hidradenitis Suppurativa Clinical Response (HiSCR) at 12 weeks compared to 26-28% with placebo 2
  • HiSCR is defined as at least 50% reduction in total abscess and inflammatory nodule count with no increase in abscess count or draining fistulas

• If unresponsive to adalimumab: Consider infliximab 5 mg/kg every 8 weeks 1

Surgical Management

Indications for Surgery

• Extensive chronic lesions with sinus tracts and scarring
• Disease unresponsive to medical therapy

Surgical Options

• Wide local excision is the preferred surgical approach for Hurley stage III disease 1, 3
  • Can be performed with scalpel, CO2 laser, or electrosurgery
  • Complete removal of all affected tissue is essential to prevent recurrence

Reconstruction Methods

• Healing by secondary intention
• Thoracodorsal artery perforator (TDAP) flap or other reconstructive methods 1
• Other options: primary closure, delayed primary closure, skin grafts, or skin substitutes 1

Perioperative Considerations

• If on biologic therapy, consider holding treatment for at least 2 weeks before and after surgery 4
  • Continuing immune-modulating therapy within 2 weeks of surgery is associated with reduced healing rates (odds ratio 0.23) 4
• Provide appropriate wound care instructions and dressings

Adjunctive Therapies

Laser Treatment

• CO2 laser excision is recommended for fibrotic sinus tracts in Hurley stage III disease 1, 5
• Neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser may be beneficial based on randomized controlled trials 1

Wound Care

• Follow principles of best-practice individualized wound care
• Choice of dressing based on drainage amount, location, periwound skin condition
• Consider negative-pressure therapy for large open wounds for 1-4 weeks followed by delayed reconstruction 1

Long-term Management

Monitoring

• Regular follow-up to assess response to treatment
• Monitor for disease progression and complications:
  • Fistulating gastrointestinal disease
  • Inflammatory arthritis
  • Genital lymphoedema
  • Cutaneous squamous cell carcinoma
  • Anemia 1

Multidisciplinary Approach

• Participation in a multidisciplinary program is the strongest predictor of long-term healing success (78% vs 45% healing rates) 4

Common Pitfalls and Caveats

• Incision and drainage alone is not recommended for chronic lesions and should only be used for acute abscesses to relieve pain 1
• Surgical interventions are underrepresented in management pathways due to limited high-quality evidence from randomized controlled trials 1
• Recurrence rates after surgery vary widely (1.1-29%) depending on technique, and new lesions may develop adjacent to treated areas in up to 35.3% of cases 5
• Hurley staging has moderate inter-rater reliability overall but almost perfect reliability for stage III disease (κ = 0.81), making it a reliable tool for surgical decision-making 6

By following this comprehensive approach combining medical and surgical interventions with appropriate monitoring and multidisciplinary care, patients with Hurley stage III hidradenitis suppurativa can achieve significant improvement in their condition and quality of life.