To whom should a patient with Hidradenitis Suppurativa (HS) be referred for management?

Referral Pathways for Hidradenitis Suppurativa

For patients with Hurley Stage III (severe) disease, immediately refer to dermatology secondary care; for all patients with HS requiring surgical intervention, refer to a multidisciplinary team that includes dermatology and surgery. 1

Primary Referral Decision Based on Disease Severity

Immediate dermatology referral is indicated for:

• Hurley Stage III disease (extensive disease with multiple interconnected sinus tracts, abscesses, and diffuse scarring across an anatomical region) 1
• Patients unresponsive to first-line oral antibiotics (tetracyclines) after 12 weeks 1
• Patients requiring biologic therapy (adalimumab, infliximab) for moderate-to-severe disease 1

Dermatology referral should be considered for:

• Hurley Stage II disease with recurrent abscesses and limited sinus tracts that may benefit from specialist medical management 2, 3
• Patients requiring second-line antibiotic therapy (clindamycin plus rifampicin combination) 1
• Diagnostic uncertainty or atypical presentations 4, 5

Multidisciplinary Team Referral

All patients with HS should be managed via a multidisciplinary team approach, particularly when considering surgical interventions. 1 This team may include:

• Dermatology (primary specialist for medical management and biologic therapy) 1
• General surgery or plastic surgery (for surgical excision, deroofing procedures, and wound reconstruction) 1, 6
• Pain management specialists (for patients with severe chronic pain) 1
• Mental health services (for screening and treatment of depression and anxiety, which are common comorbidities) 1

The British Association of Dermatologists explicitly states that management strategies span multiple specialties including emergency medicine, internal medicine, dermatology, plastic surgery, urology, gynecology, and general surgery. 1

Ancillary Service Referrals

Mandatory referrals for risk factor modification:

• Smoking cessation services for all patients who smoke (smoking has an odds ratio of 36 for HS) 1, 2
• Weight management services for patients with elevated BMI (obesity has an odds ratio of 33 for HS) 1, 2

Comorbidity-specific referrals:

• Gastroenterology if persistent gastrointestinal symptoms are present (to screen for inflammatory bowel disease) 1
• Endocrinology for patients with diabetes, metabolic syndrome, or polycystic ovary syndrome 1, 2
• Cardiology or primary care for cardiovascular risk factor management (hypertension, hyperlipidemia) 1

Timing of Surgical Referral

Surgical referral is appropriate for:

• Hurley Stage III disease with extensive sinus tracts and scarring requiring radical excision 6, 2
• Hurley Stage II disease with established sinus tracts that may benefit from deroofing or wide local excision 2, 3
• Acute flares requiring incision and drainage (may be managed in emergency department or by surgery) 1, 4
• Patients with long-standing disease at risk for cutaneous squamous cell carcinoma 1

Combining adalimumab with surgery results in greater clinical effectiveness than adalimumab monotherapy alone, so consider concurrent medical and surgical management for advanced disease. 2, 3

Critical Pitfalls to Avoid

• Do not delay dermatology referral for Hurley Stage III disease while attempting multiple courses of antibiotics, as early specialist intervention improves outcomes 1
• Do not refer to general surgery alone without dermatology involvement, as medical optimization with biologics may reduce surgical morbidity 1, 6
• Do not overlook mental health referral, as HS significantly impairs quality of life to a greater degree than many other dermatologic conditions 1, 7