HS guidelines

Guidelines for the clinical management of HS

Clinical practices for hidradenitis suppurativa (HS) are rapidly evolving because of increased attention to HS in recent years and ongoing research on disease pathophysiology and optimal treatments. This has led to the development of numerous guidelines and recommendations for the management of HS. Guidelines for specific areas of care, such as comorbidity screening, are now available.

While there are large commonalities, there are also notable differences between guidelines.

What guidelines are available?

Guidelines relating to the general management of HS, in chronological order, include:

• European S1 HS guideline (2015)¹
• European HS Foundation guidelines (2016)²
• Swiss practice recommendations (2017)³
• Canadian Dermatology Association consensus (2017)⁴
• British Association of Dermatologists guidelines (2018)⁵
• Canadian Dermatology Association recommendations (2018)⁶
• HS ALLIANCE recommendations (2019)⁷
• US and Canadian HS Foundations Guidelines, Part I and Part II (2019)^8,9
• Brazilian Society of Dermatology consensus (2019)¹⁰
• French Society of Dermatology guidelines (2021)¹¹
• Canadian Dermatology Association Practical Guidelines (2022¹²)
• Taiwanese Dermatological Association Consensus Recommendations (2023)¹³
• German S2k guideline for HS (2024)¹⁴

Guidelines focusing on a particular area of care, in chronological order, include:

• US and Canadian HS Foundations' recommendations (2022), for comorbidities screening¹⁵
• HiSTORIC consensus (2023), for treatment outcome measures¹⁶
• Asia-Pacific HS Foundation consensus guidelines (2023), for infectious disease screening¹⁷

Hear more about the US and Canadian HS Foundations’ recommendations for comorbidity screening.

Guidelines on pain management have yet to be developed, though a treatment algorithm for pain management in HS has been proposed by Savage et al. (2021)¹⁸.

How do the guidelines compare?

All the guidelines focus on a multidisciplinary approach to the management of HS, and emphasise the importance of patient education, management of pain and mental health disorders, risk-factor assessment, as well as medical and surgical treatments¹⁹. High-quality clinical trials supporting the use of pharmacological treatments have common results²⁰.

However, some differences are present between guidelines. Most agree on first-line treatment options, though second- and third-line recommendations vary¹⁹. Regional variations are also present; for example, Brazilian guidelines highlight caution with the use of rifampicin, a first-line agent for tuberculosis, owing to the high prevalence of tuberculosis in Brazil¹⁰.

Of note, the French guidelines differ to most other guidelines with respect to medical treatment of HS¹¹. In the French guidelines, tetracyclines are recommended only as preventive therapy rather than first-line treatment and, instead, amoxicillin/clavulanic acid or pristinamycin for 7 days is recommended first-line for people with Hurley stage 1 or 2 disease. For Hurley stage 2 or 3 disease, French guidelines recommend ceftriaxone/metronidazole or levofloxacin/clindamycin for 1–21 days, stating rifampicin inducing clearance of clindamycin as one of many reasons for not recommending clindamycin and rifampicin¹¹.

References

1. Zouboulis, 2015. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. https://www.doi.org/10.1111/jdv.12966
2. Gulliver, 2016. Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa. https://www.doi.org/10.1007/s11154-016-9328-5
3. Hunger, 2017. Swiss Practice Recommendations for the Management of Hidradenitis Suppurativa/Acne Inversa. https://www.doi.org/10.1159/000477459
4. Alavi, 2017. Approach to the Management of Patients With Hidradenitis Suppurativa: A Consensus Document. https://www.doi.org/10.1177/1203475417716117
5. Ingram, 2019. British Association of Dermatologists guidelines for the management of hidradenitis suppurativa (acne inversa) 2018. https://www.doi.org/10.1111/bjd.17537
6. Gulliver, 2018. Hidradenitis Suppurativa: A Novel Model of Care and an Integrative Strategy to Adopt an Orphan Disease. https://www.doi.org/10.1177/1203475417736290
7. Zouboulis, 2019. Hidradenitis suppurativa/acne inversa: a practical framework for treatment optimization - systematic review and recommendations from the HS ALLIANCE working group. https://www.doi.org/10.1111/jdv.15233
8. Alikhan, 2019. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management. https://www.doi.org/10.1016/j.jaad.2019.02.067
9. Alikhan, 2019. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part II: Topical, intralesional, and systemic medical management. https://www.doi.org/10.1016/j.jaad.2019.02.068
10. Magalhaes, 2019. Consensus on the treatment of hidradenitis suppurativa - Brazilian Society of Dermatology. https://www.doi.org/10.1590/abd1806-4841.20198607
11. Bertolotti, 2021. Guidelines for the management of hidradenitis suppurativa: recommendations supported by the Centre of Evidence of the French Society of Dermatology. https://www.doi.org/10.1111/bjd.19710
12. Johnston, 2022. Practical Guidelines for Managing Patients With Hidradenitis Suppurativa: An Update. https://www.doi.org/10.1177/12034754221116115
13. Liao, 2024. Taiwanese Dermatological Association (TDA) consensus recommendations for the definition, classification, diagnosis, and management of hidradenitis suppurativa. https://www.doi.org/10.1016/j.jfma.2023.12.012
14. Zouboulis, 2024. S2k guideline for the treatment of hidradenitis suppurativa / acne inversa - Short version. https://www.doi.org/10.1111/ddg.15412
15. Garg, 2022. Comorbidity screening in hidradenitis suppurativa: Evidence-based recommendations from the US and Canadian Hidradenitis Suppurativa Foundations. https://www.doi.org/10.1016/j.jaad.2021.01.059
16. Mastacouris, 2023. Outcome Measures for the Evaluation of Treatment Response in Hidradenitis Suppurativa for Clinical Practice: A HiSTORIC Consensus Statement. https://www.doi.org/10.1001/jamadermatol.2023.3282
17. Kozera, 2024. Infectious Disease Screening prior to Systemic Immunomodulatory Therapy in Hidradenitis Suppurativa: Consensus Guidelines from the Asia-Pacific Hidradenitis Suppurativa Foundation. https://www.doi.org/10.1159/000534575
18. Savage, 2021. Pain management in hidradenitis suppurativa and a proposed treatment algorithm. https://www.doi.org/10.1016/j.jaad.2020.09.039
19. Hendricks, 2021. A Comparison of International Management Guidelines for Hidradenitis Suppurativa. https://www.doi.org/10.1159/000503605
20. Orenstein, 2020. Medical and Surgical Management of Hidradenitis Suppurativa: A Review of International Treatment Guidelines and Implementation in General Dermatology Practice. https://www.doi.org/10.1159/000507323