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HS Guidelines

Declaration of sponsorship Novartis Pharma AG
Last updated:13th Mar 2024
Published:13th Mar 2024
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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

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

  • US and Canadian HS Foundations recommendations (2022), for comorbidities screening14
  • HiSTORIC consensus (2023), for treatment outcome measures15
  • Asia-Pacific HS Foundation consensus guidelines (2023), for infectious disease screening16

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)17.

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 treatments18. High-quality clinical trials supporting the use of pharmacological treatments have common results19.

However, some differences are present between guidelines. Most agree on first-line treatment options, though second- and third-line recommendations vary18. 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 CC, Desai N, Emtestam L, Hunger RE, Ioannides D, Juhász I, et al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. Journal of the European Academy of Dermatology and Venereology. 2015;29(4):619–644.
  2. Gulliver W, Zouboulis CC, Prens E, Jemec GBE, Tzellos T. Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa. Rev Endocr Metab Disord. 2016;17(3):343–351.
  3. Hunger RE, Laffitte E, Läuchli S, Mainetti C, Mühlstädt M, Schiller P, et al. Swiss Practice Recommendations for the Management of Hidradenitis Suppurativa/Acne Inversa. Dermatology. 2017;233(2–3):113–119.
  4. Alavi A, Lynde C, Alhusayen R, Bourcier M, Delorme I, George R, et al. Approach to the Management of Patients With Hidradenitis Suppurativa: A Consensus Document. https://doi.org/101177/1203475417716117. 2017;21(6):513–524.
  5. Ingram JR, Collier F, Brown D, Burton T, Burton J, Chin MF, et al. British Association of Dermatologists guidelines for the management of hidradenitis suppurativa (acne inversa) 2018. British Journal of Dermatology. 2019;180(5):1009–1017.
  6. Gulliver W, Landells IDR, Morgan D, Pirzada S. Hidradenitis Suppurativa: A Novel Model of Care and an Integrative Strategy to Adopt an Orphan Disease. J Cutan Med Surg. 2018;22(1):71–77.
  7. Zouboulis CC, Bechara FG, Dickinson-Blok JL, Gulliver W, Horváth B, Hughes R, et al. Hidradenitis suppurativa/acne inversa: a practical framework for treatment optimization – systematic review and recommendations from the HS ALLIANCE working group. Journal of the European Academy of Dermatology and Venereology. 2019;33(1):19–31.
  8. Alikhan A, Sayed C, Alavi A, Alhusayen R, Brassard A, Burkhart C, et al. 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. J Am Acad Dermatol. 2019;81(1):76–90.
  9. Alikhan A, Sayed C, Alavi A, Alhusayen R, Brassard A, Burkhart C, et al. 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. J Am Acad Dermatol. 2019;81(1):91–101.
  10. Magalhães RF, Rivitti-Machado MC, Duarte GV, Souto R, Nunes DH, Chaves M, et al. Consensus on the treatment of hidradenitis suppurativa – Brazilian society of dermatology. An Bras Dermatol. 2019;94(2):7–19.
  11. Bertolotti A, Sbidian E, Join-Lambert O, Bourgault-Villada I, Moyal-Barracco M, Perrot P, et al. Guidelines for the management of hidradenitis suppurativa: recommendations supported by the Centre of Evidence of the French Society of Dermatology. British Journal of Dermatology. 2021;184(5):963–965.
  12. Johnston LA, Alhusayen R, Bourcier M, Delorme I, George R, O’brien E, et al. Practical Guidelines for Managing Patients With Hidradenitis Suppurativa: An Update. J Cutan Med Surg.2022(2S):2–24.
  13. Liao Y-H, Chu C-B, Hui CR, Li C-Y, Lin S-Y, Tseng H-C, et al. Taiwanese Dermatological Association (TDA) consensus recommendations for the definition, classification, diagnosis, and management of hidradenitis suppurativa. Journal of the Formosan Medical Association. 2023. doi:10.1016/j.jfma.2023.12.012.
  14. Garg A, Malviya N, Strunk A, Wright S, Alavi A, Alhusayen R, et al. Comorbidity screening in hidradenitis suppurativa: Evidence-based recommendations from the US and Canadian Hidradenitis Suppurativa Foundations. Journal of the American Academy of Dermatology. 2022;86(5):1092–1101.
  15. Mastacouris N, Tannenbaum R, Strunk A, Koptyev J, Alhusayen R, Bechara FG, et al. Outcome Measures for the Evaluation of Treatment Response in Hidradenitis Suppurativa for 5 Clinical Practice: A HiSTORIC Consensus Statement. JAMA Dermatol. 2023;159:1258–1266.
  16. Kozera EK, Porter M, Paek SY, Mintoff D, McMeniman E, Oon HH, et al. Infectious Disease Screening prior to Systemic Immunomodulatory Therapy in Hidradenitis Suppurativa: Consensus Guidelines from the Asia-Pacific Hidradenitis Suppurativa Foundation. Dermatology. 2023;1–13.
  17. Savage KT, Singh V, Patel ZS, Yannuzzi CA, McKenzie-Brown AM, Lowes MA, et al. Pain management in hidradenitis suppurativa and a proposed treatment algorithm. Journal of the American Academy of Dermatology. 2021;85(1):187–199.
  18. Hendricks AJ, Hsiao JL, Lowes MA, Shi VY. A Comparison of International Management Guidelines for Hidradenitis Suppurativa. Dermatology. 2021;237(1):81–96.
  19. Orenstein LAV, Nguyen T V., Damiani G, Sayed C, Jemec GBE, Hamzavi I. Medical and Surgical Management of Hidradenitis Suppurativa: A Review of International Treatment Guidelines and Implementation in General Dermatology Practice. Dermatology. 2020;236(5):393–412.
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