STAGES OF HS
Moderate to severe HS can be progressive and debilitating.2-5
The severity of HS may be determined by the Hurley staging system,
a widely used classification.6
Typically presents as abscess formation, single or multiple, without sinus tracts and scarring
Hurley Stages II and III studied
in PIONEER pivotal trials
Typically presents as recurrent abscesses with sinus tract formation and scarring; single or multiple widely separated lesions
Typically presents as diffuse or near-diffuse involvement with multiple interconnected sinus tracts and abscesses across entire area
Adapted with permission from Jemec, 2012.6
HS is a chronic, debilitating immune-mediated disease that manifests on the skin, occurring in many patients’ most sensitive areas.2,3,7 Typical signs and symptoms of moderate to severe HS lesions include7:
Multiple nodules and abscesses
Inflammation in the dermis
Scarring, ulceration, and infection
PRESENTATION OF HS LESIONS IN
WOMEN AND MEN
Recurring lesions commonly affect these sensitive areas in women and men.3,8 Symptoms can start at any time between puberty and middle age—with the average age of onset around 21.5
“As you can imagine, this disease can make sitting uncomfortable when I have several large lesions around my inner thighs and buttocks.”
– Insight from actual HS female patient
FOR A REFERRAL
“The patient was [Hurley stage II/III and in need of some] relief from this condition.... While the family physician was not comfortable prescribing an injectable biologic medication, he offered the patient a referral to dermatology.”
– Insight from a physician, The Journal of Family Practice, 2015.9
PREVALENCE OF HS
HS is relatively rare. The prevalence of all forms of HS reported in published literature varies. It is estimated that the number of adults in the U.S. living with the moderate to severe form of HS is up to 200,000.10
Females are more likely than males to develop HS, with a 3:1 ratio.11
But HS may be more common than you think, as it is often misdiagnosed, or goes undiagnosed for years when hidden by embarrassed patients.3,8 From an AbbVie-conducted market research survey, patients with HS on average see 5 doctors over 8 years before they are properly diagnosed.12
RISK FACTORS TO CONSIDER
The exact cause of HS is unknown. However, it may be helpful to know that there are risk factors associated with HS that have been identified and may help you recognize this often overlooked disease.
GENETIC FACTORS: 30%-40% of patients with HS have at least one family member who has it as well13
HORMONAL FACTORS: A strong relationship exists between HS and sex hormones, as demonstrated by the onset after puberty, and lack of onset after menopause14
MECHANICAL FACTORS: Weak structural support at the junction of the sebaceous gland and the follicular duct likely predisposes to follicular rupture caused by local trauma14
OBESITY may exacerbate HS symptoms, with higher body mass index associated with increased disease severity15
SMOKING can promote follicular plugging, which may contribute to the pathogenesis of HS14
COMORBIDITIES such as Crohn's disease or spondyloarthropathy often may be present in patients with HS14
FOR A REFERRAL
“The swelling, the discharge—I know this is an incurable disease, but is it wrong for me to hope for something that can help my lesions?”
– Insight from actual HS female patient
Dr. Cather discussesIDENTIFYING AND TREATING MODERATE TO SEVERE HS
IDENTIFYING AND TREATING MODERATE TO SEVERE HS
See what HS looks like as dermatologist Dr. Cather discusses its appearance, frequency in underarms, groin and other areas, nodules, abscesses and how to differentiate it from other skin conditions, the Hurley Staging System, and common, non-FDA–approved, HS treatments.
DR CATHER: Hi, I’m Dr. Jennifer Cather and I’d like to talk to you about how to identify and treat moderate to severe hidradenitis suppurativa, or HS, and how to differentiate it from other skin conditions. We’ll also take a look at some common, but non-FDA-approved, treatment options.
To begin, it’s important to understand that HS is a dynamic, progressive disease that varies considerably from patient to patient. That can make it challenging to figure out how to help patients navigate their therapeutic options.
So, what does HS look like? Some of the typical morphological features of HS include: inflamed nodules, as seen here, abscesses, sinus tracts, and hypertrophic fibrous, or “bridged,” scarring like this. Because several other skin conditions manifest in a similar fashion, it can be difficult to distinguish HS, especially in cases where only a single nodule appears. Because of this, diagnosis of HS is sometimes delayed for as long as 7 to 8 years.
A differential diagnosis of HS is extensive and includes these skin conditions: boils, acne, anogenital cutaneous Crohn’s disease, epidermoid or dermoid cyst, furuncle—which is caused by a staphylococcal infection, and carbuncle—a cluster of furuncles, pilonidal cyst, erysipelas, and sexually transmitted infections, including granuloma inguinale, lymphogranuloma venereum, and noduloulcerative syphilis.
As HS progresses, the diagnosis becomes more apparent, especially in cases where a patient is presenting with frequent recurrences, scarring, fistulas, sinus tracts, and incomplete healing. But by then, the damage may be permanent. Which is why it’s so important to diagnose moderate to severe HS early. Because HS is a progressive condition, severity increases over time and the therapeutic needs at each stage continue to change.
To determine HS severity, dermatologists rely on the Hurley Staging System, a widely used classification system. The system classifies patients into 3 groups based largely on the presence and extent of scarring and sinus tracts. Let’s take a closer look at the 3 stages. Stage I typically presents as single or multiple abscesses, without the presence of sinus tracts or scarring. By Stage II the disease typically presents as single or multiple, widely separated, recurrent abscesses with sinus tract formation and scarring. And finally, Stage III. At this point, the disease typically presents as diffuse or near-diffuse involvement with multiple interconnected sinus tracts and abscesses across the entire area.
Now, let’s take a look at some common treatment approaches to HS. In my clinical experience, when I started my own practice and began to see patients with HS return, I realized that the inflammatory lesions under the arms, breasts, and groin were part of a bigger inflammatory disease state. After I understood the chronic, recurrent, progressive nature of HS, I became more aggressive in my management of the disease, but there wasn’t much data regarding the type of efficacy I could expect for my patients with the available options.
Many therapies have been used to manage symptoms, though none of these have been approved for HS treatment by the FDA. Although literature about specific HS treatment guidelines is limited, systemic antibiotics are frequently recommended as a first-line therapy. While the role of bacteria in HS is unclear, antibiotics, administered topically or systemically, are used to treat and prevent secondary infection in existing lesions. Corticosteroids are also used, both intralesionally and orally. Oral contraceptive agents that contain a high estrogen to progesterone ratio are used to address the possible hormonal etiology of HS. Another approach is incision and drainage. This helps by providing short-term relief for early, limited disease. And finally, surgery. When patients with HS progress beyond mild, surgery is used to excise the lesions, sinus tracts, or scarring.
While many of these treatments manage symptoms, they do not target one of the key sources that contribute to inflammation.