With new hidradenitis suppurativa research, medical guidelines for the chronic skin condition continue to evolve. Since 2015, nine expert groups and consensus panels from around the world have published unique HS treatment guidelines—including the U.S., Canada, Europe, Brazil and Switzerland.

While there is significant overlap between these HS treatment guidelines, there are also noteworthy differences. For example, there is consensus on first-line treatments such as systemic antibiotics, but country-specific guidelines differ when it comes to second and third treatment options, according to a 2021 study published in Dermatology.

The study evaluated nine different HS treatment guidelines to determine how they differ and to offer suggestions on how improved guidelines could best help clinicians and patients moving forward.

Here are seven interesting takeaways from the comparison:

    1. Hidradenitis suppurativa management requires a team-centered approach.

All of the HS treatment guidelines endorse a multidisciplinary treatment approach, including dermatology, primary care, gynecology, mental health, pain management and surgery.

    1. Broad treatment is preferred.

Because there is no one treatment for hidradenitis suppurativa, all nine of the guidelines favor a broad treatment approach that may include lifestyle changes, topicals, antibiotics, anti-inflammatories and biologics, lasers, phototherapy and surgery.

    1. Early interventions are recommended, such as:

      • Using Hurley Staging to grade clinical severity of lesions.
        • Hurley stage I: single or multiple abscesses without scarring
        • Hurley stage II: limited scarring and/or sinus tracts
        • Hurley stage III: extensive scarring and/or sinus tracts
      • Screening for comorbidities including cardiovascular disease, diabetes, metabolic syndrome, autoimmune conditions, polycystic ovary syndrome, depression and anxiety.
        Encouraging patients to quit smoking. A higher percentage of HS patients smoke compared to the general population and using tobacco is associated with increased symptom severity.
      • Encouraging patients to lose weight because higher BMI is associated with more severe symptoms.
    1.  There are some clear winners in treatment options.

There is strong and uniform support for the following treatments for hidradenitis suppurativa lesions and most have been tested in random clinical trials with HS patients: topical clindamycin, oral tetracyclines, combination clindamycin and rifampicin therapy, adalimumab and WLE. Several guidelines also recommend targeted biologics.

Nearly all guidelines mention carbon dioxide (CO2) ablative laser treatment, deroofing and wide local excision as effective treatments. European guidelines tend to favor fewer procedures for hidradenitis suppurativa compared to the North American and Brazilian guidelines. Procedures can range from light-based therapy to lasers to surgery.

    1. There is a recognized need for HS-specific dressings.

There’s a lack of wound care dressings made specifically for hidradenitis suppurativa management. Guidelines from Canada, Europe and Brazil recommend studies to evaluate dressings and wound care specifically for the HS population.

    1. There’s uncertainty about how to evaluate HS treatment effectiveness.

Five guidelines support using the Hidradenitis Suppurativa Clinical Response (i.e. more than a 50% reduction of inflamed nodules and no additional tunnels). But six guidelines recommend using the Dermatology Life Quality Index to assess patient-reported outcomes. There is an effort underway to establish core outcomes, which when established, could minimize that uncertainty.

  1. Addressing pain should be central in hidradenitis suppurativa management.

All guidelines acknowledge the pain with hidradenitis suppurativa. Specific recommended therapies include topical analgesics and non-steroidal anti-inflammatories. Guidelines hold that opioids should only be as a last resort if other methods are ineffective.

Notably, a 2019 study found that the risk of long-term opioid use was 53% higher among HS patients than those without the condition. To evaluate pain severity, most guidelines recommend using a patient tool such as a pain visual analog scale or numeric rating.

The Future of Hidradenitis Suppurativa Research and Guidelines

It can be difficult to develop strict guidelines for treatment as new hidradenitis suppurativa research requires regular review and reevaluation.

For example, a retrospective study presented in 2022 found that carbon dioxide (CO2) laser excision therapy for hidradenitis suppurativa is not associated with an increased risk of developing keloids. Some clinicians worried that because CO2 laser therapy is also used to treat keloids, using it to treat hidradenitis suppurativa could trigger the development of keloids. But researchers noted that because keloids disproportionately affect black and other skin of color patients, denying the treatment could exacerbate existing health disparities.

Because early diagnosis and treatment can be key to effective management, the authors of the global guidelines comparison suggest that stakeholders work together to consolidate global efforts around HS treatment guidelines. Or, at the very least, groups should stagger future guidelines so they are of maximum benefit to physicians and patients.

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