The Hurley and Sartorius Systems: Two Methods of Staging HS
The second part in this 3-part series discusses the staging of hidradenitis suppurativa (HS) and begins to discuss treatment options for the disease.
Two major classification systems are used to stage the severity of HS. The Hurley staging system is the older of the 2 and is still used in practice today (Table). It classifies HS into 3 stages and initially was designed to aid in treatment selection of specific body regions.1 Hurley stage I involves abscess formation without confluence of lesions; stage II involves more broadly dispersed, recurrent abscesses with some confluence and tract formation; and stage III is defined by widespread skin involvement with full confluence of abscess and sinus tracts (Figure). According to this classification system, stage I disease correlates with medical therapy, stage II with local surgery, and stage III with widespread surgical excision.2
The Sartorius system was created to offer a more dynamic and detailed staging process for HS. The system takes into account (1) the body region involved, (2) the number and types of lesions, (3) the longest distance between 2 lesions, and (4) whether all lesions are clearly separated by normal unaffected skin.3 Points are given in each category to give a regional and total score. The Sartorius system is used primarily for research purposes, whereas the Hurley staging system more often is used in the clinical setting.3
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Other clinical tools used to measure HS disease severity include the HS Physician’s Global Assessment (HS-PGA) and the Hidradenitis Suppurativa Clinical Response (HiSCR).4,5 The HS-PGA is a 6-point scale ranging from clear (score = 0) to very severe (score = 5); however, it has been faulted for failing to detect clinically important improvement in patients with severe disease.4 The HiSCR is a novel clinical endpoint used to assess the inflammatory signs and symptoms of HS, and is defined as a 50% or greater reduction in inflammatory lesion count and no increase in abscesses or draining fistulas compared with baseline. It is determined by counting the number of inflammatory nodules, abscesses, and draining fistulas before and after an intervention.4 The HiSCR was found to be more responsive to detecting change following treatment than the HS-PGA, with 54.5% of patients who received weekly adalimumab achieving a HiSCR response compared with only 20.5% of patients who received weekly adalimumab achieving a HS-PGA response.5,6
Figure. Stage III HS on the axilla.
Treatment of HS varies and depends on the patient and his or her individual disease factors. Mild disease typically is treated with topical and oral antibiotic therapies, hormone blockers, or oral immunosuppressants. More severe disease may require IV antibiotics, biologics, laser therapy, light therapy, or surgical therapy. Recommending weight loss, smoking cessation, and loose-fitting clothing to patients also may be beneficial.7 Determining the appropriate treatment for HS patients can be difficult, since there is no consistently effective treatment option or cure. Research into HS treatment consists mainly of case reports and poorly powered cohort studies due to the disease prevalence and the difficult task of diagnosing patients with HS. Only 12 RCTs were identified in our study. With the lack of reliable treatment options, many patients continue to struggle with the pain, malodor, ensuing embarrassment, and physical impairment that accompany this disease process.6,20
Topical therapies typically are first-line treatment for HS. Topical agents may be prescribed for daily use and can be combined with oral antibiotic therapy if improvement is not achieved with topical agents alone.
Topical clindamycin phosphate, 1%, is considered the standard of care in stage I HS due to its few adverse effects, efficacy, low cost, and ease of use, but this conclusion is based on old studies.20 In an RCT of 27 patients, topical clindamycin was statistically superior to placebo in terms of patient assessments and the number of abscesses, inflammatory nodules, and pustules following treatment.8 Unfortunately this effect was short-lived; after 2 to 3 months of treatment, abscesses and inflammatory nodules were no longer improved. However, another RCT demonstrated that topical clindamycin provided levels of improvement in disease activity similar to those of twice-daily oral tetracycline 600 mg in patients with stage I or II HS, suggesting that topical clindamycin has similar efficacy to systemic antibiotic therapy.9
Resorcinol, 15%, is a nonantibiotic topical agent used for chemical peels that was studied in a group of 12 women with stage I or II HS.10 After a year of once-daily application to active abscesses, the patients experienced decreased pain and shortening of the duration of HS flares. Resorcinol can be compounded with other agents, including clindamycin and gentamycin.
Oral and IV antibiotics
For more severe disease or stage I disease not responding to topical treatments, the next step often is adding a combination oral antibiotic regimen. Most of the recommendations for oral antibiotics are based on clinical experience, although some studies support their use.11-13 First-line oral antibiotic treatment for HS traditionally consists of a combination of oral rifampicin and clindamycin, 300 to 600 mg twice daily, with a 71% to 86% improvement in 4 available studies.11-14 Both clindamycin and rifampicin have anti-inflammatory properties, which may contribute to their efficacy.13 When given together, these 2 antibiotics also have a synergistic bactericidal action.15
Another antibiotic combination with efficacy in a retrospective study is oral rifampin (10 mg/kg once daily)-moxifloxacin (400 mg daily)-metronidazole (500 mg 3 times daily) triple therapy, which enabled complete remission of refractory HS after a median of 2.4 months and 3.8 months of treatment in patients with stage I and stage II disease, respectively.16 Hurley staging was a prognostic factor of response when treating patients with this combination, and prolonged treatment was suggested for lasting results.
Tetracyclines9 and oral dapsone (50-200 mg/d)17-19 have been used in HS treatment with limited success compared with other antibiotics, including rifampin. Dapsone has not been evaluated in an RCT. Currently, monotherapy with dapsone or tetracyclines cannot be recommended. In particular, there is no evidence that doxycycline ameliorates HS, and it should not be used as treatment.
IV antibiotics with broad bacterial coverage, typically in combination with oral antibiotics, may be implemented for treatment of severe HS, often in patients who are not surgical candidates. In case reports and cohort studies, ertapenem, ceftriaxone, and other combination IV antibiotics were found effective.17,20,21 However, IV antibiotics may be an impractical, debilitating, and costly therapy for many patients. IV antibiotics can be seen as a bridge to surgery or other treatments.
Systemic retinoids (vitamin A analogues), typically used for acne, have been used in the treatment of HS with some success.22-26 A recent systematic review27 reported that 73% of patients who received etretinate (not available in the United States) and/or its metabolite acitretin experienced significant improvement of their HS lesions. Isotretinoin had dubious efficacy in the review—only 18% of patients who received it experienced a significant response. The significant adverse and teratogenic effects, as well as high relapse rates after discontinuation, make retinoids difficult for long-term use.6
HS has been associated with high rates of polycystic ovary syndrome (PCOS), irregular menstruation, hirsutism, and acne vulgaris, along with significantly higher total testosterone levels than in control subjects.28 Some patients notice variations in disease severity with their menstrual cycle and disease improvement following menopause, suggesting a possible hormonal influence.29 Consequently, oral contraceptive pills and antiandrogen therapies have demonstrated efficacy in patients with HS.30-33 A 12-month crossover study of 24 women participants with moderate to severe HS compared 50 µg ethinyl estradiol and 500 µg norgestrel daily on days 5 to 25 of each menstrual cycle with 50 µg ethinyl estradiol and 50 mg cyproterone acetate on days 5 to 14 of each menstrual cycle.30 Both treatment regimens were effective, with statistically significant improvement compared with baseline disease status. Additionally, finasteride, a 5α-reductase inhibitor, prescribed at 5 mg daily has been reported to improve lesions and provide remission up to 18 months in both men and women with HS.32,33 Spironolactone, a synthetic steroid with antiandrogenic activity, was effective at doses of 100 to 125 mg daily after 3 to 6 months of treatment in patients with mild to moderate HS.34 Metformin also has been used in HS patients with some success,35 but no clear data show that it helps.
Ultimately, hormonal manipulation may be considered in HS patients, and a workup for underlying PCOS and insulin resistance may be beneficial in women with the condition.31
Brooke Rothstein, BA, is at the Tufts University School of Medicine in Boston, Massachusetts.
Noah Scheinfeld, MD, is in the Department of Dermatology at Weill Cornell Medical College in New York, New York.
William W. Huang, MD, MPH, is in the Department of Dermatology at Wake Forest School of Medicine in Winston-Salem, North Carolina.
Steven R. Feldman, MD, PhD, is in the departments of dermatology, pathology, and public health sciences at Wake Forest School of Medicine in Winston-Salem, North Carolina.
Brooke Rothstein, BA, has no conflicts of interest to disclose.
Noah Scheinfeld, MD, is a speaker and has served on the advisory board for AbbVie.
William W. Huang, MD, MPH, has no conflicts of interest to disclose.
Steven R. Feldman, MD, PhD, is a consultant and speaker for Galderma, Stiefel/GlaxoSmithKline, Abbott, Warner Chilcott, Janssen, Amgen, PhotoMedex, Genentech, Biogen Idec, and Bristol-Myers Squibb. He has received grants from Galderma, Astellas, Abbott, Warner Chilcott, Janssen, Amgen, PhotoMedex, Genentech, Biogen Idec, Coria/Valeant, PharmaDerm, Ortho, Aventis, Roche Dermatology, 3M, Bristol-Myers Squibb, Stiefel/GlaxoSmithKline, Novartis, Medicis, Leo, HanAll Pharmaceutical, Celgene, Basilea, and Anacor. He has received stock options from PhotoMedex. He is the founder of and holds stock in Causa Research.
The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, LP.
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35. Verdolini R, Clayton N, Smith A, Alwash N, Mannello B. Metformin for the treatment of hidradenitis suppurativa: a little help along the way. J Eur Acad Dermatol Venereol. 2013;27(9):1101-1108.