Hidradenitis Suppurativa

Overview

Hidradenitis Suppurativa (HS) 

• Is a chronic, inflammatory, painful, follicular disease.
• Previously considered rare, but actually relatively common – Prevalence 0.7-1.2% population US & Europe.
• 2-3 x more common in African American and Biracial (Type 4-6) vs White skin (Type 1-2).
• Has a significant negative psychological impact.

Making a diagnosis

• Typical lesions: inflammed nodules/boils,open comedones, sinus tracts, bridging scars
• Typical sites: flexural locations such as armpits, groins, perineum, infra/inter mammary. Neck and ears are also other sites that can be affected.
• Frequency: 2 lesions in space of 6 months or lifetime history of 5 or more lesions.
• Onset: often starts in adolescence (although not exclusively)

Early recognition is key to prevent progression to a severe, scarring, life-altering disease which is difficult to treat.

Treatment such as lifestyle advice and medication can be initiated in primary care with early referral to dermatology for refractory cases.

Guidelines

PCDS - Hidradenitis suppurativa (syn. acne inversa) (pcds.org.uk) (1) - guidelines give advice on management in primary care including suggested antibiotics and other treatment options and when to refer:

Red Flags

Acute Infection- may require prolonged course (2 weeks) of antibiotics and/or immediate admission for surgical intervention for incision and drainage of abscesses (see Surgical Emergency Care page). These patients should subsequently be referred to dermatology for further management to try and avoid progression of the disease.

Squamous cell carcinoma  - can arise in long standing inflammation.

Mental health - potential for a large impact on quality of life and is linked to a higher risk of depression and suicide.

What to do before referral

Start Treatment Immediately

Do not delay starting treatment if you suspect HS, even if a referral is made. Encourage the lifestyle changes below and use the PCDS Guidelines(1).

Investigations

Consider the following investigations and checks to rule out underlying conditions. Include results in any referral:

• Bloods: HbA1c, TFTs, Lipid profile (dyslipidaemia), Testosterone (PCOS). Consider HIV test in at risk groups. Consider screen for inflammatory arthritis in patients with joint disease.
• Blood pressure - association with hypertension and cardiovascular disease.
• Faecal calprotectin - HS can be associated with Crohn's disease.
• PHQ9 - screen for depression

Lifestyle, Self - Care and Mental Health

• Patient information leaflet - from BAD. 
• Smoking cessation - Nicotine contributes to follicular occlusion therefore alternatives to nicotine replacement are required.
• Weight management -obesity leads to increased skinfold friction and hormonal imbalance. There are also poorer treatment outcomes in patients with obesity. Early referral to tier 3/4 services should be considered if criteria are met.
• Mental health support  - self refer to NHS Talking Therapies or consider PCLS referral if more severe mental health concerns.

Pain management

• Managing pain is a priority as it can be a very painful condition.

Staging

It is very helpful to stage severity of the condition which can then guide the most appropriate referral pathway. Please use the Hidradenitis Suppurativa (HS) Hurley Stages in any referral letter. These Hurley stages refer to each site of disease. 

• Stage 1 - Solitary or multiple isolated abscess formation without sinus tracts or scarring. Can usually be managed in primary care but refer to community dermatology if additional support is required. Once the sinuses and tracts occur, resolution with oral medication is very difficult so treatment before this stage develops is key and refer if any site develps stage 2 or stage 3 disease.
• Stage 2 - Recurrent abscesses, single or multiple widely spaced lesions, with sinus tract formation. Refer to community dermatology via eRS or managed referral for additioinal lifestyle support and more intensive drug treatment. 
• Stage 3 - Diffuse involvement of an area with multiple interconnected sinus tracts and abscesses. Refer to secondary care dermatology via eRS. This group of patients have a complex clinical picture, no cure but aim for remission, control and improvement in quality of life, management requires tertiary care MDT approach. 

Dressings and Garments

Patients requiring dressings for HS lesions should be referred as detailed in the referral section below but primary care nursing teams may also need to manage wounds. The BNSSG wound care/formeo formulary should be adhered to when making decisions about appropriate dressings.

Patients who have more complex wounds or where formulary dressings do not meet their needs should be referred to secondary care for review of management. The community Wound Care /TVN team can also offer advice.

Garment assessments (e.g HidraWear) for patients may be reviewed at community or secondary care clinics and a request sent to their GP for prescriptions. See Appliances and Part IX page of the BNSSG formulary for details.

Referral

If failed management in primary care or patient presents with Stage 2/3 disease then consider referral for further medical management:

• Dermatology Advice and Guidance via eRS - for management advice if required in early disease.
• Community Dermatology Referral via eRS or managed referral. For patients with stage 2 disease or stage 1 requiring additional support.  Referral on to secondary care can be done from this service for consideration of second line systemic treatment or biologics.
• Secondary care dermatology referral via eRS. For patients with stage 3 disease UHBW have a specific hidradenitis suppurativa clinic which can be accessed via a general dermatology referral on eRS. NBT also see patients with hidradenitis suppurativa via a general dermatology referral via eRS but will tend to pass on more complex patients to UHBW. NBT do not prescribe biologics which are often the main medical treatment for severe HS. UHBW is therefore the preferred place of referral for stage 3 patients rather than NBT. 

Surgical Management

Direct referral for surgical management outside of the acute setting (see Red Flags) is not normally advised from primary care and may be subject to the Benign Skin Lesion funding policy.

Surgical treatment may be considered for the following situations and will be decided using a MDT approach in secondary care (1):

• Persistent hidradenitis lumps may be excised after several months of conservative treatment.
• Radical excisional surgery is reserved for very severe cases of hidradenitis suppurativa.

If an acute abscess needs draining then please contact the on call surgical team to arrange (funding policy does not apply in this case)

Resources

Guidelines

• PCDS: Hidradenitis suppurativa (syn. acne inversa) (pcds.org.uk)
• BAD: British Association of Dermatologists guidelines for the management of hidradenitis suppurativa (acne inversa) 2018 - Ingram - 2019 - British Journal of Dermatology - Wiley Online Library
• BNSSG Position Statement: Prescribing HidraWear for Hidradenitis Suppurativa

Staging

• Hurley staging system- Hidradenitis Suppurativa (HS) Hurley Stages (hsdiseasesource.com)

Patient Impact Questionnaires

• Measure quality of life: DLQI: cardiff.ac.uk/medicine/resources/quality-of-life-questionnaires
• PHQ-9 (The Patient Health Questionnaire – Screening for Depression): patient.info/doctor/patient-health-questionnaire-phq-9 
• GAD-7 (Generalised anxiety disorder assessment): patient.info/doctor/generalised-anxiety-disorder-assessment-gad-7
• Measuring pain- Visual analogue pain (VAS)/Pain score: britishpainsociety.org.uk/ 

Support Groups 

• Hidradenitis suppurativa Foundation
• (20+) The HS Support Network - UK and Ireland | Facebook - For details of support and meetings you can email: HSSNUKandireland@outlook.com
• British skin Foundation 
• Changing faces  – offers guides for improving mental health and wellbeing and offering advice and support. Helpline available.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.