British Association of Dermatologists Guidelines for the Management of Hidradenitis Suppurativa (Acne Inversa) 2018

J.R. Ingram; F. Collier; D. Brown; T. Burton; J. Burton; M.F. Chin; N. Desai; T.E.E. Goodacre; V. Piguet; A.E. Pink; L.S. Exton; M.F. Mohd Mustapa

Disclosures

The British Journal of Dermatology. 2019;180(5):1009-1017. 

In This Article

Summary of Recommendations

The following recommendations and ratings were agreed upon unanimously by the core members of the GDG and patient/carer representatives. For further information on the wording used for recommendations and strength of recommendation ratings, see Table 1. The evidence for recommendations is based on the studies as listed. GDG recommendations relating to referral pathways are based on discussion and clinical experience, as evidence-based details are not available at the time of writing. The GDG is aware of the lack of high-quality evidence for some of these recommendations, therefore strong recommendations with an asterisk (*) are based on available evidence, as well as consensus and specialist experience. Good practice point (GPP) recommendations (R) are derived from informal consensus.

R1 (GPP) Manage people with HS via a multidisciplinary team approach, particularly when considering surgical interventions.

R2 (GPP) In all people with HS, document the Hurley stage at baseline for the worst-affected region. For Hurley stage III (severe) disease consider immediate referral to dermatology secondary care.

R3 (GPP) Provide a patient information leaflet (www.bad.org.uk/leaflets) to all people with HS, treat pain if needed and provide dressings for pus-producing lesions.

R4 (GPP) Screen people with HS for associated comorbidities including depression, anxiety and cardiovascular risk factors (diabetes, hypertension, hyperlipidaemia and central obesity). If persistent gastrointestinal symptoms are reported refer for inflammatory bowel disease screening.

R5 (GPP) Where relevant, refer people with HS to smoking-cessation services.

R6 (GPP) Where relevant, refer people with HS to weight-management services.

R7 (GPP) Measure treatment response in people with HS using recognized instruments for pain and quality of life, including an inflammatory lesion count for those on adalimumab therapy.

R8 (GPP) In people with long-standing, moderate-to-severe HS, monitor for fistulating gastrointestinal disease, inflammatory arthritis, genital lymphoedema, cutaneous squamous cell carcinoma, and also for anaemia.

R9 (↑↑) Offer* oral tetracyclines such as doxycycline or lymecycline for at least 12 weeks to people with HS, considering treatment breaks to assess need for ongoing therapy and to limit the risk of antimicrobial resistance.

R10 (↑↑) Offer* combination treatment with oral clindamycin 300 mg twice daily and rifampicin 300 mg twice daily for 10–12 weeks to people with HS who are unresponsive to oral tetracyclines.

R11 (↑) Consider acitretin 0·3–0·5 mg kg−1 day−1 in males and nonfertile females with HS who are unresponsive to antibiotic therapies.

R12 (↑) Consider dapsone in people with HS who are unresponsive to antibiotic therapies.

R13 (↑↑) Offer* adalimumab (licensed for children and young people aged 12–17 years, and adults) 40 mg weekly to people with moderate-to-severe HS that is unresponsive to conventional systemic therapy.

R14 (↑) Consider infliximab 5 mg kg−1 every 8 weeks in people with moderate-to-severe HS that is unresponsive to adalimumab therapy.

R15 (↑) Consider clindamycin 1% solution in people with HS.

R16 (↑) Consider intralesional corticosteroid injections for carefully selected, individual HS lesions during the acute phase.

R17 (GPP) Consider metformin in people with HS with concomitant diabetes mellitus, and females with HS and polycystic ovary syndrome or pregnancy.

R18 (↑) Consider extensive excision in people with HS to minimize recurrence rate.

R19 (↑) Consider extensive excision for people with HS when conventional systemic treatments have failed.

R20 (↑) Consider secondary intention healing [or TDAP (thoracodorsal artery perforator) flap closure for axillary wounds] in people with HS following extensive excision.

R21 (↓↓) Do not offer* isotretinoin to people with HS unless there are concomitant moderate-to-severe acneiform lesions of the face or trunk.

R22 (↓↓) Do not offer* adalimumab 40 mg every other week to people with moderate-to-severe HS that is unresponsive to conventional systemic therapy.

R23 (↓↓) Do not offer* etanercept to people with moderate-to-severe HS that is unresponsive to conventional systemic therapy.

R24 (↓↓) Do not offer* cryotherapy to people with HS to treat lesions during the acute phase due to pain from the procedure.

R25 (↓↓) Do not offer* microwave ablation to people with HS.

Insufficient Evidence to Support any Recommendation

Θ Currently, there is insufficient evidence to recommend alitretinoin, anakinra, apremilast, atorvastatin, azathioprine, ciclosporin, colchicine, cyproterone, ethinyloestradiol with cyproterone acetate, ethinyloestradiol with norgestrel, finasteride, fumaric acid esters, hydrocortisone, hyperbaric oxygen therapy, intravenous antibiotics, isoniazid, laser and photodynamic therapies, MABp1 [anti-interleukin (anti-IL)-1 therapy], methotrexate, oral prednisolone, oral zinc, phototherapy, photochemotherapy, radiotherapy, secukinumab, spironolactone, staphage lysate, tolmetin sodium and ustekinumab for people with HS that is unresponsive to conventional systemic therapy.

List of key Future Research Recommendations

The following list outlines future research recommendations (FRRs).

FRR1 A prospective randomized controlled trial (RCT) evaluating the alignment/role of biologic therapy with surgical intervention in HS, in terms of pre-/post-surgical treatment and peri-operative continuation of biologic therapy.

FRR2 A prospective RCT evaluating the efficacy and safety of anakinra in people with (moderate-to-severe) HS (that is unresponsive to conventional systemic therapy).

FRR3 A prospective RCT evaluating the efficacy and safety of ustekinumab in people with (moderate-to-severe) HS (that is unresponsive to conventional systemic therapy).

FRR4 A prospective RCT evaluating the efficacy and safety of secukinumab in people with (moderate-to-severe) HS (that is unresponsive to conventional systemic therapy).

FRR5 A registry of people with HS receiving systemic therapy, including biologic therapy, to determine the long-term safety and efficacy of these interventions.

FRR6 A prospective RCT evaluating the relative efficacy and tolerability of topical antiseptics and topical antibiotics for mild HS.

FRR7 A prospective RCT evaluating the efficacy and safety of laser and light therapies in people with HS. Trials adopting a within-participant design should incorporate a sham intervention where possible, with matched left/right anatomical sites, and report all results fully (i.e. number of participants with (i) positive outcomes for both interventions, (ii) positive outcomes for only one intervention (reported separately for each intervention) and (iii) negative outcomes for both interventions).

FRR8 A larger, prospective RCT evaluating the dosing, efficacy and safety of oral tetracyclines in HS.

FRR9 A prospective RCT evaluating the efficacy, duration of treatment and safety of oral clindamycin and rifampicin in people with HS.

FRR10 A prospective RCT evaluating the efficacy and safety of oral retinoids in people with HS.

FRR11 A prospective RCT evaluating the efficacy and safety of dapsone in people with HS.

FRR12 A prospective RCT investigating the management of acute flares, including intralesional triamcinolone injections.

FRR13 A prospective RCT evaluating lifestyle modifications, such as smoking cessation and weight loss, on HS severity.

FRR14 A long-term pharmacovigilance study (open registry) for systemic therapy including biologic therapy.

FRR15 Studies on stratification of treatment response (personalized medicine) – phenotype, genotype, biomarkers, pK studies.

FRR16 A prospective RCT investigating intravenous antibiotics in people with moderate-to-severe HS.

FRR17 A prospective RCT investigating endocrine therapies in people with HS.

FRR18 A prospective RCT of extensive excision of axillary HS (Hurley stages II and III) with closure using TDAP flaps vs. secondary intention closure (possibility of within-participant, bilateral studies).

FRR19 A prospective RCT of continued optimal nonsurgical therapy with extensive surgical excision of a single site for comparative evaluation of outcome between operated site and contralateral nonoperated axilla or groin.

FRR20 A prospective head-to-head RCT of deroofing vs. best medical intervention.

FRR21 A long-term study looking at recurrence and complication rates following surgery.

FRR22 A prospective RCT of extensive excision of axillary HS compared with narrow-margin excision of active lesions (possibility of within-participant, bilateral studies).

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