Severity staging of hidradenitis suppurativa: is Hurley classification the answer?

Overview and comparison of the clinical scores in hidradenitis suppurativa: A real-life clinical data

Introduction

Partly due to its clinical heterogeneity, hidradenitis suppurativa (HS) is difficult to score accurately; illustrated by the large number of disease scores. In 2016, a systematic review by Ingram et al. reported the use of about thirty scores, and since then, this number has increased further. Our aim is twofold: to provide a succinct but detailed narrative review of the scores used to date, and to compare these scores with each other for individual patients.

Materials and methods

The review of the literature was done among articles in English and French, on Google, Google scholar, Pubmed, ScienceDirect and Cochrane. To illustrate the differences between scores, data from some Belgian patients included in the European Registry for HS were selected. A first series of patients compares the severity of the following scores: Hurley, Hurley Staging refined, three versions of Sartorius score (2003, 2007, 2009), Hidradenitis Suppurativa Physician Global Assessment (HS-PGA), International Hidradenitis Suppurativa Severity Scoring System (IHS4), Severity Assessment of Hidradenitis Suppurativa (SAHS), Hidradenitis Suppurativa Severity Index (HSSI), Acne Inversa Severity Index (AISI), the Static Metascore, and one score that is not specific to HS: Dermatology Life Quality Index (DLQI). A second set of patients illustrates how some scores change over time and with treatment: Hurley, Hurley Staging refined, Sartorius 2003, Sartorius 2007, HS-PGA, IHS4, SAHS, AISI, Hidradenitis Suppurativa Clinical Response (HiSCR), the very new iHS4-55, the Dynamic Metascore, and DLQI.

Results

Nineteen scores are detailed in this overview. We illustrate that for some patients, the scores do not predictably and consistently correlate with each other, either in an evaluation of the severity at a time-point t, or in the evaluation of the response to a treatment. Some patients in this cohort may be considered responders according to some scores, but non-responders according to others. The clinical heterogeneity of the disease, represented by its many phenotypes, seems partly to explain this difference.

Conclusion

These examples illustrate how the choice of a score can lead to different interpretations of the response to a treatment, or even potentially change the results of a randomized clinical trial.

Potential use of microwave technology in dermatology

BACKGROUND

Microwaves are used in medicine for diagnostics, and treatment of cancer. Recently, novel microwave devices (Swift^®, Emblation Ltd, UK and miraDry^®, Miramar Labs Inc., CA) have been cleared by the FDA and Health Canada for various dermatological conditions.

OBJECTIVE AND METHODS

To review the dermatological use of microwave-based treatments (plantar warts, corns, actinic keratosis, dermatophytosis, axillary hyperhidrosis, osmidrosis, and hidradenitis suppurativa). Clinical trials, case reports, or in vitro studies for each condition are summarized.

RESULTS AND CONCLUSION

Microwaves are a promising alternative therapy for cutaneous warts, actinic keratosis, axillary hyperhidrosis, and osmidrosis, with favorable safety profiles. However, patients with hidradenitis suppurativa have had negative clinical outcomes. Limited treatment of corns showed good pain reduction but did not resolve hyperkeratosis. A preliminary in vitro study indicated that microwave treatment inhibits the growth of T. rubrum. We present the first case of toenail onychomycosis successfully treated with microwaves. Despite the advancements in the use of microwaves, the mechanism of action in non-ablative treatment is not well understood; further research is needed. More high-quality randomized clinical trials with larger groups and long follow-up periods are also required to evaluate the clinical benefits and possible adverse effects of microwaves in treating dermatological conditions.

Hidradenitis Suppurativa: Where We Are and Where We Are Going

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease primarily affecting apocrine gland-rich areas of the body. It is a multifactorial disease in which genetic and environmental factors play a key role. The primary defect in HS pathophysiology involves follicular occlusion of the folliculopilosebaceous unit, followed by follicular rupture and immune responses. Innate pro-inflammatory cytokines (e.g., IL-1β, and TNF-α); mediators of activated T helper (Th)1 and Th17 cells (e.g., IFN-γ, and IL-17); and effector mechanisms of neutrophilic granulocytes, macrophages, and plasma cells are involved. On the other hand, HS lesions contain anti-inflammatory mediators (e.g., IL-10) and show limited activity of Th22 cells. The inflammatory vicious circle finally results in pain, purulence, tissue destruction, and scarring. HS pathogenesis is still enigmatic, and a valid animal model for HS is currently not available. All these aspects represent a challenge for the development of therapeutic approaches, which are urgently needed for this debilitating disease. Available treatments are limited, mostly off-label, and surgical interventions are often required to achieve remission. In this paper, we provide an overview of the current knowledge surrounding HS, including the diagnosis, pathogenesis, treatments, and existing translational studies.

Efficacy of non-surgical monotherapies for hidradenitis suppurativa: a systematic review and network meta-analyses of randomized trials

OBJECTIVE

We determined the relative efficacy of non-surgical monotherapies for hidradenitis suppurativa (HS).

METHODS

Network meta-analyses were conducted to determine treatments' surface under the cumulative ranking curve (SUCRA) value (i.e., an estimate that ranks efficacy); pairwise comparisons were conducted.

RESULTS AND CONCLUSIONS

Ten trials were eligible for quantitative analyses; however, all did not have a common endpoint. Outcomes corresponded to pain severity, clinical response, quality of life and abscess count. For pain reduction, infliximab was ranked most efficacious (SUCRA =94%) compared to bermekimab, anakinra and placebo; infliximab reduced pain more significantly (p < 0.05) than anakinra and than placebo. For occurrence of clinical response, bimekizumab had the highest SUCRA (67%) relative to adalimumab, anakinra and placebo; bimekizumab was more efficacious than placebo (p < 0.05). For quality of life in mild HS, Botox had the highest SUCRA (94%) compared to adalimumab and placebo; Botox was more efficacious than placebo (p < 0.05). For reduction in abscess count, oral tetracycline had the highest SUCRA (48%) compared to topical clindamycin and vehicle. Our work-being the first NMA study on non-surgical HS monotherapies-contributes to the comparative effectiveness literature for this condition.