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Advances in dermatology and venereology Acta Dermato-Venereologica
Hurley Staging Refined: A Proposal by the Dutch Hidradenitis Suppurativa Expert Group
Barbara HORVÁTH 1, 6, Ineke C. JANSE 1, 6, Janine L. BLOK 1, 6, Rieke J. B. DRIESSEN 2, Jurr BOER 3, 6, Jan R. MEKKES 4, Errol P. PRENS 5, 6 and Hessel H. VAN DER ZEE 5, 6 Departments of Dermatology, 1 University of Groningen, University Medical Center Groningen, Hanzeplein 1, NL-9700 RB Groningen, 2 Radboud University Medical Center, Nijmegen, 3 Deventer Hospital, Deventer, 4 Academic Medical Center, Amsterdam, 5 Erasmus University Medical Center, Rotterdam, The Netherlands, and 6 Member of the European Hidradenitis Suppurativa Foundation. E-mail: b. horvath @ umcg. nl Accepted Aug 16, 2016; Epub ahead of print Aug 18, 2016
Sir, Hidradenitis suppurativa( HS) is a chronic, recurring, debilitating inflammatory skin disease, which mainly affects the inverse areas of the body leading to scarring and disfigurement( 1, 2).
The European S1 guideline for the treatment of HS summarized all published treatments for HS( 1). The quality of evidence for these treatments is generally low, as was recently demonstrated in a Cochrane Review on interventions for HS, which identified only 12 randomized controlled trials( RCTs)( 3). Moreover, HS is a heterogeneous disease with distinct clinical phenotypes that may require different treatment strategies, further complicating the therapeutic decision-making process( 4).
The European S1 guideline proposed a“ Hurley severity grade-relevant treatment algorithm”( 1). More recently Gulliver et al.( 5) proposed another treatment algorithm based on disease severity measured by Hurley grade or PGA.
Hurley stage is a 3-stage classification of severity. Hurley stage I is characterized by abscess formation with out sinus tracts and scarring. In Hurley II, patients have single or multiple separated areas of recurrent abscesses with sinus tracts and scarring, whereas in stage III the multiple interconnected sinus tracts and abscesses cover the whole affected anatomical area. This classification in its original form was created mainly for surgical purposes and does not take into account the inflammatory component. In addition, the extension of the disease, i. e. the number of anatomical areas involved, is not assessed. Accurate stratification of the wide variety of HS clinical phenotypes is therefore not possible with the original Hurley score.
Furthermore, the recently invented dynamic scoring system Hidradenitis Suppurativa Clinical Response( 6) focuses mainly on the inflammatory component and is more or less comparable with a PASI 50 improvement in psoriasis and therefore is mainly suitable for the follow-up of systemic
treatments. How ever, these scores do not calculate or include the extensiveness of the disease. The number of anatomical areas involved is important in designing a holistic treatment plan as this should take into account the estimated number of surgical interventions needed( Fig. S1 1).
Here, we( the Dutch HS expert group and as a part of the European Hidradenitis Suppurativa Foundation e. V.) propose a refinement of the current Hurley staging.
Briefly, a 3 stepwise algorithm, including assessing the presence of sinus tracts, degree of inflammation and the extensiveness, enables the clinician to assess severity across the different phenotypes of HS and helps to guide treatment( Fig. 1).
In the first step of the algorithm the presence of sinus tracts is assessed, clearly separating Hurley I from Hurley II and III. In Hurley I the differentiation between fixed and migratory lesions is essential. Hurley 1C is considered as severe HS and is characterized by the presence of migratory lesions and corresponds with the recently proposed scarring folliculitis and frictional furuncle phenotype( 4). Since migratory lesions point to a strong inflammatory component, the cornerstone of treatment
1 https:// www. medicaljournals. se / acta / content / abstract / 10.2340 / 00015555-2513
Fig. 1. Refinement of the Hurley classification: the 3-step algorithm. BSA: body surface area. doi: 10.2340 / 00015555-2513 Acta Derm Venereol 2017; 97: 412 – 413
This is an open access article under the CC BY-NC license. www. medicaljournals. se / acta Journal Compilation © 2017 Acta Dermato-Venereologica.