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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 .