Joint AAD & HS Foundation clinical guidelines
Guidelines of Care for the Management of Hidradenitis Suppurativa
Every recommendation with its strength, certainty of evidence, dosing, and monitoring.
View and download the guidelines
4strong recommendations
2good practice statements, treated as strong
37recommendations in total
40therapies where evidence generation is needed
How to read these guidelines
Who it covers
Adults, adolescents, and children over age 9 with a clinical diagnosis of HS.
What it covers
Topical therapies, systemic antibiotics, hormone therapy, oral retinoids, biologics, systemic therapies, procedural interventions, supportive management, weight reduction, diet, and complementary and alternative medicines available in the United States.
How the recommendations were built
The workgroup searched the literature for all available therapeutic interventions for HS, regardless of whether the quality of the evidence turned out to be high, low, or very low. Evidence was systematically retrieved and assessed, certainty was rated, and recommendations were formulated using GRADE, a standard framework for grading the certainty of evidence and the strength of recommendations. Searches also covered patient values and preferences, resource use, and feasibility, and patient partners contributed input on preferences and values at key stages.
The workgroup
A multidisciplinary workgroup of 15 members convened by the American Academy of Dermatology and the Hidradenitis Suppurativa Foundation, funded by the AAD and the HS Foundation. Alongside the HS clinical experts, the workgroup included members with methodological expertise and a medical writer, all experienced in guideline development and in the use of GRADE. Workgroup disclosures of relationships with industry are published with the guidelines.
Haley Naik, MD, MHSc
Co-chair
University of California, San Francisco
Craig Burkhart, MD, MSBS, MPH
Co-chair
Burkhart Pediatric & Adolescent Dermatology, Cary, NC
Howa Yeung, MD, MSc
Emory University School of Medicine
Lindsy Frazer-Green, PhD
American Academy of Dermatology
Steven Daveluy, MD
Wayne State University School of Medicine
Amit Garg, MD
Northwell Health
Amy McMichael, MD
Wake Forest University School of Medicine
Christopher Sayed, MD
University of North Carolina at Chapel Hill
George Hightower, MD
UC San Diego School of Medicine; Rady Children’s Hospital
Ginette Okoye, MD
Howard University College of Medicine
Kelly Keeler, MS
American Academy of Dermatology
Lauren Orenstein, MD, MSc
Emory University School of Medicine
Melanie Plotke, PharmD
American Academy of Dermatology
Melissa Shive, MD, MPH
University of California, Irvine School of Medicine
Peggy Wu, MD, MPH
University of California, Davis
What the labels mean
Strength of recommendation
These describe the recommendation itself and how confidently it should be acted on.
| Label | What it tells you |
|---|---|
| Strong | Benefits clearly outweigh risks and burdens. Applies to most patients in most circumstances. |
| Conditional | Benefits are closely balanced with risks and burdens. Applies to most patients, but the most appropriate action may differ depending on the clinical situation or on patient values. |
| Good practice | Viewed by the workgroup as imperative to clinical practice based on strong sentiment for the need, in spite of an absence of direct data. Treated as a strong recommendation. |
| No recommendation | The therapy was evaluated and the evidence was insufficient to recommend for or against it. This is an area where evidence generation is needed, not a recommendation against use. |
Certainty of evidence
These describe the quality of the underlying evidence, which is a separate question from how strongly the therapy is recommended.
| Label | What it tells you |
|---|---|
| High | Very confident that the true effect lies close to the estimate. |
| Moderate | Moderately confident. The true effect is likely close to the estimate, though it could differ substantially. |
| Low | Confidence is limited. The true effect may be substantially different from the estimate. |
| Very low | The estimate is very uncertain. The true effect may be substantially different. |
Terminology
| Term | What it means |
|---|---|
| Tunnels | The preferred term over sinus tracts or fistulas, which may require imaging confirmation. HS lesions are also classified as papules, pustules, nodules, plaques, ulcers, abscesses, and comedones, as well as cysts, granulating growths, and ropelike scars. |
| IHS4 | International Hidradenitis Suppurativa Severity Score System, a clinician-reported severity measure used across the trials cited in the guidelines. |
| HiSCR-50 | Hidradenitis Suppurativa Clinical Response, 50 percent. An improvement of at least half in abscess and nodule count with no new abscesses or tunnels. The primary efficacy endpoint in most HS trials. |
| Moderate to severe HS | Several recommendations apply specifically to moderate to severe disease. The guidelines are explicit that this should not be read as a requirement to document severity with a specific measure before a patient can access treatment. |
Disclaimer
The guidelines carry a disclaimer to the effect that adherence will not ensure successful treatment in every case, that they do not set a standard of care or exclude other reasonable methods, and that the ultimate judgment on any specific therapy rests with the clinician and patient in light of the individual circumstances. They reflect the best available data at the time of preparation, and future studies may require revision. The published version will carry this disclaimer verbatim; the wording here is paraphrased.