European S2k guidelines for hidradenitis suppurativa/acne inversa part 2: Treatment

This second part of the S2k guidelines is an update of the 2015 S1 European guidelines. These guidelines aim to provide an accepted decision aid for the selection, implementation and assessment of appropriate and sufficient therapy for patients with hidradenitis suppurativa/acne inversa (HS). The chapters have been selected after a Delphi procedure among the experts/authors. Certain passages have been adopted without changes from the previous version. Potential treatment complications are not included, being beyond the scope of these guidelines. Since the S1 guidelines publication, validation of new therapeutic approaches has almost completely overhauled the knowledge in the field of HS treatment. Inflammatory nodules/abscesses/draining tunnels are the primary lesions, which enable the classification of the disease severity by new validated tools. In relation to the degree of detectable inflammation, HS is classified into the inflammatory and the predominantly non-inflammatory forms. While the intensity of the inflammatory form can be subdivided by the IHS4 classification in mild, moderate and severe HS and is treated by medication accordingly, the decision on surgical treatment of the predominantly non-inflammatory form is based on the Hurley stage of the affected localization. The effectiveness of oral tetracyclines as an alternative to the oral combination of clindamycin/rifampicin should be noted. The duration of systemic antibiotic therapy can be shortened by a 5-day intravenous clindamycin treatment. Adalimumab, secukinumab and bimekizumab subcutaneous administration has been approved by the EMA for the treatment of moderate-to-severe HS. Various surgical procedures are available for the predominantly non-inflammatory form of the disease. The combination of a medical therapy to reduce inflammation with a surgical procedure to remove irreversible tissue damage is currently considered a holistic therapeutic approach. Suitable therapeutic options while considering HS severity in the therapeutic algorithm according to standardized criteria are aimed at ensuring a proper therapy.