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OBJECTIVE: Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the hair follicle. Its treatment often requires a surgical approach. The aim of our study was to evaluate the occurrence of post-surgical complications following a new standard of surgical management. This included presurgical lesion mapping by ultra-high frequency ultrasound (UHFUS) with a 70MHz probe. Postoperative management was based on the principles of HS-TIME (time, inflammation/infection, moisture, edges). METHOD: A single-centre, retrospective study was conducted by the Department of Dermatology of the University of Pisa. Patients with moderate and severe HS, refractory to previous medical and surgical therapies, were enrolled. All of the patients were treated with wide surgical excision of lesions, previously explored through a UHFUS evaluation with VEVO MD (Fujifilm VisualSonics, Inc., Canada) using a 48MHz and a 70MHz ultrasound probe. Following surgery, all patients were treated with secondary intention healing following the principles of HS-TIME. For each patient, we assessed the occurrence of post-surgical complications at follow-up visit six months after surgery. For each patient we assessed the occurrence of early post-surgical complications at every follow-up visit after surgery until complete wound healing. The occurrence of delayed complications was then assessed in all patients with an observation time after complete healing of >3 months (n=23). RESULTS: A total of 26 patients were enrolled in the study. There were no reported cases of post-surgical bleeding or haematoma occurrence, while three (11.5%) patients developed minor surgical site infection. The average severity of pain decreased from a numerical rating scale of 5.3 immediately after surgery to 1.3 after four weeks. The average healing time was 33.3±16.8 days, and only five (19.2%) patients reported a complete wound healing time of >6 weeks. Focusing on delayed complications: 1/23 (4.3%) patient had hypertrophic scarring; 2/23 (8.7%) patients reported dysaesthesia; and 2/23 (8.7%) cases of clinical relapse were reported. No cases of limited mobility at the surgery site were registered. CONCLUSION: The findings of the study demonstrated the efficacy of a novel surgical protocol, including a preoperative ultrasound evaluation and appropriate postoperative wound management. Further prospective studies are needed to validate the observed results; however, we conclude that the low recurrence rates and post-surgical complications confirmed that our proposed protocol would represent an effective strategy for the management of patients with HS eligible for surgical therapy.

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BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory disease that leads to the formation of nodules, abscesses and fistulas, with the formation of scars and fibrosis, causing significant impairment in patient quality of life. The diagnosis is clinical, using scores to classify the severity of the condition; currently the most recommended classification is the International Hidradenitis Suppurativa Severity Scoring System (IHS4). Doppler ultrasound has been used to complement the clinical evaluation of patients with HS. It is possible to observe subclinical lesions that change the staging, the severity of the case, and its treatment, either clinical or surgical. Correct treatment is essential to minimize the consequences of this disease for the patient. OBJECTIVE: To establish an outpatient protocol for the use of Doppler ultrasound in the care of patients with HS. METHODS: A narrative review of the literature was carried out on the use of Doppler ultrasound in patients with hidradenitis suppurativa; a referring protocol and technique orientations for imaging assessment in HS were created. RESULTS: Recommendation to perform ultrasound evaluation of symptomatic areas eight weeks after using antibiotics and four, 12, and 24 weeks after starting immunobiologicals; apply SOS-HS ultrasound severity classification. STUDY LIMITATIONS: The review did not cover all literature on ultrasound and HS; no systematic review was carried out, but rather a narrative one. CONCLUSIONS: The correct assessment of patients staging must be carried out using dermatological ultrasound to avoid progression to scars and fibrosis, which compromise patients quality of life.

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La hidradenitis supurativa (HS) es una enfermedad inflamatoria crónica y recurrente derivada de la unidad pilosebácea, que afecta aproximadamente al 1% de la población general. Se caracteriza clínicamente por nódulos inflamatorios, abscesos y túneles en las áreas intertriginosas del cuerpo, especialmente en las regiones axilar, inguinal y anogenital. La etiopatogenia de la HS no está totalmente aclarada, aunque se considera que es multifactorial, y resultado de una compleja interacción entre factores genéticos, hormonales, ambientales e inmunológicos. En este sentido, determinadas citocinas proinflamatorias como el factor de necrosis tumoral-alfa (TNF-α), la interleucina (IL)-1β y la IL-17, entre otras, parecen desempeñar un papel fundamental en la patogénesis de la enfermedad. Actualmente, la HS es considerada una enfermedad inflamatoria sistémica asociada con numerosas comorbilidades, incluyendo enfermedades cardiovasculares, inmunomediadas y trastornos endocrino-metabolicos. El tratamiento de la HS debe realizarse con un enfoque individualizado y orientado al paciente, considerando modalidades de tratamiento médico y quirúrgico.(AU)

Hidradenitis suppurativa (HS) is a chronic and debilitating inflammatory disease derived from the pilosebaceous unit, that affects approximately 1% of the general population. Clinically, it is characterized by inflammatory nodules, abscesses, and tunnels in the intertriginous areas of the body, especially in the axillary, inguinal, and anogenital regions. The etiopathogenesis of HS is not completely understood, although it is considered to be multifactorial, and the result of a complex interaction between genetic, hormonal, environmental, and immunological factors. In this sense, several proinflammatory cytokines, such as tumor necrosis factor-alpha (TNF-α), interleukin (IL)-L-1β, and IL-17, among others, appear to play a crucial role in the pathogenesis of the disease. Currently, HS is recognized as a systemic disease associated with numerous comorbidities, including cardiovascular, immune-mediated, and endocrine-metabolic diseases. The treatment of HS must be carried out with an individualized and patient-oriented approach, considering medical and surgical treatment modalities.(AU)

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Hidradenitis suppurativa (HS) is a devasting autoimmune cutaneous disease that affects the hair follicles and can clinically present palpable nodules, abscesses, and tunnels (fistulas), usually in the intertriginous regions. It has been widely reported that color Doppler ultrasound can detect subclinical abnormalities and stage the severity of the disease more accurately. Nevertheless, the ultrasound diagnostic criteria were reported with 15 MHz 10 years ago, and now it is possible to detect early anatomical abnormalities in HS using 70 MHz. Thus, an update of the ultrasonographic diagnostic criteria is needed. The most widely used sonographic staging of severity of HS (SOS-HS) includes the number of affected regions, besides counting the number of key lesions like pseudocysts, fluid collections, and tunnels; however, the total number of affected regions may fit better in an activity scoring. Furthermore, a high number of tunnels or communicated tunnels can complicate the management and may indicate an even more urgent treatment, which should be considered in the severity classification. To date, no hidradenitis scoring of activity has been reported in the literature, making it difficult to track the degree of inflammation under treatment objectively. Therefore, two new scorings are proposed. The first is an updated sonographic scoring of severity called modified SOS-HS (mSOS-HS), and the second is an activity ultrasound scoring of HS called US-HSA. Both staging systems can provide better anatomical information for discriminating the categories and, therefore, selecting more appropriate treatments and supporting research and clinical trials by giving more objective anatomical tools in real-world settings.

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BACKGROUND: The assessment of hidradenitis suppurativa (HS) severity requires detailed, and error-prone lesion counts. This proof-of-concept study aimed to automatically classify HS disease severity using machine learning of clinical smartphone images. METHODS: 777 ambient-light and size-controlled images were used to build a class-balanced synthetic dataset (n = 7675). Convolutional neural networks (CNN) were used for automated severity classification (scale 0-3), and to assess disease-dynamics. International Hidradenitis Suppurativa Severity Score System (IHS4) served as reference. A U-NET algorithm was implemented for automated localization of diseased skin. RESULTS: CNNs were able to distinguish no/mild from moderate/severe disease with an overall prediction accuracy of 78% [receiver operating curve (AUC) 0.85]. Correct IHS4 classification was achieved with an overall accuracy of 72% (AUC 0.84-0.89). In addition, disease dynamics using IHS4 numerical values aligned with CNN outputs (NRMSE 0.262). The UNET algorithm localized lesions with a pixel accuracy of 88.1% and test loss of 0.42. LIMITATIONS: Limitations in assessing tattooed and hairy skin. Limited number of patients with dark skin colour and Hurley I. CONCLUSION: CNNs were able to distinguish no/mild from moderate/severe disease, classify disease severity over time, and automatically identify diseased skin areas and the skin phototype. This study breaks new grounds for fast, reliable, reproducible and easy-to-use HS severity assessments using clinical images.

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Hidradenitis suppurativa is a chronic, inflammatory, recurrent, and debilitating disease of the hair follicle. It presents with painful, deep-seated, inflamed lesions, such as nodules, abscesses, sinus tracts, and fistulas, generally located in the main folds. Clinical severity assessment alone can be reductive; noninvasive skin imaging technologies, such as ultrasound, magnetic resonance imaging, medical infrared thermography, computed tomography, and positron emission tomography, provide subclinical anatomical and functional details. These instrumental techniques confirm the clinical suspect, thus allowing an earlier diagnosis and improving patients' clinical evaluation, staging, and management. Finally, they might be helpful for preoperative mapping. In this contribution, we provide an overview of the current knowledge about noninvasive skin imaging techniques with a particular focus on ultrasonography, which is widely used thanks to its precision, versatility, and availability.

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Hidradenitis suppurativa (HS) is a chronic, inflammatory follicular skin disease that frequently affects the apocrine gland-bearing skin of the axillary, inguinal and anogenital regions. HS has a significant impact on the psychosocial health and quality of life of patients. Diagnosis of HS is typically clinical, and relies on the ability of physicians to recognize the signs of HS. However, lesions may present at the dermal and subcutaneous skin layers, which cannot be diagnosed by clinical examination alone. Further, the complexity of the clinical presentation of HS can lead to misdiagnosis and delay of diagnosis and appropriate treatment. Imaging is an important tool that can address these issues by detecting inflammatory activity and the early subclinical and dermal features of HS, and accurately characterizing lesional morphology, thereby informing on optimal therapeutic strategies. Overall, imaging is a key tool that can be used in conjunction with clinical examination to improve the management of HS by providing additional information to physicians, and thus optimize clinical decision making. In this narrative review, we provide an overview of the general role of imaging in the management of HS, and we illustrate HS-specific applications of two pertinent imaging modalities, ultrasound and magnetic resonance imaging. Finally, based on the literature, we summarize their uses in HS and provide considerations relating to standardizing the practise of ultrasound and effectively implementing the use of imaging in the management of HS.

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BACKGROUND: Pain is not a trivial issue for hidradenitis suppurativa (HS) patients and has been considered a domain in the Core Outcome Set. To date, there is no evidence about pain caused by the ultrasound examinations. OBJECTIVE: The aim of the study was to assess the presence of pain generated by the ultrasound examinations of HS patients. METHODS: A multicentric cross-sectional study for detecting pain during the ultrasound examinations of HS patients using a validated verbal questionnaire immediately after the imaging studies. Statistical analysis included demographic data and possible associations with sex, age, location, clinical (Hurley), and ultrasonographic scoring (SOS-HS). The statistical tests were two proportions Z test, χ2 test, Student's t test, and ANOVA. A p < 0.05 was considered significant. RESULTS: 317 patients met the criteria. 77.3% of them did not present pain. Of cases with pain, 59.8% were mild, 16.7% moderate, and 23.6% severe. No significant association was found with sex, age, staging, location, or the number of affected regions. Although nonsignificant, severe pain cases were more frequent in the clinical Hurley III and ultrasonographic SOS-HS III stages. CONCLUSION: Pain generated by the ultrasound examination of HS patients is infrequent.

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Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease involving apocrine-bearing sites. It is characterized by recurrent painful nodules and abscesses that potentially rupture, resulting in sinus tract formation, fistulas, and scarring. HS tends to be found in the intertriginous areas (i.e., the axillary, inguinal, and perianal areas of the body). HS may be uncommon for radiologists because its diagnosis is usually based on clinical assessment. However, diagnosis based solely on clinical manifestations can underestimate the severity of HS. Ultrasonography and MRI play a critical adjunct role in determining the severity and extent of the disease and greatly aid its management. Given that MRI is an effective imaging tool, its role in the analysis of severe and anogenital HS lesions merits considerable attention. Unfortunately, anoperineal HS imposes diagnostic dilemmas. It has multiple symptoms and presentations and often mimics other diseases in the intertriginous areas. Therefore, a thorough understanding of HS is essential to avoid delayed diagnoses. This review highlights the typical MRI imaging features and staging of HS, emphasizing on the anoperineal location. The review also differentiates the disease from mimics to facilitate the prompt delivery of appropriate treatment and improve patients' quality of life.

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Hidradenitis suppurativa (HS) is an inflammatory disease characterized by a recurrent-remission trend and clinical lesions that range from asymptomatic to inflamed, deep-seated nodules with scarring and suppuration. The aim of our study was to identify morphologic and vascular features of HS nodules by means of dynamic optical coherence tomography (D-OCT) and to define if they are correlated to patient endotype and risk of disease progression. A set of standardized clinical pictures and D-OCT images were acquired from 57 inflammatory nodules of 40 patients affected by HS. A set of 20 clinical and D-OCT images were acquired from 20 healthy volunteers as a control group. The comparison of D-OCT features among HS and control group was analysed. The correlation between HS patient endotype and D-OCT features of the lesions was calculated. D-OCT enabled to identify vascular and morphological aspects characterizing HS nodular inflammatory lesions. In addition, several D-OCT features were significantly different among distinct disease endotypes. The characterization of HS nodular inflammatory lesions through D-OCT, corresponding to blood vessel dilation and inflammatory associated hyper-vascularization, may have important clinical consequences in the assessment of HS risk of progression, therapeutic decisions and treatment efficacy monitoring.

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BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease presenting with diverse manifestations ranging from nodules and abscesses to draining tunnels. Whether the underlying inflammation from lesions extends to relatively healthy-appearing adjacent perilesional and distant nonlesional skin has not been systematically evaluated. OBJECTIVE: We sought to characterize lesional, perilesional, and nonlesional skin in patients with HS. METHODS: Skin biopsy samples were collected under ultrasound guidance from patients with active, untreated moderate-to-severe HS. Site-matched control biopsy samples from healthy volunteers were used for comparison. RESULTS: RNA sequencing demonstrated that HS skin clustered separately from healthy control skin, with perilesional and lesion skin clustering together and away from nonlesional skin. Immunohistochemistry analysis identified psoriasiform hyperplasia with keratin 16 positivity in both perilesional and lesional skin, with comparable levels of CD3+, CD11c+, and neutrophil elastase-positive cellular infiltration. There was a marked upregulation of IL-17 signaling in perilesional and lesional skin. HS samples clustered on the basis of expression of lipocalin-2 (LCN2), with samples characterized by high LCN2 expression in the skin exhibiting a differing transcriptomic profile with significantly higher overall inflammation than that of skin characterized by low LCN2 levels. CONCLUSIONS: Perilesional HS skin has a transcriptomic and molecular profile comparable to that of lesional skin. HS can be grouped into 2 distinct subtypes based on molecular levels of LCN2 in the skin, with the LCN2-high subtype exhibiting an overall higher inflammatory burden and an upregulation of targetable cytokines. To our knowledge, this is the first study to characterize a unique HS subtype (and a potential endotype) that may guide future therapeutic targets.

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BACKGROUND: Hidradenitis suppurativa (HS) staging and severity is typically based upon physical examination findings, which can result in misclassification of severity based on subclinical disease activity and significant variation between healthcare providers. Ultrasonography (US) is an objective tool to help evaluate subclinical disease and to more accurately classify disease severity. AIM: To evaluate inter-rater reliability in HS disease severity assessment using clinical and US techniques. METHODS: In total, 20 subjects underwent clinical evaluation of HS, independently by two physicians, using clinical outcome measures, including Hurley, Sartorius, HS Physician Global Assessment (HS-PGA) and Hidradenitis Suppurativa Clinical Response (HiSCR). US was subsequently performed, and clinical assessments were repeated. Intraclass correlation coefficients (ICC) were obtained to evaluate inter-rater agreement of each outcome measure before and after US. RESULTS: Pre-US to post-US improvement in ICC was seen with the Sartorius, HiSCR nodule and abscess count, and the HiSCR draining fistula count. The scores went from having 'good' rater agreement for Sartorius and HiSCR nodule and abscess count, to 'poor' rater agreement for HiSCR draining fistula count, to 'excellent' rater agreement among these scores. CONCLUSION: US improved inter-rater agreement and should be used in conjunction with physical examination findings to evaluate disease severity to ensure uniform staging of HS.

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The management of hidradenitis suppurativa (HS) flares with intralesional steroids lacks strong scientific evidence but limited data suggest that it may be useful. The objective of this study is to assess the clinical and ultrasound responses of HS flares to ultrasound-guided injections of intralesional triamcinolone (40 mg/ml) with a dilution 1:4 versus 1:2 at 30-day (t1), 60-day (t2), and 90-day (t3) follow-up. We recruited patients with ≤3 acute lesions, unresponsive to topical therapy. At baseline we assessed lesions clinically and by ultra-high frequency ultrasound (48 or 70 MHz) and randomly performed an ultrasound-guided injection of triamcinolone. Assessments were repeated at t1, t2, and t3 follow-up, re-injecting the lesion in the case of no or partial response. We treated 49 lesions: 38.8% showed improvements at t1; 46.9% at t2; 6% at t3; and 8.3% showed no clinical and ultrasound improvements. Long-term follow-up data confirmed a statistically significant reduction in Visual Analogue Scale (VAS)-pain, Dermatology Life Quality Index (DLQI), and HS-Physician Global Assessment (HS-PGA), as well as edema and vascular signals. No adverse effects were reported. Our study suggests that ultrasound-injections with a 1:2 dilution are beneficial for HS flares that do not respond to topical treatment and should be included in the therapeutic algorithm.

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OBJECTIVE: To bring awareness and close gaps between dermatologists and radiologists about the contribution of imaging techniques for diagnosis, treatment, and follow-up of hidradenitis suppurativa (HS). DATA SOURCES: Investigators searched the PubMed database for articles on HS and radiology techniques. STUDY SELECTION: Databases were searched up to December 2018. The query retrieved 257 publications, of which 103 were unique; of these, 7 were inaccessible. From the remaining 96, 33 were irrelevant (did not discuss HS lesion features). After applying the inclusion criteria, 63 studies were relevant to this study. DATA EXTRACTION: A standardized form was constructed to extract data from eligible studies by two independent authors. DATA SYNTHESIS: Imaging techniques are significant and useful tools in HS management. Imaging should be carried out to evaluate disease severity, subclinical features, treatment success, and intraoperative patient assessment. Providers should consider nonconventional radiology techniques, which are underused in clinical management of HS. Further, dermatology and radiology require a shared terminology of disease features to better understand patient status. CONCLUSIONS: Publications on HS lesion imaging have increased over the years. Imaging techniques have proven useful for determining HS severity and treatment effectiveness, as well as intraoperative patient assessment. These authors strongly recommend the use of these techniques in routine clinical practice for patients with HS.

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