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Hidradenitis suppurativa: severity assessment

Author: Hon A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand, 2015.


How is severity and extent of hidradenitis assessed?

The severity and extent of hidradenitis suppurativa should be recorded at assessment and when determining the impact of a treatment. Two scoring systems are in common use: Hurley Stages and Sartorius Hidradenitis Suppurativa Score.

Hurley Stages

The Hurley system describes three distinct clinical stages [1].

Stage 1 – solitary or multiple, isolated abscess formation without scarring or sinus tracts
Stage 2 – recurrent abscesses, single or multiple widely separated lesions, with sinus tract formation
Stage 3 – diffuse or broad involvement, with multiple interconnected sinus tracts and abscesses.

Hurley stages

Sartorius Hidradenitis Suppurativa Score

The Sartorius Hidradenitis Suppurativa Score is made by counting involved regions, nodules and sinus tracts [2].

  • Anatomic region involved (axilla, groin, genital, gluteal, or other inflammatory region left and/or right): 3 points per region involved
  • Number and scores of lesions (abscesses, nodules, fistulas, scars): 2 points for each nodule, 4 points for each fistula, 1 point for each scar, 1 point each for "other"
  • Longest distance between 2 relevant lesions (ie, nodules and fistulas, in each region, or size if only 1 lesion): Less than 5 cm, 2 points; less than 10 cm, 4 points; more than 10 cm, 8 points
  • Lesions clearly separated by normal skin in each region: If yes, 0 points; if no, 6 points


The six-point hidradenitis suppurativa Physician Global Assessment (PGA) ranges from clear to very severe. It is used in clinical trials to measure clinical improvement in inflammatory nodules, abscesses and draining fistulae [3].  


The Hidradenitis Suppurativa Clinical Response (HiSCR) is defined as a ≥ 50% reduction in inflammatory lesion count (abscesses + inflammatory nodules), and no increase in abscesses or draining fistulas when compared with baseline. It has been recently used to assess the effectiveness of treatment with biologics [3].


It is also useful to consider the degree of pain, the number of flares, and the impact on daily life in hidradenitis suppurativa. The Cardiff Dermatology Life Quality Index or DLQI questionnaire is often used.

A Hidradenitis Suppurativa Burden of Disease (HSBOD) tool has been described but is not fully validated [5].



  1. Hurley H. Axillary hyperhidrosis, apocrine bromhidrosis, hidradenitis suppurativa, and familial benign pemphigus: surgical approach. In: Roenigh R, Roenigh H, eds. Dermatologic surgery. New York: Marcel Dekker; 1989:729-739.
  2. Sartorius K, Emtestam L, Jemec GB et al. Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesity. Br J Dermatol 2009; 161: 831–839.
  3. Kimball AB, Jemec GEB, Yang M et al. Assessing the validity, responsiveness and meaningfulness of the hidradenitis suppurativa clinical response (HiSCR) as the clinical endpoint for hidradenitis suppurativa treatment. Br J Dermatol 2014; 171: 1434–42.
  4. Kimball AB, Kerdel F, Adams D et al. Adalimumab for the treatment of moderate to severe hidradenitis suppurativa: a parallel randomized trial. Ann Intern Med 2012; 157: 846–855.
  5. Pinard J, Vleugels RA, Joyce C, Merola JF, Patel M. Hidradenitis suppurativa burden of disease tool: Pilot testing of a disease-specific quality of life questionnaire. J Am Acad Dermatol. 2018 Jan;78(1):215-217.e2. doi: 10.1016/j.jaad.2017.08.030. PubMed PMID: 29241793. Journal (PDF).

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