HS Case Study: Setting Treatment Goals in Severe Disease

In "HS Case Study: Setting Treatment Goals in Severe Disease," the panel takes on its third case: a warehouse supervisor with 12 years of progressively worsening HS.

The panel's final case is a 42-year-old man who reluctantly seeks a second opinion after 12 years of inconsistent HS care. He has multiple inflammatory nodules, abscesses, and moderate scarring across both axillae and the inguinal region, with limited tunnels in each axilla and the groin, placing him at Hurley Stage 2, though panelists note his multi-site involvement and high inflammatory burden feel closer to Stage 3. He works a physically demanding warehouse job, reports significant sleep disturbance and rising psychological distress, and rates his pain at seven out of ten, rising to nine during flares. His history includes well-controlled hypertension, newly diagnosed moderate depression on an SSRI, and two years of adalimumab with only partial, plateaued response after multiple prior antibiotic courses and steroid injections failed.

One panelist immediately classifies this as straightforwardly severe disease, calculating an IHS4 score of roughly twelve, above the threshold typically marking severe HS, compounded by work absenteeism and a high symptom burden. He frames treatment goals in two phases: a roughly sixteen-week short-term goal of visible improvement on a new therapy, followed by a longer-term goal of durable disease control, minimal pain, and no new tunnel formation, since outcomes tend to improve the longer patients remain on effective biologic therapy.

Panelists read his reluctance as disillusionment with a healthcare system that has repeatedly failed him, whether he came in on his own or under pressure from family or his employer. They agree he needs decisive treatment now rather than another trial of conservative therapy, and that surgical intervention may eventually help clear damaged tissue, though only after inflammation is under better medical control, since operating too early risks new HS activity at the surgical site.

The next episode in this series, "Managing Tunneling HS and Screening for Comorbid Crohn's Disease," has the panel differentiating biologic options for patients with extensive tunneling disease.