Hurley Staging System for Hidradenitis Suppurativa

Hurley Staging Classification

The American Academy of Dermatology recommends the Hurley staging system, which divides hidradenitis suppurativa into three stages based on the presence of abscesses, sinus tracts, and scarring, with Stage I characterized by recurrent nodules and abscesses with minimal or no scarring 1, 2, 3
The Hurley staging system classifies Stage II as one or a limited number of sinuses and/or scarring within a body region, and Stage III as multiple or extensive sinuses and/or scarring affecting an entire body region 1, 2, 3

The American Academy of Dermatology recommends the Hurley staging system for clinical practice due to its simplicity and ability to help determine therapeutic needs 2, 3

The Hurley score is a static score and not sufficiently responsive to change, particularly for measuring inflammatory components of hidradenitis suppurativa, according to the Endocrine Society 4, 5
More dynamic scoring systems like the Hidradenitis Suppurativa Clinical Response (HiSCR) are now used in research and clinical trials to better assess treatment response, as recommended by the American Academy of Dermatology 1, 4

For Hurley Stage I/mild Stage II, the American Academy of Dermatology recommends topical clindamycin 1% twice daily for 3 months as first-line treatment, with a moderate strength of evidence 4, 6
For Hurley Stage II/III, biologics such as adalimumab may be required for moderate to severe disease unresponsive to antibiotics, with a moderate strength of evidence 4
For Hurley Stage III, surgical procedures are recommended for extensive scarring, with a high strength of evidence 4, 6

The American Academy of Dermatology recommends using the Pain Visual Analog Scale and Dermatology Life Quality Index (DLQI) as valuable adjuncts to Hurley staging in clinical practice, with a moderate strength of evidence 3
The Hidradenitis Suppurativa Clinical Response (HiSCR) is a more validated tool for assessing treatment response in clinical trials, with a high strength of evidence 1, 3

Chronic purulent discharge is a defining clinical feature of Hidradenitis Suppurativa that significantly impacts patient morbidity, along with pain, persistent malodor, and involvement of intimate sites 7
The combination of persistent pain, chronic purulent discharge, persistent malodor, and involvement of intimate sites results in significant patient morbidity 7
Patients demonstrate an average DLQI score of 8.9, indicating moderate effect on quality of life 7

Hurley Stage III is defined by multiple or extensive sinuses and/or scarring affecting entire body regions, resulting in persistent purulent discharge from numerous draining tracts 8
Guidelines recommend providing dressings for pus-producing lesions as part of initial management, with consideration of immediate clindamycin and rifampicin therapy for Hurley stage III disease 9, 10
Local wound care for surgical and nonsurgical wounds follows best-practice individualized wound care principles, with dressing choice based on the amount of drainage, location, periwound skin condition, cost, and patient preference 11

The American Academy of Dermatology notes that mixed normal flora and skin commensals are the main bacteria cultured from suppurative discharge, though gram-negative organisms may be abundant in some lesions 8
The British Journal of Dermatology recommends against interpreting purulent drainage as solely representing bacterial infection requiring only antimicrobial therapy, as the drainage primarily reflects the chronic inflammatory nature of the disease 7, 8