1. Patient History

Clinical Presentation

History and current presentation of HS (locations, lesion types)

Timeline of lesion onset

Symptoms (wound drainage, pain, itch)

Symptom severity rating scales (DLQI and VAS for pain)

Potential Triggers

Premenstrual/perimenstrual flaring

Smoking history and current status

Sweating (focal hyperhidrosis)

Dietary triggers

Clothing, hair removal practices (shaving/waxing)

Current medications review (check for lithium, progesterone-only contraceptives)

Previous Treatments

Dietary changes and supplements tried

Previous medications and response

Previous surgical interventions

Current wound care routine

Pain management history

Current contraceptive use and pregnancy plans

2. Physical Examination

Lesion Morphology

Single or double open comedones

Papules, nodules, abscesses

Sinus tracts and fistulas

Scarring pattern and extent

Distribution of Lesions

Axillary region

Inframammary region

Inguinal/groin area

Vulvar/Perineal/Perianal areas

Gluteal folds

Nape of neck

Abdomen

Hurley Staging

Stage I: Single or multiple abscesses without sinus tracts/scarring

Stage II: Recurrent abscesses with sinus tracts/scarring, single/multiple separated lesions

Stage III: Diffuse involvement with multiple interconnected tracts/abscesses

3. Comorbidity Screening

Essential Screening

Inflammatory Bowel Disease (IBD)

Inflammatory arthritis

Optional Screening

PCOS

Diabetes mellitus

Thyroid disease

Anemia

Metabolic syndrome evaluation (obesity, hypertension, dyslipidemia)

Depression and anxiety screening

4. Treatment Plan

Lifestyle Modifications

Smoking cessation plan

Weight management strategy

Dietary modifications (low glycemic/Mediterranean diet)

Clothing recommendations (loose-fitting, moisture-wicking)

Hair removal modification plan

Medical Treatments

Topical Therapies

Clindamycin phosphate 1% solution

Resorcinol 15% cream

Apply twice daily to affected areas

Supplements

Zinc gluconate 45-90 mg daily

Take with food, separate from copper supplement

Copper 2-4 mg daily

Hormonal Therapy

OCP with drospirenone (Yasmin®, Yaz®)

OCP with cyproterone acetate (Diane-35®)

Spironolactone 50-200 mg daily

Finasteride 5-10 mg daily

Systemic Antibiotics

Doxycycline 100 mg BID × 12 weeks

Take with food, avoid dairy products

Clindamycin 300 mg BID × 12 weeks

Rifampin 300 mg BID × 12 weeks (with Clindamycin)

Monitor liver function tests

Other Systemic Medications

Metformin 500 mg BID

Start at 500 mg daily, increase gradually

Biologics

Consider after failure of conventional therapy

Adalimumab

Initial: 160mg, Week 2: 80mg, then 40mg weekly

Secukinumab

300mg weekly for 5 weeks then 300mg every 4 weeks

other options: Infliximab or Anakinra

Pain Management

Acute Flares

Resorcinol 15% cream

Diclofenac 10% gel

Acetaminophen 500 mg q4-6h (max 4g/day)

Ibuprofen 400 mg q4-6h

Naproxen 250-500 mg q12h

Chronic Pain

Topical lidocaine 5% patch

Topical menthol preparations

SSNRIs (duloxetine, venlafaxine)

TCAs (amitriptyline, nortriptyline)

Gabapentinoids (pregabalin, gabapentin)

Procedural Interventions

Intralesional triamcinolone acetonide injections

2.5-10 mg/mL depending on location

Botulinum toxin injections

Laser hair removal

Deroofing procedures

Local excision

Wide excision

5. Referrals and Follow-up

Specialist Referrals

Smoking cessation counseling

Registered dietitian

Plastic surgery consultation

Rheumatology (if joint symptoms present)

Gastroenterology (if IBD symptoms present)

Pain management specialist

Mental health professional

Follow-up Plan

Schedule follow-up visit (4-6 weeks)

Provide contact information for flares

Document baseline photos (with patient consent)

Provide patient education materials

Review wound care instructions

Discuss lifestyle modification goals