Received: 14 August 2023 | Accepted: 17 November 2023
DOI: 10.1111/jdv.19681
LETTER TO THE EDITOR
International Hidradenitis Suppurativa Severity Scoring System
(IHS4) as a holistic measure of hidradenitis suppurativa disease
severity compared with Hurley staging: A post hoc analysis of the
SUNRISE and SUNSHINE phase 3 trials of secukinumab
Dear Editor,
Hidradenitis suppurativa (HS) is a heterogeneous, chronic,
inflammatory skin disease with different stages existing
along its spectrum. Among the several instruments available
to assess HS severity, Hurley staging is commonly used.1-­3
However, as a static tool, it cannot accurately assess the ex-
tent of inflammation within each stage.4,5 The International
Hidradenitis Suppurativa Severity Scoring System (IHS4) is
a simple and more comprehensive scoring system that dy-
namically assesses the severity of HS by assigning different
weights to different lesion types.6
In this analysis, pooled baseline data from two pivotal
phase 3 trials of secukinumab was used to compare Hurley
staging with disease severity using the IHS4. Adults with
moderate to severe HS were included in the SUNSHINE
(N = 541) and SUNRISE (N = 543) trials.7 The IHS4 disease
severity (mild, moderate, severe) was categorized by Hurley
staging (I–III) at baseline. All data are reported as observed.
At baseline, among patients with Hurley stage I (N = 40),
II (N = 639) and III (N = 405), 45% and 55% (Hurley I), 25.4%
and 74.6% (Hurley II) and 7.4% and 92.6% (Hurley III) were
classified as having moderate and severe disease using IHS4,
respectively; no patients were considered to have mild dis-
ease. In patients with Hurley stage III, the mean duration
since HS diagnosis was ~8 years, whereas the duration was
~4 years in patients with Hurley stage I with severe disease
according to IHS4 (N = 22) (Table 1).
The abscesses and inflammatory nodules (AN) count at
baseline was higher in patients classified as severe disease
compared to those classified as moderate disease using IHS4,
however, there was no meaningful difference in AN count
across Hurley stages. Although the number of draining tun-
nels increased with Hurley staging and IHS4 grading, many
patients with Hurley II stage, which is often misinterpreted
to denote moderate disease, meet criteria for severe disease
by IHS4. Within Hurley stage I, although the draining tun-
nels were absent, patients with severe disease could still be
identified using IHS4 by the presence of multiple abscesses
and inflammatory nodules (Table 1). These differences can
be attributed to the quantitative approach used by IHS4,6
© 2023 European Academy of Dermatology and Venereology.
J Eur Acad Dermatol Venereol. 2023;00:1–4. 
while Hurley staging largely relies on the largest extension of
HS lesions at any area of the body.4 In line with these results,
Figure 1 shows the difference in disease severity based on
IHS4 grading in patients classified as Hurley stage I-­III, in-
dicating that Hurley staging cannot accurately assess disease
severity.
Furthermore, the baseline Dermatology Life Quality Index
(DLQI) and numeric pain rating scale (NRS) scores did not
differ among Hurley stages, however, these scores were clearly
differentiated in IHS4 disease severity subtypes, with higher
scores for higher disease severity (Table 1). Irrespective of the
Hurley staging, the number of patients with hidradenitis sup-
purativa physician's global assessment (HS-­PGA) ‘moderate’
and ‘severe’ scores was consistent with IHS4 moderate and
severe disease grades. All patients with HS-­PGA score ‘very
severe’ had IHS4 severe disease grade and were in the Hurley
stage II/III category. Patients with IHS4 severe disease grade
had a trend for involvement of a greater number of body areas
compared to IHS4 moderate disease grade, irrespective of
Hurley staging. Pelvis and axilla were the most involved body
areas. Taken together, IHS4 scoring provided a more accurate
estimate of impact on quality of life.
This analysis of more than 1000 patients with moderate
to severe HS suggests that IHS4 provides a higher sensitiv-
ity to capture HS disease severity than Hurley staging, given
that IHS4 includes a numeric and parameterized assessment
of all HS lesions, including draining tunnels, on all areas af-
fected by HS. IHS4 may help physicians assess HS severity
and dynamically monitor treatment effect, allowing earlier
intervention to improve outcomes in patients with HS.8,9
AC K N O​W L E​D G E​M E N T S
Medical writing support was provided by Nihal Ganesh
Maremanda and Ramji Narayanan (Novartis Healthcare
Pvt. Ltd., Hyderabad, India), which was funded by Novartis
Pharma AG.
F U N DI N G I N F OR M AT ION
This investigation was sponsored by Novartis Pharma AG,
Basel, Switzerland.
wileyonlinelibrary.com/journal/jdv | 1
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2 |    LETTER TO THE EDITOR

TA BL E 1 Baseline characteristics and number of body areasa by IHS4 grade and Hurley stage.

Hurley stage I, N = 40 II, N = 639 III, N = 405

Moderate, Moderate, Moderate, Severe,

IHS4 grade N = 18 Severe, N = 22 N = 162 Severe, N = 477 N = 30 N = 375
Age, years 37.4 ± 15.0 31.1 ± 9.8 35.5 ± 10.9 35.2 ± 11.5 33.9 ± 9.7 38.2 ± 11.7
Weight ≥ 90 kg, n (%) 10 (55.6) 13 (59.1) 74 (45.7) 264 (55.3) 15 (50.0) 197 (52.5)
BMI, kg/m2 34.2 ± 7.0 34.0 ± 9.7 31.1 ± 7.1 32.4 ± 7.8 33.5 ± 7.1 31.9 ± 7.3
Time since HS symptom onset, years 10.4 ± 6.9 11.9 ± 10.0 12.4 ± 9.7 12.5 ± 9.1 13.1 ± 8.7 14.5 ± 10.3
Time since diagnosis, years 4.1 ± 4.2 4.3 ± 4.0 7.4 ± 8.0 6.6 ± 6.5 8.0 ± 7.2 8.4 ± 7.9
AN count 6.7 ± 1.6 14.8 ± 5.7 6.5 ± 1.6 12.9 ± 7.4 6.9 ± 1.4 16.7 ± 10.9
Inflammatory nodule count 6.4 ± 2.0 13.0 ± 6.2 6.0 ± 1.8 10.3 ± 7.1 6.2 ± 1.6 11.6 ± 8.9
Abscess count 0.3 ± 0.8 1.9 ± 1.4 0.5 ± 0.9 2.6 ± 3.0 0.7 ± 1.0 5.1 ± 6.1
Draining tunnel count 0.0 ± 0.0 0.0 ± 0.2 0.1 ± 0.3 2.2 ± 2.7 0.1 ± 0.4 4.7 ± 4.0
Total tunnel count 0.1 ± 0.2 0.0 ± 0.2 1.3 ± 2.4 3.9 ± 4.2 2.3 ± 3.2 8.1 ± 5.8
Skin pain/NRS 3.9 ± 2.8 5.6 ± 2.3 4.2 ± 2.6 5.1 ± 2.4 3.9 ± 2.2 5.9 ± 2.3
DLQI, total score 10.5 ± 7.5 14.4 ± 5.2 11.8 ± 6.6 14.3 ± 6.8 12.2 ± 5.4 16.1 ± 6.9
b
HS-­PGA , n (%)
2 = Mild 0 (0.0) 0 (0.0) 3 (1.9) 1 (0.2) 0 (0.0) 0 (0.0)
3 = Moderate 18 (100.0) 14 (63.6) 155 (95.7) 236 (49.5) 28 (93.3) 75 (20.0)
4 = Severe 0 (0.0) 8 (36.4) 4 (2.5) 112 (23.5) 2 (6.7) 72 (19.2)
5 = Very severe 0 (0.0) 0 (0.0) 0 (0.0) 128 (26.8) 0 (0.0) 228 (60.8)
Number of body areas, n (%)
1 4 (22.2) 4 (18.2) 41 (25.3) 68 (14.3) 3 (10.0) 47 (12.5)
2 12 (66.7) 6 (27.3) 81 (50.0) 190 (39.8) 20 (66.7) 158 (42.1)
3 2 (11.1) 8 (36.4) 39 (24.1) 169 (35.4) 7 (23.3) 116 (30.9)
4 0 (0.0) 4 (18.2) 1 (0.6) 50 (10.5) 0 (0.0) 54 (14.4)
Body areas involved, n (%)
Pelvic 14 (77.8) 19 (86.4) 144 (88.9) 426 (89.3) 25 (83.3) 353 (94.1)
Axilla 13 (72.2) 13 (59.1) 108 (66.7) 380 (79.7) 27 (90.0) 299 (79.7)
Mammary 2 (11.1) 11 (50.0) 25 (15.4) 146 (30.6) 4 (13.3) 114 (30.4)
Other 5 (27.8) 13 (59.1) 47 (29.0) 203 (42.6) 8 (26.7) 161 (42.9)

Note: Data are presented as mean ± SD, unless otherwise specified.

Abbreviations: AN, abscesses and inflammatory nodules; BMI, body mass index; DLQI, Dermatology Life Quality Index; HS-­PGA, hidradenitis suppurativa physician's
global assessment; IHS4, International Hidradenitis Suppurativa Severity Score System; N, total number of patients; Skin Pain/NRS, numeric rating scale of the Patient's
Global Assessment of skin pain at worst (averaged over the last 7 days); SD, standard deviation.
a
Number of body areas with ≥1 total tunnel, inflammatory nodule or abscess. Body areas are defined as axilla, pelvic (inclusive of buttock, inguinocrural, perianal and
perineal regions), mammary and other. Lesions in more than one region within the defined body area were counted as one.
b
No patients were considered to have clear or minimal disease based on HS-­PGA scoring. Pooled observed data from the SUNSHINE and SUNRISE trials.

C ON F L IC T OF I N T E R E S T S TAT E M E N T received investigator-­initiated grants from AbbVie, Celgene,

Christos Zouboulis reports consultancy/advisory boards
disease-­
relevant honoraria from Almirall, Boehringer
Ingelheim, Incyte, InflaRx, Janssen, Novartis, Sanofi, UCB
and Viatris. He is President of the EHSF e.V., coordinator
of the ALLOCATE Skin group of the ERN Skin and chair
of the ARHS Task Force group of the EADV. He is Editor of
the EADV News; is copyright co-­holder of IHS4 on behalf
of the EHSF e.V. His employer has received disease-­relevant
grants from Boehringer Ingelheim, InflaRx, Novartis and
UCB for his participation as clinical investigator. Errol P.
Prens reports advisory boards/speaker fees from AbbVie,
Amgen, Celgene, Eli Lilly, Janssen-­Cilag, Galderma, InflaRx,
Novartis, UCB, Regeneron and Pfizer. His employer has
Janssen-­Cilag and UCB. Christopher J. Sayed has received
advisory boards/speaker fees from AbbVie, InflaRx, Incyte,
Sonoma Biotherapeutics, Alumis, Novartis and UCB and
grants from AbbVie, Chemocentryx, Incyte, InflaRx,
Novartis and UCB. He is a Board member of the HSF Inc
(USA) and a member of the EHSF. Alejandro Molina Leyva
reports consultancy/speaker's honoraria and/or travel grants
and/or participated in clinical trials sponsored by AbbVie,
Almirall, Boehringer Ingelheim, Celgene, Janssen-­ Cilag,
LEO Pharma, Lilly, Novartis, Pfizer, Sandoz, Sanofi and
UCB. Vincenzo Bettoli reports speaker/consultancy/advi-
sory boards honoraria from AbbVie, Novartis, UCB, Biogen,
Difa Cooper, Galderma and Mylan. Marco Romanelli reports
 14683083, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jdv.19681 by Universidad De Granada, Wiley Online Library on [01/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
LETTER TO THE EDITOR     | 3

F I G U R E 1 Patients classified as Hurley stage I-­III with markedly different IHS4-­assessed severities. (a) Moderate HS (3 abscesses: IHS4 = 6), (b)
severe HS (11 inflammatory nodules: IHS4 = 11), (c) moderate HS (3 abscesses: IHS4 = 6), (d) severe HS (3 draining tunnels, 2 abscesses, one inflammatory
nodule: IHS4 = 17), (e) moderate HS (one draining tunnel, one abscess, 2 inflammatory nodules; IHS4 = 8), (f) severe HS (2 draining tunnels, 2 abscesses,
one inflammatory nodule: IHS4 = 13). IHS4, International Hidradenitis Suppurativa Severity Score System. These pictures were not from patients
enrolled in the SUNSHINE and SUNRISE trials and are included to illustrate differences in Hurley staging vs IHS4 grading in the clinic. These images
were collected from patients during an outpatient visit at Staedtisches Klinikum Dessau, Dessau, Germany.

speaker/consultancy/advisory boards honoraria from Sanofi, Ethics Committee (IEC) or Institutional Review Board
AbbVie, Novartis, Lilly. Jacek C. Szepietowski has served as (IRB) for each center. The study was conducted according to
an advisor for LEO Pharma, Novartis, Pierre Fabre, Sanofi-­ ICH E6 Guidelines for Good Clinical Practice that have their
Genzyme, UCB and Trevi; he has received speaker honoraria origin in the Declaration of Helsinki. The patients in this
from AbbVie, Janssen-­Cilag, LEO Pharma, Novartis, Sanofi-­ manuscript have given written informed consent to publica-
Genzyme and Eli Lilly, and he has received clinical trial tion of their case details.
funding from AbbVie, Almirall, Amgen, Galapagos, Holm,
Incyte Corporation, InflaRX, Janssen-­Cilag, Novartis, Pfizer, C L I N IC A L T R I A L R E G I S T R AT ION
Regeneron, Trevi and UCB. Angela Llobet Martinez, Torben SUNSHINE (NCT03713619); SUNRISE (NCT03713632).
Kasparek, Iryna Lobach, Magdalena B. Wozniak, Christine-­
Elke Ortmann, Nicolas Thomas, Teresa Bachhuber and Shoba Christos C. Zouboulis1,2
Ravichandran are employees of Novartis. Thrasyvoulos Errol P. Prens1,3
Tzellos reports consultancy/advisory boards/speaker fees Christopher J. Sayed1,4
from AbbVie, Novartis, Boehringer Ingelheim and UCB. He Alejandro Molina-­Leyva1,5
is Treasurer of the EHSF e.V. Vincenzo Bettoli1,6
Marco Romanelli1,7
DATA AVA I L A BI L I T Y S TAT E M E N T Jacek C. Szepietowski1,8
The data that support the findings of this study are available Angela Llobet Martinez9
from the corresponding author upon reasonable request. Torben Kasparek9
Iryna Lobach9
E T H IC S S TAT E M E N T Magdalena B. Wozniak10
For both the SUNSHINE and SUNRISE trials, the study pro- Christine-­Elke Ortmann9
tocol and all amendments were reviewed by the Independent Nicolas Thomas9

4 |    LETTER TO THE EDITOR
Teresa Bachhuber9
Shoba Ravichandran11
Thrasyvoulos Tzellos1,12
1
European Hidradenitis Suppurativa Foundation
(EHSF), Dessau, Germany
2
Departments of Dermatology, Venereology,
Allergology and Immunology, Staedtisches Klinikum
Dessau, Brandenburg Medical School Theodor
Fontane and Faculty of Health Sciences Brandenburg,
Dessau, Germany
3
Department of Dermatology, Erasmus University
Medical Center Rotterdam, Rotterdam, The
Netherlands
4 2015;231:184–90.
Department of Dermatology, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina,
USA
5
Hidradenitis Suppurativa Unit, Instituto de
Investigación Biosanitaria ibs and Servicio de
Dermatologia, Hospital Universitario Virgen de Las
Nieves, Granada, Spain
6
Section of Dermatology and Infectious Diseases,
Department of Medical Sciences, University of Ferrara,
Ferrara, Italy
7 5. Hessam S, Scholl L, Sand M, Schmitz L, Reitenbach S, Bechara FG. A
Department of Dermatology, University of Pisa, Pisa,
Italy
8
Department of Dermatology, Venereology and
Allergology, Wroclaw Medical University, Wrocław,
Poland
9 a novel dynamic scoring system to assess HS severity. Br J Dermatol.
Novartis Pharma AG, Basel, Switzerland
10
Novartis Ireland Limited, Dublin, Ireland
11
Novartis Pharmaceuticals Corporation, East
Hanover, New Jersey, USA
12
Department of Dermatology, Nordland Hospital
Trust, Bodø, Norway
Correspondence
Christos C. Zouboulis, Departments of Dermatology,
Venereology, Allergology and Immunology,
Staedtisches Klinikum Dessau, Brandenburg Medical
School Theodor Fontane and Faculty of Health
Sciences Brandenburg, Aueweg 38, Dessau 06847,
Germany.
Email: christos.zouboulis@mhb-fontane.de
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ORC I D
Christos C. Zouboulis https://orcid.
org/0000-0003-1646-2608
Christopher J. Sayed https://orcid.
org/0000-0003-3201-4637
Alejandro Molina-­Leyva https://orcid.
org/0000-0001-6882-2113
Vincenzo Bettoli https://orcid.org/0000-0002-2760-4600
Marco Romanelli https://orcid.org/0000-0002-4127-0141
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