Chronicity is one of the main features of HS. In a questionnaire survey of 110 patients Von der Werth and Williams reported that in their population - mean age 40 years - the average duration of the disease had been 18.8 years and 98/110 still had active disease . This is indeed a "heart sink" condition for the patient. Furthermore, there is an extreme variation in the severity of HS. In a personal series of 164 patients , 76% were in Hurley's stage I, 20% in stage II and 4% in stage III. Most of the patients were therefore early or mild cases where diagnosis remains the most difficult. Premenstrual flare is commonly observed, and may aid the diagnosis of HS. Patient physiology and behaviour may influence the severity of the disease. The BMI does not appear to be an independent risk factor for disease onset, but may influence the course of the disease. Overweight and obese patients have significantly more severe disease, as evaluated by the Sartorius' index . The smoking of tobacco may, in contrast, be a risk factor for the development of HS. In terms of disease severity, 3 current smokers appear to have slightly more severe disease, but the difference does not reach statistical significance. These factors are of clinical importance to the management of patients.
The disease is highly intrusive in the lives of patients. Von der Werth and Williams reported that 62% of patients acknowledged the presence of permanently painful boils that failed to subside . In our own series 30% of the 164 patients experienced pain more than 15 days a month . It is obvious that the pain, suppuration and repercussions for the patient's social and sex life are responsible for this disease's severe impact on quality of life [11, 13].
General practitioners and most specialists are more familiar with the dramatic aspect of severe disease and remember this picture, thus possibly overlooking the less severe cases that are intermittent, benign or of medium severity. This failure to recognize mild forms of HS explains why the prevalence of HS is generally underestimated.
modes of disease evolution. The disease may be restricted to a single region - e.g. axillary - or expand to all possible areas. The disease severity may also vary. It may be active in all areas or only in one or two areas; and in each involved area the degree of involvement may vary. It may be massive with no normal skin left or the disease may be represented by only one or two nodules or draining sinuses. In a given region, each new attack may be a revival of an old lesion or alternatively the appearance of new nodules and abscesses each time.
If one is to classify the severity of intermediate disease further the number of areas involved, the extent of lesions in each area, and the number of days with pain and/or suppuration are the main factors in the assessment.
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