A Modified TIME Concept in Hidradenitis Suppurativa Topical Management

Teresa Oranges, MD; Agata Janowska, MD; Andrea Chiricozzi, MD; Marco Romanelli, MD, PhD; Valentina Dini, MD, PhD


Wounds. 2019;31(9):222-227. 

In This Article

Abstract and Introduction


Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory disorder characterized by lesions such as abscesses and fistulas. The disease may require medical and/or surgical treatment, and the role of wound care is crucial. The acronym TIME (tissue nonviable, inflammation/infection, moisture imbalance, edge of wound) is widely recognized as a standardized approach to wound bed preparation.

Objective: The aim of this study is to describe a modified concept of TIME useful in the management of HS: HS-TIME.

Materials and Methods: The authors modified the standard TIME table considering the pathophysiology, the therapeutic approaches, and the possible neoplastic evolution in HS. Moreover, 2 distinct groups of lesions were distinguished: typical HS lesions and postsurgical wounds.

Results: The proper management of HS lesions according to the HS-TIME rules could help the healing process, reduce pain, prevent severe complications, and improve the patient's quality of life.

Conclusions: Considering the lack of strong evidence regarding wound care in HS, the authors propose the new concept of HS-TIME, based on the TIME wound bed preparation rules, as a new, helpful, easy-to-use tool that may assist physicians in identifying the best wound approach in these patients.


Wound bed preparation (WBP) has gained international recognition as a concept that can provide practitioners with a structured approach when assessing and managing patients with wounds. To assist the concept of WBP, the TIME acronym was introduced to summarize the 4 main components of WBP: devitalized tissue management (T), control of infection and inflammation (I), moisture imbalance (M), and advancement of the epithelial edge of the wound (E). The TIME framework is a useful, practical tool based on identification and removal of barriers to healing.[1]

Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder of the terminal follicular epithelium in the apocrine gland-bearing skin, due to a primary keratin plugging followed by inflammation of apocrine glands. It is characterized by recurrent, tender, and deep-seated nodules, abscesses, fistulas, sinus tracts, and scarring in those regions of the body with a higher density of apocrine glands, such as the axillary, inguinal, gluteal, and inframammary areas.[2] Epidemiological studies of HS have shown a range of prevalence from 0.053% to 4%.[3] The female-to-male ratio of HS is about 3:1, and people aged 18 to 44 years are affected more frequently.[4,5] Smoking and elevated body mass index are associated factors[6] and abnormal levels of hormones, such as androgens, also may be detected.[7] Concomitant and secondary diseases such as obesity, metabolic syndrome, inflammatory bowel diseases, pyoderma gangrenosum, spondyloarthropathy, and SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome have been described.[2] The diagnosis is made upon the presence of HS lesions in common areas with at least 2 recurrences in the past 6 months. Several clinical scores have been used to evaluate the severity of the disease: Hurley, modified Sartorius score, HS Severity Index, HS Physician Global Assessment, Acne Inversa Severity Index, and Dermatology Life Quality Index.[2,8] The Hurley staging system is the most widely used HS severity scale in clinical practice. This staging system classifies HS patients into 3 stages: stage 1, abscesses without sinus tracts and scarring; stage 2, widely separated abscesses with tract formation and scarring; and stage 3, diffuse/near-diffuse involvement or abscesses and multiple interconnected tracts across the entire area (Figure 1).[2]

Figure 1.

Hidradenitis suppurativa (HS) in different Hurley stages. (A) Nodules, abscesses, and pustules on the gluteal areas in a man with Hurley stage 1 HS; (B) abscesses, fistulas, and scarring on the right axilla of a man with Hurley stage 2 HS; and (C) multiple abscesses, fistulas, nodules, and scarring involving the entire gluteal areas and the upper part of the thighs in a man with Hurley stage 2 HS.

The main differential diagnoses of HS are staphylococcal infections, cutaneous Crohn's disease, simple abscesses, neoplasms, lymphogranuloma venereum, cutaneous actinomycosis, and cutaneous tuberculosis (scrofuloderma type).[2] Lesions may severely impair patient quality of life[9] due to pain, malodorous lesions, and complications, such as reduction of limb mobility due to scarring, lymphedema, and depression.[10] This condition is associated with embarrassment and social stigma with a strong negative impact on interpersonal relationships, education, and work.[11] Moreover, squamous cell carcinoma (SCC) may arise on chronic HS lesions and be lethal.[12] Treatment for HS includes topical and systemic antibiotics as well as anti-inflammatory and biologic drugs. Local wound care includes the use of antiseptics, topical antibiotics, and steroids to control infection and inflammation. Absorbent dressings also are employed for moisture control.[13] In the case of long-term disease, hypergranulation tissue may develop and, in select cases, a skin biopsy is recommended to rule out the presence of SCC. In a mild to severe case, laser treatment and surgical excision of the affected tissue may provide a rapid and satisfying result, but recurrence of HS is reported frequently.[14,15] The type of surgical procedure depends mainly on the size and location of the affected tissue. Therefore, postsurgical HS wound care may include the removal of necrotic tissue, inflammation reduction, bacterial load management, moisture balance, and granulation tissue promotion.[1,13]

TIME Concept in Wound Healing

In 2000, Falanga[16] described critical targets and ways to achieve optimal WBP, including necrotic tissue removal, edema and exudate control, bacterial balance, and vascularization promotion. In the same year, Sibbald et al[17] defined WBP as a "changing paradigm that links treatment to the cause and focuses on three components of local wound care: debridement, wound-friendly moist interactive dressings, and bacterial balance."

The addition of another component – the epidermal edge – led to the TIME acronym, a clinical tool for the management of chronic wounds that was developed in June 2002 by a group of experts in the field of wound care and management. These 4 components were first published in 2003 in the form of a table that linked clinical observation to the proposed underlying pathology and highlighted the clinical outcomes for each of the 4 aspects.[1]

The aim of this study is to describe a modified concept of TIME useful for the management of HS: HS-TIME. In particular, the authors propose to modify the TIME concept in order to correctly address 2 distinct groups of HS lesions: typical HS lesions and postsurgical wounds.