Opioid, alcohol, and cannabis misuse among patients with hidradenitis suppurativa: A population-based analysis in the United States

Medical and Surgical Management of Hidradenitis Suppurativa: A Review of International Treatment Guidelines and Implementation in General Dermatology Practice

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic painful skin disease that severely impairs patients' quality of life. While high-quality trials of HS therapies remain limited, medical knowledge of best treatment practices is rapidly evolving, leading to the recent publication of multiple international treatment guidelines for HS.

SUMMARY

This review compares international HS treatment guidelines, describes evidence for effectiveness of common and emerging HS therapies, and provides guidance for integrating evidence-based HS care into practice. Although over 50 medical and procedural treatments are mentioned across international HS guidelines, only adalimumab and infliximab have grade B/weak recommendation or higher across all major guidelines. This review describes the appropriate patient selection and effectiveness of the most commonly used medical and procedural treatments for HS. It also includes recommendations for counseling, dosing, and duration of medical therapies as well as procedure videos for the practicing dermatologist.

Is substance use disorder more prevalent in patients with hidradenitis suppurativa?

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that disproportionately affects women and is associated with significant physical and psychosocial impact. Recent studies have reported an increased prevalence of substance abuse among patients with HS, including increased alcohol, opioid, and cannabis use. Whether substance use disorder is more prevalent among patients with HS is controversial because these data come from small studies and a major confounder is that patients with HS are often prescribed opioids for HS-associated pain. This review summarizes the current literature on substance use in HS to investigate whether substance use disorder is more likely in this patient population. We also highlight possible cofounders and areas of unmet need in HS that are potential causes of abuse, such as adequate pain control and impaired quality of life, and suggest opportunities for provider intervention. Evidence suggests that there is an increased prevalence of substance use disorder in patients with HS, but the full extent is still difficult to determine. However, with early screening and appropriate referrals to specialists, dermatologic providers may properly intervene and prevent substance use disorder in patients with HS.

Incidence of Long-term Opioid Use Among Opioid-Naive Patients With Hidradenitis Suppurativa in the United States

IMPORTANCE

Risk of long-term opioid use among patients with hidradenitis suppurativa (HS), who experience pain that substantially impairs quality of life, is unknown to date.

OBJECTIVE

To compare overall and subgroup incidence of long-term opioid use in a population of opioid-naive patients with HS and control patients.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was based on a demographically heterogeneous population-based sample of more than 56 million unique patients from January 1, 2008, through December 10, 2018. Patients with HS (n = 22 277) and controls (n = 828 832) were identified using electronic health records data. Data were analyzed from December 13, 2018, through January 28, 2019.

MAIN OUTCOMES AND MEASURES

The primary outcome was incident long-term opioid use.

RESULTS

Among the 22 277 patients with HS, mean (SD) age was 40.8 (14.6) years, 16 912 (75.9%) were women, and 13 190 (59.2%) were white. Crude 1-year incidence of long-term opioid use among opioid-naive patients with HS was 0.33% (74 of 22 277), compared with 0.14% (1168 of 828 832) among controls (P < .001). In adjusted analysis, patients with HS had 1.53 (95% CI, 1.20-1.95; P < .001) times the odds of new long-term opioid use compared with controls. Among patients with HS, advancing age (odds ratio [OR], 1.02 per 1-year increase; 95% CI, 1.00-1.03; P = .05), ever smoking (OR, 3.64; 95% CI, 2.06-6.41; P < .001), history of depression (OR, 1.97; 95% CI, 1.21-3.19; P = .006), and baseline Charlson comorbidity index score (OR, 1.15 per 1-point increase; 95% CI, 1.03-1.29; P = .01) were associated with higher odds of long-term opioid use. Among patients with HS and long-term opioid use, 4 of 74 (5.4%) were diagnosed with opioid use disorder during the study period. The most frequent schedule II opioid prescriptions included oxycodone hydrochloride (55 of 74 patients [74.3%]), hydrocodone bitartrate (44 [59.5%]), hydromorphone hydrochloride (16 [21.6%]), morphine sulfate (13 [17.6%]), and fentanyl citrate (6 [8.1%]). Tramadol hydrochloride (32 [43.2%]) represented the most frequent non-schedule II prescription. Disciplines prescribing the most opioids to patients with HS included primary care (398 [72.8%]), anesthesiology/pain management (48 [8.8%]), gastroenterology (25 [4.6%]), surgery (23 [4.2%]), and emergency medicine (10 [1.8%]).

CONCLUSIONS AND RELEVANCE

In this study, patients with HS were at higher risk for long-term opioid use. These results suggest that periodic assessment of pain and screening for long-term opioid use may be warranted, particularly among patients who are older, who smoke tobacco, or who have depression and other medical comorbidities.

Evaluating patients' unmet needs in hidradenitis suppurativa: Results from the Global Survey Of Impact and Healthcare Needs (VOICE) Project

BACKGROUND

A needs assessment for patients with hidradenitis suppurativa (HS) will support advancements in multidisciplinary care, treatment, research, advocacy, and philanthropy.

OBJECTIVE

To evaluate unmet needs from the perspective of HS patients.

METHODS

Prospective multinational survey of patients between October 2017 and July 2018.

RESULTS

Before receiving a formal HS diagnosis, 63.7% (n = 827) of patients visited a physician ≥5 times. Mean delay in diagnosis was 10.2 ± 8.9 years. Patients experienced flare daily, weekly, or monthly in 23.0%, 29.8%, and 31.1%, respectively. Most (61.4% [n = 798]) rated recent HS-related pain as moderate or higher, and 4.5% described recent pain to be the worst possible. Access to dermatology was rated as difficult by 37.0% (n = 481). Patients reported visiting the emergency department and hospital ≥5 times for symptoms in 18.3% and 12.5%, respectively. An extreme impact on life was reported by 43.3% (n = 563), and 14.5% were disabled due to disease. Patients reported a high frequency of comorbidities, most commonly mood disorders. Patients were dissatisfied with medical or procedural treatments in 45.9% and 34.6%, respectively.

LIMITATIONS

Data were self-reported. Patients with more severe disease may have been selected.

CONCLUSION

HS patients have identified several critical unmet needs that will require stakeholder collaboration to meaningfully address.

Comorbidities of hidradenitis suppurativa: A review of the literature

Background

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that affects the follicular portion of folliculopilosebaceous units. It causes painful nodules, abscesses, and draining sinus tracts throughout multiple regions of the body. HS primarily affects women; the overall HS prevalence in women is three times that in men. Although cutaneous disease itself causes substantial morbidity, recent evidence has shown that HS is a systemic inflammatory disease with multiple associated comorbidities.

Objective

A review of the literature was conducted to elucidate existing information on this topic to assist in clinical decision-making for dermatologists.

Methods

A review of the literature using the PubMed database was conducted with the search term "hidradenitis suppurativa comorbidities". The search was conducted from March 3, 2019 to March 20, 2019, and yielded 55 articles, case reports, and reviews.

Results

Metabolic and cardiovascular comorbidities were the most commonly associated with HS. HS has a significant comorbidity burden beyond the skin, including metabolic, cardiovascular, endocrine, gastrointestinal, rheumatologic, and psychiatric disorders, which collectively decrease the quality of life of patients.

Conclusions

Dermatologists should be aware of these associations to encourage appropriate screening and referral for management of these disorders.

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management

Hidradenitis suppurativa is a chronic inflammatory disorder affecting hair follicles, with profoundly negative impact on patient quality of life. Evidence informing ideal evaluation and management of patients with hidradenitis suppurativa is still sparse in many areas, but it has grown substantially in the last decade. Part I of this evidence-based guideline is presented to support health care practitioners as they select optimal management strategies, including diagnostic testing, comorbidity screening, and both complementary and procedural treatment options. Recommendations and evidence grading based on the evidence available at the time of the review are provided.

All-cause mortality among patients with hidradenitis suppurativa: A population-based cohort study in the United States

BACKGROUND

The mortality risk for patients with hidradenitis suppurativa (HS) is largely unknown.

OBJECTIVE

To compare mortality risk among individuals with and without HS in the United States.

METHODS

Retrospective cohort study in a population sample identified by using electronic health records data between January 1, 2012, and December 31, 2016. Primary outcome was incidence of 5-year all-cause mortality.

RESULTS

The crude 5-year mortality rate among patients with HS was 2.4% (321/13 289), compared with 2.7% (18 508/685 573) among control individuals. In the fully adjusted model, the increase in HS mortality risk was 14% (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.01-1.28). Overall, excess risk of death attributable to HS was 3.1 deaths per 1000 patients (95% CI, 0.2-6.0) during the study period. Characteristics associated with mortality among patients with HS included age (OR, 1.05; 95% CI, 1.04-1.06), male sex (OR, 1.40; 95% CI, 1.09-1.79), ever-smoking status (OR, 1.48; 95% CI, 1.16-1.92), and Charlson Comorbidity Index score (OR, 1.25; 95% CI, 1.21-1.29).

LIMITATIONS

The follow-up period may not have been long enough to assess the influence of disease severity or duration on mortality.

CONCLUSION

HS appears to confer an independent risk of all-cause mortality. This risk is also influenced by tobacco smoking and comorbidities, which may be modifiable.

The Comorbidity Burden of Hidradenitis Suppurativa in the United States: A Claims Data Analysis

INTRODUCTION

Prior studies have reported that hidradenitis suppurativa (HS) is accompanied by a myriad of physical and mental conditions. However, given the small sample sizes and the limited number of pre-selected comorbidities, these studies do not provide a complete picture of the comorbidity burden of HS in the USA. Moreover, the relationship between HS severity and comorbidity burden has yet to be characterized. Using a large US claims database, we estimated the comorbidity burden associated with HS, stratified by disease severity.

METHODS

A retrospective matched cohort design was used. Patients with HS were classified into two severity cohorts (milder and more severe) using an empirical algorithm based on treatments received. The comorbidity burden was compared between each HS cohort and their matched HS-free cohort, and between patients with milder vs. those with more severe forms of HS.

RESULTS

Several physical and mental comorbidities were found to be more prevalent in both cohorts of patients with milder and more severe forms of HS than in their matched HS-free cohorts. The comorbidity burden also increased greatly as the disease progressed to more severe forms.

CONCLUSIONS

The results of this study highlight the complexity of the comorbidity burden of HS patients and the need for a multidisciplinary approach to optimize the management of HS and its numerous associated comorbidities.

FUNDING

AbbVie, Inc.

Antiandrogen therapy with spironolactone for the treatment of hidradenitis suppurativa

BACKGROUND

Hormonal therapy is a potential treatment for hidradenitis suppurativa (HS). However, few data exist describing the efficacy of spironolactone in treatment of HS.

OBJECTIVE

To assess whether spironolactone treatment improves HS disease severity and patient-reported pain.

METHODS

We performed a single-center chart review of female patients with HS who were treated with spironolactone between 2000 and 2017. Primary outcome measurements included the HS Physician's Global Assessment (HS-PGA), Hurley staging, inflammatory lesion count, fistula count, and a numeric rating scale for pain.

RESULTS

On average, subjects were exposed to 75 mg of spironolactone daily over a 7.1-month follow-up period. Patients achieved significant disease improvement with regard to pain (Δ-1.5 [P = .01]), inflammatory lesions (Δ-1.3 [P = .02]), and HS-PGA score (Δ-0.6 [P < .001]). As expected, no change was found for Hurley stage (Δ0 [P = .32]) or fistulas (Δ0 [P = .73]). There was no difference in improvement between subjects who received less than 75 mg of spironolactone daily (n = 25; average dose, 45 mg/d) and those who received more than 100 mg daily (n = 21; average dose, 112 mg/d).

LIMITATIONS

Retrospective nature, limited sample size, and variations in severity measures documented were limiting factors.

CONCLUSIONS

Management of HS with spironolactone reduces lesion count, HS-PGA score, and pain. Lower doses appear to be effective and may be an appropriate option for patients with tolerability concerns.