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

A Case of Concurrent Psoriasis and Hidradenitis Suppurativa Successfully Treated with Tildrakizumab

INTRODUCTION

Plaque psoriasis and hidradenitis suppurativa are chronic inflammatory skin conditions with common pathogenetic pathways.

METHODS

We report the case of a 38-year-old man with 15-year history of psoriasis and hidradenitis suppurativa successfully treated with tildrakizumab for both conditions. After treatment failure to adalimumab, secukinumab, and guselkumab, tildrakizumab therapy was initiated and resulted in complete remission of psoriasis and the achievement of hidradenitis suppurativa clinical response after 40 weeks, without reporting adverse events. These responses were maintained at week 52.

CONCLUSION

Tildrakizumab may be an effective and safe therapeutic option for concomitant psoriasis and hidradenitis suppurativa.

Hidradenitis Suppurativa and Five Key Vitamins and Minerals

Hidradenitis suppurativa (HS), a chronic inflammatory disease characterized by painful abscesses and nodules, has limited effective treatment options. However, adjuncts to standard therapeutics such as dietary modifications have been increasingly investigated in recent years. This comprehensive review aimed to analyze the literature concerning the relationship between HS and 28 essential vitamins and minerals. A literature search was performed via PubMed, Embase, Ovid, and Scopus using search terms related to HS and the essential vitamins and minerals. A total of 215 unique articles were identified and analyzed. Twelve essential nutrients had documented associations with HS; definitive supplementation or monitoring recommendations were identified for 7 of the 12 HS-associated nutrients in the literature. Evidence is growing that supports adjunct supplementation of zinc, vitamin A, and vitamin D in the treatment of HS. Further, obtaining serum levels of zinc, vitamin A, vitamin D, and vitamin B12 upon initial diagnosis of HS may be beneficial to optimize standard HS treatment. In conclusion, optimizing nutrition in addition to standard HS therapeutics may help reduce disease burden; however more research is needed.

Systemic Antibiotic Therapy in Hidradenitis Suppurativa: A Review on Treatment Landscape and Current Issues

Hidradenitis suppurativa (HS) is a chronic, recurrent, and inflammatory skin disease characterized by painful, deep-seated, nodules, abscesses, and sinus tracts in sensitive areas of the body, including axillary, inguinal, and anogenital regions. Antibiotics represent the first-line pharmacological treatment of HS because of their anti-inflammatory properties and antimicrobial effects. This narrative review summarizes the most significant current issues on the role of systemic antibiotics in the management of HS, critically analyzing the main limits of their use (antibiotic resistance and toxicity). Although, in the last decades, several cytokines have been implicated in the pathomechanism of HS and the research on the use of novel biologic agents in HS has been intensified, antibiotics remain a valid therapeutic approach. Future challenges regarding antibiotic therapy in HS comprise their use in association with biologics in the management of acute flare or as a bridge therapy to surgery.

Characteristics and Outcomes of Patients Undergoing Surgical Management of Hidradenitis Suppurativa: An ACS-NSQIP Data Analysis

Objective: Hidradenitis suppurativa (HS) is a painful inflammatory skin disease. Management is largely medical, with surgery reserved for severe refractory cases. In this study, we sought to conduct a retrospective analysis of a multi-institutional surgical database to investigate the surgical management of patients with HS and identify trends in the postoperative outcomes. Approach: The 2011-2019 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed to identify patients who underwent surgery for management of HS. Postoperative outcomes were assessed, including surgical and medical complications, length of hospital stay, reoperation, readmission, and nonhome discharge. This article was reported according to the STROBE criteria. Results: We identified 1,030 patients, of which 62% were female and 50% were black. The most common comorbidity was obesity (61%). Surgery was mainly performed by general surgeons (62%) and plastic surgeons (31%). Complications were overall low, with readmission being the most common (7.1%, unplanned 6.0%), followed by reoperation (5.8%). The most common surgical complication was superficial incisional infection (5.1%) and most common medical complication was sepsis (3.8%). Obesity is seen to affect surgical complication rates, with patients with obesity having higher rates of dehiscence (obese: 3.1% and nonobese: 1.0%; p = 0.03) but lower rates of organ space infection (obese: 0.5% and nonobese: 2.0%; p = 0.03) and transfusion (obese: 2.5% and nonobese: 5.2%; p = 0.04). A focus on complications in patients undergoing flap reconstruction (n = 293; 23%), identified higher rates of surgical complications, with superficial incisional infection being the most common (flap reconstruction: 7.5% and incision and drainage, debridement, skin graft: 4.1%; p = 0.04). Innovation: The surgical management of HS is analyzed at the national level, with postoperative complications seen to depend on race and obesity-status. Conclusions: Surgical management for HS is associated with low postoperative complications, making surgery a viable treatment option for this debilitating disease.

Skin Inflammation with a Focus on Wound Healing

Significance: The skin is the crucial first-line barrier against foreign pathogens. Compromise of this barrier presents in the context of inflammatory skin conditions and in chronic wounds. Skin conditions arising from dysfunctional inflammatory pathways severely compromise the quality of life of patients and have a high economic impact on the U.S. health care system. The development of a thorough understanding of the mechanisms that can disrupt skin inflammation is imperative to successfully modulate this inflammation with therapies. Recent Advances: Many advances in the understanding of skin inflammation have occurred during the past decade, including the development of multiple new pharmaceuticals. Mechanical force application has been greatly advanced clinically. Bioscaffolds also promote healing, while reducing scarring. Critical Issues: Various skin inflammatory conditions provide a framework for analysis of our understanding of the phases of successful wound healing. The large burden of chronic wounds on our society continues to focus attention on the chronic inflammatory state induced in many of these skin conditions. Future Directions: Better preclinical models of disease states such as chronic wounds, coupled with enhanced diagnostic abilities of human skin, will allow a better understanding of the mechanism of action. This will lead to improved treatments with biologics and other modalities such as the strategic application of mechanical forces and scaffolds, which ultimately results in better outcomes for our patients.

Pediatric hidradenitis suppurativa: Describing care patterns in the emergency department

BACKGROUND/OBJECTIVES

The emergency department (ED) is a common point of care for many pediatric hidradenitis suppurativa (HS) patients; however, ED care may not align with recommended treatment standards. The objective of this study is to describe the care pediatric HS patients receive in the ED compared to both HS management guidelines and the management of pediatric skin and soft tissue abscess (SSTA) patients.

METHODS

We performed a retrospective chart review of pediatric HS and SSTA patients who presented to a single pediatric ED. Demographic and ED encounter data including medications, procedures, recommendations, consults, and referrals were collected.

RESULTS

58 HS and 175 SSTA charts were reviewed. 69.5% of patients were female and 93.6% were African American/Black. 29.3% of HS and 61.7% of SSTA encounters involved incision and drainage (I&D); 62.1% of HS and 70.1% of SSTA encounters involved the prescription or administration of oral clindamycin; 3.4% of HS and 0.6% of SSTA encounters involved dermatology consultation in the ED; and 22.4% of HS and 5.1% of SSTA encounters involved outpatient referrals to dermatology.

CONCLUSIONS

Our data reveal a pediatric HS and SSTA population that is predominantly female and African American/Black. Significant differences were found in the average ages and number of lesions between HS and SSTA patients. I&D and oral clindamycin were the most common treatments across groups; however, I&D was performed significantly more frequently among SSTA encounters than HS encounters. Our results suggest that subtle knowledge gaps may exist in ED provider management of pediatric HS.

Surgical Procedural Definitions for Hidradenitis Suppurativa Developed by Expert Delphi Consensus

Importance

Various surgical approaches for hidradenitis suppurativa (HS) have been described in the literature, but the nomenclature is inconsistent. Excisions have been described as wide, local, radical, and regional with variable descriptions of margins. Deroofing procedures have been described with various approaches though descriptions of the approach are generally more uniform. No international consensus has been formed to globally standardize terminology for HS surgical procedures. Lack of such agreement may contribute to misunderstanding or misclassification in HS procedural research studies and impair clear communication among clinicians or between clinicians and patients.

Objective

To create a set of standard definitions for HS surgical procedures.

Design, Setting, and Participants

This consensus agreement study was conducted from January to May 2021 using the modified Delphi consensus method to reach agreement among a group of international HS experts regarding standardized definitions for an initial set of HS surgical terms, including "incision and drainage," "deroofing/unroofing," "excision," "lesional excision," and "regional excision," ultimately expanded to 10 terms. Provisional definitions were drafted based on existing literature and discussion among an expert 8-member steering committee. Online surveys were disseminated to members of the HS Foundation, direct contacts of the expert panel, and the HSPlace listserv to reach physicians with considerable experience with HS surgery. Consensus was defined as greater than 70% agreement to accept a definition.

Results

In the first and second modified Delphi round, 50 and 33 experts participated, respectively. Ten surgical procedural terms and definitions reached consensus with greater than 80% agreement. Overall, the term "local" excision was abandoned and replaced with the descriptors "lesional" or "regional" excision. Of note, "regional" replaced the terms "wide" and "radical" excision. Furthermore, modifiers such as "partial" vs "complete" should also be included when describing surgical procedures. A combination of these terms helped formulate the final glossary of HS surgical procedural definitions.

Conclusion and Relevance

An international group of HS experts agreed on a set of definitions describing surgical procedures frequently used by clinicians and in the literature. The standardization and application of such definitions are vital to allow for accurate communication, reporting consistency, and uniform data collection and study design in the future.

[Guidelines for the Management of Patients with Hidradenitis Suppurativa]

Hidradenitis suppurativa is a chronic and recurrent inflammatory dermatosis characterized by the presence of inflammatory nodules and abscesses in the apocrine gland-rich areas that may progress to suppurative fistulas and scars. Despite being considered one of the dermatological conditions with the greatest impact on patient quality of life, it is often underdiagnosed. Hidradenitis suppurativa, especially in its severe forms, is associated with numerous comorbidities, so a holistic and multidisciplinary perspective is crucial for the management of these patients. The therapeutic approach is complex and challenging. The medical treatment options are diverse and must be adapted to clinical presentation and disease severity. Surgical therapy should be considered as an adjuvant to medical treatment, particularly in refractory cases and in the presence of scars or anatomical and/or functional mutilation. These recommendations reflect the main aspects of the management of the patient with hidradenitis suppurativa and are addressed to all healthcare professionals who take part in their follow-up.

Relevant Dermatoses Among U.S. Military Service Members: An Operational Review of Management Strategies and Telemedicine Utilization

Despite skin being the largest and most exposed organ of the human body, skin issues can be challenging to diagnose in deployed military service members. Common reasons deployed soldiers seek dermatological evaluation include infections, inflammatory skin conditions, and skin growth. Due to limited access to specialized care in deployed settings, dermatological conditions are undertreated and underdiagnosed. As a result, dermatological conditions are a leading contributor to decreased combat effectiveness among deployed medical forces. To lessen the burden of dermatological diseases, military providers should promptly identify operational skin diseases and alleviate modifiable barriers faced by service members. In a post-pandemic era with novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and monkeypox infections, the duty to effectively treat operational skin lesions is ever important. The need for military dermatologists continues to rise as the global landscape continues to evolve with unprecedented infections and increased bioterrorism threats. Teledermatology offers many solutions to mitigate the high demand for dermatologists during pandemics. Dermatological consultations account for the highest number of telemedicine visits in the US Military Health System (MHS). As such, increased utilization of teledermatology will reduce infection-related dermatological sequelae and prevent the medical evacuation of service members from military operations. This review collates and categorizes relevant dermatological conditions encountered among deployed personnel. This report outlines the standard of care and modified treatments recommended according to potential barriers faced in operational settings.

A Practical Guide for Primary Care Providers on Timely Diagnosis and Comprehensive Care Strategies for Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic, progressive inflammatory disease of the skin with many systemic implications. Hidradenitis suppurativa is frequently underdiagnosed or misdiagnosed, particularly because of heterogeneity in presentation and low disease recognition. Patients can see multiple types of health care providers, including primary care providers, along their journey to an accurate diagnosis. This review provides a comprehensive overview of the clinical presentation, associated comorbidities, and life impact associated with hidradenitis suppurativa. Disease features described here can facilitate earlier identification of hidradenitis suppurativa, differentiation from common mimickers, and timely referrals for multidisciplinary management when needed. Engagement of the medical community will also support comprehensive care strategies necessary in hidradenitis suppurativa.

Non-surgical treatment of hidradenitis suppurativa: the role of cryotherapy

Background

Hidradenitis suppurativa is a chronic and recurrent inflammatory disease with a great impact on a patient's quality of life, due to the painful involvement of very sensitive areas, such as the groin, mammary area, and genitals, with malodourous discharge. Multiple treatment options are available; however, no single treatment is effective for all patients, and usually, a combination of medical therapy with various surgical and physical procedures is provided. Cryotherapy is not a routine technique to treat HS, although usually available in the majority of medical clinics, and is cheaper than laser and surgical treatments. The aim of this study was to evaluate the effectiveness of cryotherapy on persistent HS nodules, to reduce the burden of local disease.

Materials and methods

Retrospective observational study in all patients treated with liquid nitrogen cryotherapy for persistent nodules of hidradenitis suppurativa in the last 2 years, with at least 6 months of follow-up after the procedure. Disease severity was assessed with Hurley staging and sonographic staging according to SOS-HS (18 MHz probe, Esaote-MyLab™). The results were scored with a 0-3 points scale, as complete remission (3), partial response (2 to 1), or no response (0), after one session of treatment. Local cleansing and antiseptic treatment after the procedure was the same as previously performed in each patient, not to influence recovery.

Results

In total, 23 patients were included, with a total of 71 persistent nodules treated with a single cryotherapy session. The treatment has been effective in 63 out of 71 nodules treated (88.7%), and the patients attested that they recommend the treatment, the discomfort during recovery was minimal, and the management was not different from daily routine. Persistence was considered as having a failure rate (11.3% overall) and occurred in 7.5% of the nodules of the axillary region, 18.2% on the groin, and 11.2% for nodules of the gluteal region.

Conclusion

Cryotherapy is a simple and effective procedure for the treatment of persistent nodules of HS not responding to medical therapy, and it is a valid alternative to local surgery or laser ablation.

Management of axillary hidradenitis suppurativa: A case report

Hidradenitis suppurativa is a rare, chronic, and recurrent skin disease that affects the pilosebaceous-apocrine unit. Its diagnosis is challenging and it usually manifests in advanced stages due to a lack of knowledge about this entity. To date, there are no standardized therapeutic protocols available for its management. We present a case of a 22-year-old woman with the left axillary hidradenitis suppurativa and underwent surgical treatment successfully. This report emphasizes the importance of educational programs among primary care professionals and public awareness campaigns about this disease, which is under-reported in our community, to avoid physical and psychological complications.

Systematic review of photodynamic therapy for the treatment of hidradenitis suppurativa

OBJECTIVE

To perform a systematic review of available literature regarding the use of 5-aminolevulinic acid (ALA) and ALA derivative photodynamic therapy (PDT) in the treatment of hidradenitis suppurativa (HS) and provide recommendations on its use.

METHODS

A systematic review was performed of all published studies up to September 1, 2019 from nine databases, including PubMed, that evaluated PDT in the treatment of HS. For each study, quality of evidence and risk of bias was evaluated. Recommendations from the body of evidence were created based on Strength of Recommendation and Taxonomy (SORT) criteria.

RESULTS

Eighteen studies met inclusion criteria. The majority of studies had a high risk of bias. Blue light PDT with 20% ALA and red light PDT with 16% methyl aminolevulinate (MAL) demonstrated some benefit based on a small number of poor-quality studies with a high risk of bias (Grade C, level III evidence). The most promising results were for 1%-5% ALA with intralesional diode, with good to complete response in 78%-94% of anatomic sites treated (Grade B, level II evidence).

LIMITATIONS

The majority of studies contained high levels of bias, with significant heterogeneity between studies. Conclusions are limited by small samples sizes, lack of randomized controlled trials, and differing protocols.

CONCLUSION

Further studies are needed to determine the clinical efficacy of 20% ALA with blue light and MAL with red light. Intralesional diode PDT shows the most promise and warrants further investigation in larger, randomized controlled trials.

Perineal burn injury with hidradenitis suppurativa: A case report

RATIONALE

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease which usually presents with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas. Severe HS has interconnecting sinus tracts and when it occurs in the perianal region, perianal fistulas can form. Obesity and smoking are 2 risk factors for the development of HS.

PATIENT CONCERNS

We report a case of a 33-year-old male diagnosed with perianal HS and perianal fistula following a burn injury to the area that occurred during childhood.

DIAGNOSIS

Through integration of the clinical signs and imaging results, the patient was diagnosed with HS, Hurley stage III with perianal fistulas.

INTERVENTIONS

The patient accepted surgical therapy. Performed under the general anesthesia, the procedure comprised sinus tracts excision and drainage.

OUTCOMES

The patient was discharged from the hospital 6 weeks after surgery.

LESSONS

The pathogenesis of the HS in this case was the burn injury interfering with sweat gland formation around the anus. Moreover, the scar from the burn made surgical treatment difficult.

Communicating with health providers and romantic partners: The impact of negative emotions on quality of life for individuals with hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, inflammatory, debilitating skin disease that impacts an estimated 1 to 4% of the population; women are twice as likely to be diagnosed as men. There is no cure for HS, and many patients face a lifetime of various healthcare appointments, medical interventions, and personal experiences living with the disease.

OBJECTIVE

This study aimed to explore social, emotional, and medical experiences for individuals with HS, and to understand connections between those experiences and quality of life.

METHODS

Participants (n = 243) in the community-based convenience sample completed a cross-sectional survey about their experiences and quality of life and reported high rates of anxiety, embarrassment, and depressed mood. These and other negative emotions were commonly experienced during interactions with healthcare providers and romantic partners.

RESULTS

Participants who had more negative interactions with providers and partners surrounding their HS tended to experience a lower quality of life.

LIMITATIONS

Limited generalizability due to convenience sampling.

CONCLUSION

Providers should consider how patients experience patient -provider communication about HS, and how this communication impacts other areas of patients' lives, including quality of life, mental health, and romantic relationships. Future care approaches should prioritize mental health strategies in HS patients' care plans, and establish partnerships between dermatology practices and mental health professionals to aid in the multidisciplinary approach recommended for the treatment of HS.

Microbiome in Hidradenitis Suppurativa—What We Know and Where We Are Heading

Recently, interest in the microbiome of cutaneous diseases has increased tremendously. Of particular interest is the gut-brain-skin axis proposed by Stokes and Pillsbury in 1930. The microbiome has been suggested in the pathogenesis of hidradenitis suppurativa, however the link between the commensals and the host is yet to be established. Across all studies, the increased abundance of Porphyromonas, Peptoniphilus, and Prevotella spp., and a loss of skin commensal species, such as Cutibacterium in HS lesions, is a consistent finding. The role of gut and blood microbiome in hidradenitis suppurativa has not been fully elucidated. According to studies, the main link with the intestine is based on the increased risk of developing Crohn’s disease and ulcerative colitis, however, further research is highly needed in this area. Lifestyle, dietary approaches, and probiotics all seem to influence the microbiome, hence being a promising modality as adjuvant therapy. The aim of this review was to present the latest reports in the field of research on skin, blood, and gut microbiome in terms of hidradenitis suppurativa.

Pharmacological interventions for hidradenitis suppurativa: a protocol for systematic review and network meta-analysis of randomised trials and non-randomised studies

INTRODUCTION

Therapeutic recommendations for hidradenitis suppurativa (HS) have recently shifted towards non-invasive pharmacological options. Recent evidence has shown promising efficacy for specific treatments. However, data regarding the comparative efficacy of these treatments in patients with HS are still limited. Therefore, we plan to conduct a systematic review and network meta-analysis (NMA) to summarise the benefits and harms of different pharmacological interventions for treating people living with HS.

METHODS AND ANALYSIS

We will search electronic databases, including Medline, Embase, PubMed, Web of Science, Scopus, CINAHL and Cochrane Library beginning from their inception dates with no language restrictions. A grey literature search will be performed to supplement the electronic databases. Both randomised trials and non-randomised studies using validated measurement tools that investigated the benefits and harms of pharmacological interventions among people living with HS will be included. The predefined primary outcomes will include treatment responses that reflect the patient's perspective and all-cause discontinuation. Screening, selection, extraction, assessment of the risk of bias and analysis of the strength of the evidence will be performed independently by a pair of reviewers. A two-step approach of traditional pairwise and NMA will be performed. Based on a random-effects model, standardised weighted mean differences and ORs with corresponding 95% CIs will be pooled as effect estimates for the continuous and categorical endpoints, respectively. Statistical and methodological heterogeneities will be assessed. Preplanned subgroup analyses and univariate meta-regression will be conducted to quantify the potential sources of heterogeneity. Evidence-based synthesis will be based on the magnitudes of effect size, evidence certainty and the surface under the cumulative ranking curve values.

ETHICS AND DISSEMINATION

Ethical approval is not required because this study is based on existing published data. These findings will be disseminated through scientific meetings and publications in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42022302795.

Coexistence of pachyonychia congenita and hidradenitis suppurativa: more than a coincidence

BACKGROUND

The coexistence of pachyonychia congenita (PC) and hidradenitis suppurativa (HS) has been described in case reports. However, the pathomechanism underlying this association and its true prevalence are unknown.

OBJECTIVES

To determine the genetic defect underlying the coexistence of PC and HS in a large kindred, to delineate a pathophysiological signalling defect jointly leading to both phenotypes, and to estimate the prevalence of HS in PC.

METHODS

We used direct sequencing and a NOTCH luciferase reporter assay to characterize the pathophysiological basis of the familial coexistence of HS and PC. A questionnaire was distributed to patients with PC registered with the International Pachyonychia Congenita Research Registry (IPCRR) to assess the prevalence of HS among patients with PC.

RESULTS

Direct sequencing of DNA samples obtained from family members displaying both PC and HS demonstrated a missense variant (c.275A>G) in KRT17, encoding keratin 17. Abnormal NOTCH signalling has been suggested to contribute to HS pathogenesis. Accordingly, the KRT17 c.275A>G variant resulted in a significant decrease in NOTCH activity. To ascertain the clinical importance of the association of HS with PC, we distributed a questionnaire to all patients with PC registered with the IPCRR. Seventy-two of 278 responders reported HS-associated clinical features (25·9%). Disease-causing mutations in KRT17 were most prevalent among patients with a dual phenotype of PC and HS (43%).

CONCLUSIONS

The coexistence of HS and KRT17-associated PC is more common than previously thought. Impaired NOTCH signalling as a result of KRT17 mutations may predispose patients with PC to HS. What is already known about this topic? The coexistence of pachyonychia congenita (PC) and hidradenitis suppurativa (HS) has been described in case reports. However, the pathomechanism underlying this association and its true prevalence are unknown. What does this study add? A dual phenotype consisting of PC and HS was found to be associated with a pathogenic variant in KRT17. This variant was found to affect NOTCH signalling, which has been previously implicated in HS pathogenesis. HS was found to be associated with PC in a large cohort of patients with PC, especially in patients carrying KRT17 variants, suggesting that KRT17 variants causing PC may also predispose to HS. What is the translational message? These findings suggest that patients with PC have a higher prevalence of HS than previously thought, and hence physicians should have a higher level of suspicion of HS diagnosis in patients with PC.

Practical Guidelines for Managing Patients With Hidradenitis Suppurativa: An Update

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease that is characterized by the formation of comedones, papules, nodules, abscesses and sinus tracts in the axillary, inframammary, groin, and gluteal areas. Up to 3.8% of the Canadian population has HS, though due to a lack of awareness of HS, many patients are initially misdiagnosed and do not receive adequate treatment early on in the disease course. Once a diagnosis of HS is made, developing an effective management plan can be a dilemma for many providers. There is significant variability in response to any given therapy within the HS patient population and many HS patients have other medical comorbidities which must be taken into consideration. The aim of this review is to provide a practical approach for all healthcare providers to diagnose and manage HS and its associated comorbidities. A sample electronic medical record template for HS management was developed by the Canadian Hidradenitis Suppurativa Foundation Executive Board and is intended for use in clinical settings. This will help to increase collaboration between primary healthcare providers, dermatologists, and other medical specialists and ultimately improve the quality of care that HS patients receive.

Certolizumab Pegol in the Treatment of Severe Hidradenitis Suppurativa After Adalimumab Failure: A Real-Life Experience

INTRODUCTION

There exists an unmet need to treat hidradenitis suppurativa (HS) despite several approved therapeutic agents for its treatment. We sought to investigate the role of certolizumab pegol in severe, recalcitrant HS patients unresponsive to adalimumab.

PATIENTS AND METHODS

This retrospective cohort includes HS patients over 18 years of age who had a history of unresponsiveness to adalimumab and whose treatments were switched to certolizumab pegol with dosing similar to psoriasis (400 mg every two weeks). For subjects who achieved a hidradenitis suppurativa clinical response (HiSCR) following 12 and 24 weeks of treatment, dermatological life quality index (DLQI), abscess, inflammatory nodule count (AN count), and International Hidradenitis Suppurativa Severity Score System (IHS4) were evaluated as outcome measures.

RESULTS

Eleven severe, recalcitrant HS patients with Hurley stage III HS were enrolled for this study. All patients were male and had a history of prior adalimumab exposure. Only three (27.2%) patients also had a history of using biologic agents other than adalimumab for HS. Six of 11 patients (54.5%) achieved HiSCR at week 12. However, two among these six responders lost response at week 24 despite continued therapy (HiSCR at week 24: 33.3%). The decrease in DLQI (p: 0.017 and 0.021) and IHS4 (p: 0.008 and 0.007) scores of the patients at weeks 12 and 24 showed a significant difference compared to the baseline.

CONCLUSION

Certolizumab pegol is a promising treatment option for severe, recalcitrant HS patients who are unresponsive to adalimumab. This article is protected by copyright. All rights reserved.

Real-World Considerations of Candidacy for Biologics in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, progressive inflammatory skin disease that is often recalcitrant to multiple treatments. In determining biologic candidacy for patients with HS, we propose a paradigm shift away from Hurley staging and towards consideration of other variables. Biologics represent a long-term treatment option for HS that may serve as a disease-modifying agent. These medications are typically initiated in patients with moderate to severe disease, which, based on inclusion criteria in clinical trials, is often defined as Hurley stage II or III disease, at which point irreversible tissue damage has already occurred. In real-world clinical settings, these considerations include treatments tried and failed, predicted disease trajectory, disease characteristics beyond lesion type, impact of disease on patients' functional status and quality of life, and patient comorbidities, venturing away from the limitations of Hurley stage designations. Future clinical trials may benefit from inclusion of recalcitrant Hurley stage I patients, which may then re-shape treatment guidelines and insurance coverage and improve patient access to biologic treatments.

Impact of Hidradenitis Suppurativa Surgical Treatment on Health-Related Life Quality

(1) Background: Hidradenitis suppurativa is a disease that affects the intimacy of patients. This disease reduces the quality of life and functioning of patients in everyday life. The surgical treatment of HS is one of the treatments for HS that can improve the quality of life. (2) Methods: The main goal of this study was to assess quality of life before the surgical treatment and after the surgical treatment of HS at Center for Burn Treatment in Siemianowice Śląskie, Poland, using the EQ-5D-5L survey before the operation and at follow-up (6 months after). (3) Results: The average quality of life measured with the EQ-5D-5L survey before therapy was 39.3 ± 20.1 (min., 0; max., 60; most frequent value, 50), whereas after surgical treatment, the mean quality of life was 89.5 ± 12.5 (min., 50; max., 100; most frequent value, 100). The average increase in the quality of life was 50.2 ± 19.5 (min., 30; max., 100; most frequent value, 30), and it was statistically significant (p < 0.001).

Similar Levels of Efficacy of Two Different Maintenance Doses of Adalimumab on Clinical Severity and Quality of Life of Patients with Hidradenitis Suppurativa

Adalimumab is the only biologic agent approved for the treatment of moderate-to-severe hidradenitis suppurativa (HS) patients (i.e., with Hurley II or III), which is recommended in two different maintenance doses (i.e., 40 mg weekly or 80 mg every two weeks). We conducted a prospective multicentric study to measure outcomes related to the severity of disease and quality of life (QoL) of patients affected by moderate-to-severe HS, treated with adalimumab at a maintenance dosing of 40 mg or 80 mg. Assessments were performed at baseline (T0) and after 32 weeks of treatment (T32). We enrolled 85 moderate-to-severe HS Italian patients, 43 men (50.6%) and 42 women, aged between 16 and 62 years (median 31 years, interquartile range 24.4–43.8). Statistically significant improvements were observed for clinical status (with a mean reduction of 7.1 points for the International Hidradenitis Suppurativa Severity Score System (IHS4)), pain levels (3.1 mean decrease in VAS), and QoL (3.4 mean improvement in DLQI score). Patients with no comorbidities, and those with higher levels of perceived pain showed significantly greater improvement in QoL than their counterpart from T0 to T32. As for the proportion of patients who at follow-up reached the minimal clinical important difference (MCID) in QoL, significantly higher proportions of success were observed for age (patients in the 29–39 category), pain (patients with higher reported pain), and Hurley stage III. While both treatment regimen groups (i.e., 40 vs. 80 mg) improved significantly, no statistical differences were observed when comparing the two treatment dosages.

Surgical Treatment in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, progressive inflammatory disorder of follicular occlusion with pubertal onset that presents as painful inflammatory nodules, sinus tracts, and tunnelling in apocrine-gland-rich areas, such as the axilla, groin, lower back, and buttocks. The disease course is complicated by contractures, keloids, and immobility and is often associated with a low quality of life. It is considered a disorder of follicular occlusion with secondary inflammation, though the exact cause is not known. Management can often be unsatisfactory and challenging due to the chronic nature of the disease and its adverse impact on the quality of life. A multidisciplinary approach is key to prompt optimal disease control. The early stages can be managed with medical treatment, but the advanced stages most likely require surgical intervention. Various surgical options are available, depending upon disease severity and patient preference. In this review an evidence-based outline of surgical options for the treatment of HS are discussed. Case reports, case series, cohort studies, case-control studies, and Randomized Clinical Trials (RCT)s available in medical databases regarding surgical options used in the treatment of HS were considered for the review presented in a narrative manner in this article.

Treatment of Hidradenitis Suppurativa Evaluation Study (THESEUS): protocol for a prospective cohort study

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, painful, inflammatory skin disease with estimates of prevalence in the European population of 1%-2%. Despite being a relatively common condition, the evidence base for management of HS is limited. European and North American management guidelines rely on consensus for many aspects of treatment and within the UK variations in management of HS have been identified. The HS James Lind Alliance Priority Setting Partnership (PSP) published a top 10 list of future HS research priorities including both medical and surgical interventions. The aims of the THESEUS study are to inform the design of future HS randomised controlled trials (RCTs) and to understand how HS treatments are currently used. THESEUS incorporates several HS PSP research priorities, including investigation of oral and surgical treatments. Core outcome domains have been established by the HIdradenitis SuppuraTiva cORe outcomes set International Collaboration (HISTORIC) and THESEUS is designed to validate instruments to measure the domains.

METHODS AND ANALYSIS

The THESEUS study is a prospective observational cohort study. Participants, adults with active HS of any severity, will be asked to select one of five HS treatment options that is appropriate for their HS care. Participants will be allocated to their chosen treatment intervention and followed for a period of up to 12 months. Outcomes will be assessed at 3-monthly intervals using HISTORIC core outcome instruments. Video recordings of the surgical and laser operations will provide informational and training videos for future trials. Nested mixed-methods studies will characterise the interventions in clinical practice, understand facilitators and barriers to recruitment into future HS RCTs and examine patients' and clinicians' perspectives on HS treatment choices.

TRIAL REGISTRATION NUMBER

ISRCTN69985145.

Hidradenitis Suppurativa International Online Community: Patient Characteristics and a Novel Model of Treatment Effectiveness

Treatment for hidradenitis suppurativa is diverse, yet frequently unsatisfactory. The aims of this study were to create a reproducible artificial intelligence-based patient-reported outcome platform for evaluation of the clinical characteristics and comorbidities of patients with hidradenitis suppurativa, and to use this to grade treatment effectiveness. A retrospective patient-reported outcome study was conducted, based on online questionnaires completed by English-speaking patients registered to the hidradenitis suppurativa Stuff-ThatWorks^® online community. Data collected included patient characteristics, comorbidities and treatment satisfaction. These were recoded into scalable labels using a combination of machine learning algorithm, manual coding and validation. A model of treatment effectiveness was generated. The cohort included 1,050 patients of mean ± standard deviation age 34.3 ± 10.3 years. Greater severity of hidradenitis suppurativa was associated with younger age at onset (p < 0.001) and male sex (p < 0.001). The most frequent comorbidities were depression (30%), anxiety (26.4%), and polycystic ovary syndrome (16.6%). Hurley stage I patients rated topical agents, dietary changes, turmeric, and pain relief measures more effective than tetracyclines. For Hurley stage II, adalimumab was rated most effective. For Hurley stage III, adalimumab, other biologic agents, systemic steroids, and surgical treatment were rated more effective than tetracyclines. Patients with hidradenitis suppurativa often have comorbid psychiatric and endocrine diseases. This model of treatment effectiveness provides a direct comparison of standard and complementary options.

New and Emerging Targeted Therapies for Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory skin disease deriving from the hair follicles. The formation of inflammatory nodules, abscesses, fistulas, and sinus tracts is characterized by a large inflow of key pro-inflammatory mediators, such as IFN-γ, TNF-α, IL-1, IL-17, and IL-12/23. Adalimumab is currently the only Food and Drug Administration (FDA)- and European Medicines Agency (EMA)-approved biologic therapy for moderate to severe HS in adults and adolescents. However, the long-term effectiveness of this TNF-α inhibitor in HS patients has shown to be highly variable. This review aims to review the evidence for emerging therapies that target the main pro-inflammatory cytokines in HS pathogenesis. A review of the literature was conducted, using the PubMed and Google Scholar repositories, as well as Clinicaltrials.gov. Presently, the most promising biologics in phase III trials are anti-IL-17 antibodies, secukinumab, and bimekizumab. Furthermore, an anti-IL-1 biologic, bermekimab, is currently in phase II trials, and shows encouraging results. Overall, the clinical efficacies of all new targeted therapies published up to this point are limited. More studies need to be performed to clarify the precise molecular pathology, and assess the efficacy of biological therapies for HS.

Real-World Moderate-to-Severe Hidradenitis Suppurativa: Decrease in Disease Burden With Adalimumab

BACKGROUND

Real-world knowledge of the burden of hidradenitis suppurativa (HS) on patients remains limited.

OBJECTIVES

To measure the impact of adalimumab on moderate-to-severe HS patients' health-related quality of life (HRQoL) and work productivity.

METHODS

In 23 Canadian centres, 138 adults with moderate-to-severe HS requiring a change in ongoing therapy were treated with adalimumab for up to 52 weeks as per the physician's practice. Patient-reported outcome measures (PROMs) were obtained at baseline, weeks 24 and 52 to measure overall HRQoL, HS severity, levels of anxiety and depression, impact and symptoms of HS, work productivity and activity impairment. A post-hoc analysis further explored the PROMs by abscess and inflammatory nodule (AN) count at baseline (≤5, low; 6-10, medium; ≥11, high).

RESULTS

From baseline to weeks 24 and 52, all PRO overall scores improved significantly (P ≤ .0023). The number of patients reporting "good disease control" and "complete disease control" increased from 9.7% to 66.4% over 52 weeks. The score in Health Utility Index Mark 3 (HUI3) pain attribute meaningfully decreased over 52 weeks (mean difference ≥.05). The HS symptoms skin "tenderness" and "itchiness" improved the most. Work productivity loss and activity impairment improved by approximately 20% over 52 weeks. Disease burden improved more in 24 week responders with low and medium AN counts at baseline than in those with high AN count or in 24 week nonresponders.

CONCLUSION

At week 24 and maintained at week 52 in a real-world setting, adalimumab meaningfully improved HRQoL, work productivity, and activity impairment in moderate-to-severe HS patients.

Hidradenitis Suppurativa: morphologic and vascular study of nodular inflammatory lesions by means of optical coherence tomography

BACKGROUND

Hidradenitis Suppurativa (HS) is an inflammatory disease characterized by a recurrent-remission trend and clinical lesions that range from asymptomatic to inflamed, deep-seated nodules with scarring and suppuration.

OBJECTIVE

To identify morphologic and vascular features of HS nodules by means of dynamic optical coherence tomography (D-OCT) and to define if they are correlated to patient endotype and risk of disease progression.

METHODS

A set of standardized clinical pictures and D-OCT images were acquired from 57 inflammatory nodules of 40 patients affected by HS. A set of 20 clinical and D-OCT images were acquired from 20 healthy volunteers as a control group. The comparison of D-OCT features among HS and control group was analyzed. The correlation between HS patient endotype and D-OCT features of the lesions was calculated.

RESULTS

D-OCT enabled to identify vascular and morphological aspects characterizing HS nodular inflammatory lesions. In addition, several D-OCT features were significantly different among distinct disease endotypes.

CONCLUSION

The characterization of HS nodular inflammatory lesions through D-OCT, corresponding to blood vessel dilation and inflammatory associated hyper-vascularization, may have important clinical consequences in the assessment of HS risk of progression, therapeutic decisions and treatment efficacy monitoring.

Real-world safety and effectiveness of adalimumab in patients with hidradenitis suppurativa: 12-week interim analysis of post-marketing surveillance in Japan

Hidradenitis suppurativa (HS) is a painful chronic skin disease characterized by abscesses, nodules, and tunnels in the skin. Adalimumab, a monoclonal antibody against tumor necrosis factor‐α, is approved for the treatment of HS in Europe, the USA, and Japan. This multicenter, open‐label, post‐marketing, observational study (ClinicalTrials.gov: NCT03894956) evaluated the safety and effectiveness of adalimumab in routine clinical practice in Japan (March 2019–May 2021). Patients with HS were treated with s.c. doses of adalimumab according to the dosage described in the package insert. The primary end‐point was safety (data cut‐off, December 2020). Secondary end‐points assessed effectiveness, including HS Clinical Response (HiSCR), skin pain, Dermatology Life Quality Index (DLQI), and C‐reactive protein (CRP). Here, we report 12‐week interim effectiveness results. A total of 84 eligible patients from 65 sites were enrolled; 83 patients were included in this analysis. Mean age was 42.0 years, mean body mass index was 26.9 kg/m², 78.3% of patients were male, 61.4% had Hurley stage III disease, 39.8% had a disease duration ≥10 years, and 7.2% had a family history of HS. The most common affected sites were the axilla (60.2%), buttocks (59.0%), and the inguinal and femoral regions (47.0%). Mean abscess and inflammatory nodule count was 13.0 (standard deviation, 12.0). Among patients with a comorbidity (57.8%), the most common were diabetes mellitus, hypertension, and chronic kidney disease. No patient reported a serious infection or any safety event of special interest. One patient died from a serious adverse event of cardiac failure unrelated to adalimumab. At week 12, 57.4% of patients achieved HiSCR, and significant reductions from baseline in skin pain, DLQI (both p < 0.0001), and CRP (p = 0.0029) were observed. These results support the administration of adalimumab as a well‐tolerated and effective treatment for Japanese patients with HS in real‐world clinical practice.

Surgical Management of Hidradenitis Suppurativa: A Narrative Review

OBJECTIVE

Hidradenitis suppurativa (HS) is a debilitating, chronic, dermatological inflammatory skin disease that affects apocrine gland bearing skin in the axillae, groin, and inframammary regions. It is underdiagnosed and its pathogenesis incompletely understood. This paper provides a comprehensive review of the existing literature on the surgical management of HS, focusing upon outcomes of definitive surgery.

METHODS

A literature search was conducted according to PRISMA guidelines. PubMed and EMBASE databases were searched for original studies pertaining to the surgical management of HS published from January 1970 to July 2020. A total of 33 papers were included for analysis.

RESULTS

Management options include risk factor modification, pharmacological agents, and surgical intervention. Many surgical management techniques exist, including incision and drainage, CO₂ laser therapy, deroofing, wide local excision, and reconstructive surgery. Incision and drainage is commonly utilized for symptom relief of sepsis. While data on curative surgical management are lacking, studies on surgical approaches have shown favorable outcomes in highly selected cases.Wide excision with flap reconstruction results in high patient satisfaction rates, good cosmesis, and reduced disease recurrence.

LIMITATIONS

A small number of suitable papers met our specific focus and inclusion and exclusion criteria. Novel techniques described in case studies were missed. Additionally, this study examined HS management as a whole, but region-specific management was not reviewed closely.

CONCLUSION

The success of surgical management is dependent on multiple factors. Thus far, the precise role of surgery in elective treatment of refractory HS requires further analysis and reporting of outcomes.

Hidradenitis Suppurativa: Host-Microbe and Immune Pathogenesis Underlie Important Future Directions

Hidradenitis suppurativa (HS) is an inflammatory disease of the skin with a chronic, relapsing-remitting course. The pathogenesis of the disease is poorly understood and involves multiple factors, including genetics, environment, host-microbe interactions, and immune dysregulation. In particular, the composition of the cutaneous microbiome shifts as the disease progresses, although it is unclear whether this is a primary or secondary process. Trials with immunomodulatory therapy elucidate the role of specific immune pathways and cytokine signaling in disease mechanism, such as TNF-α, IL-1β, IL-12, IL-17, IL-23, and complement. Future studies should continue examining the causes of and contributing factors to microbial changes and immune dysregulation in HS pathogenesis.

Exploring Access to Surgical Interventions for Hidradenitis Suppurativa: Retrospective Population-Based Analysis

BACKGROUND

Hidradenitis suppurativa (HS) is a painful inflammatory disorder that confers significant distress to patients, with surgery as an integral treatment modality.

OBJECTIVE

To inform improvements in care, patterns in HS surgery were assessed.

METHODS

A retrospective population-based analysis was performed on Ontario billing claims for HS surgery across a period of 10 years from January 1, 2008 to December 31, 2017. HS surgery was defined as the excision of inguinal, perineal, or axillary skin and sweat glands for hidradenitis. The top 5 billing specialties, including general and plastic surgery, were analyzed. The total number of procedures performed as well as the number performed per physician were investigated. Patient and physician locations were compared.

RESULTS

A total of 7195 claims for the excision of inguinal, perineal, or axillary skin and sweat glands for HS were submitted across the study period. Annual HS surgery claims showed an increasing trend across 10 years, ranging between 4.9 and 5.8 per 100,000 population. However, overall, for every additional year, the number of claims per 100,000 population only increased slightly, by 0.03 claims. The number of providers steadily decreased, ranging between 1.7 and 1.9 per 100,000, with approximately twice as many general than plastic surgeons. However, again overall, for every additional year, the number of providers per 100,000 population decreased slightly, by 0.002 physicians. The mean annual number of procedures per physician rose from 2.8 to 3.1. In rural areas, analyzed per claim, general surgeons performed the majority of surgeries (1318/2003, 65.8%), while in urban areas, surgeries were more equally performed by general (2616/5192, 50.4%) and plastic (2495/5192, 48.1%) surgeons. Of HS surgery claims, 25.7%-35.9% were provided by a physician residing in a different area than the patient receiving care.

CONCLUSIONS

No significant improvements in access to HS surgery were seen across the study period, with access potentially worsening with annual HS claims rising overall and number of providers decreasing, with patients travelling further to access surgery. System barriers across the continuum of HS diagnosis and management must be evaluated to improve access to surgical care.

New perspectives on the treatment of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by the presence of painful nodules, abscesses, chronically draining fistulas, and scarring in apocrine gland-bearing areas of the body. The exact pathogenesis of HS is not yet well understood, but there is a consensus in considering HS a multifactorial disease with a genetic predisposition, an inflammatory dysregulation, and an influence of environmental modifying factors. Therapeutic approach of HS is challenging due to the wide clinical manifestations of the disease and the complex pathogenesis. This review describes evidence for effectiveness of current and emerging HS therapies. Topical therapy, systemic treatments, biological agents, surgery, and light therapy have been used for HS with variable results. Adalimumab is the only US Food and Drug Administration (FDA) approved biologic agent for moderate-to-severe HS, but new therapeutic options are being studied, targeting different specific cytokines involved in HS pathogenesis. Comparing treatment outcomes between therapies is difficult due to the lack of randomized controlled trials. Treatment strategy should be selected in concordance to disease severity and requires combination of treatments in most cases.

Consulting 'Dr YouTube': a content analysis of YouTube® videos related to hidradenitis suppurativa treatments

YouTube® is a powerful resource for the dissemination of health information to the general public. We assessed the quality, understandability and evidence-based content of YouTube videos discussing hidradenitis suppurativa treatments, categorized by source: dermatologists, other healthcare professionals, or patients. We demonstrated patient videos were the most popular by viewers, but had the worst ratings for quality and understandability of information presented. Moreover, patient videos were the least likely to recommend the evidence-based treatments. Moving forward, there should be a partnership between dermatologists and patient advocates to create engaging, educational online content for patients to take ownership of their own health.

Vulvoperineal Hidradenitis Suppurativa: Diagnosis, Treatment, and Management of Deformities

Importance

Hidradenitis suppurativa (HS) is a chronic, inflammatory disorder affecting skin of intertriginous areas that is often encountered and treated by nondermatologic specialists.

Objective

The purpose of this literature review is to provide a comprehensive, clinical source of information on HS as it relates to incidence of disease, pathophysiology, diagnosis, and overall management of this condition.

Evidence Acquisition

Sources were obtained through a comprehensive literature search using PubMed and PMC. Various terms were used to query the database, including "hidradenitis suppurativa," "pathogenesis," "prevalence," "management," "surgery," "perineal," and "vulva."

Results

Underreported prevalence and unknown pathogenesis have subsequently led to variable approaches in clinical management, often employing a combination of medical and surgical management.

Conclusions

Early diagnosis and treatment of HS may lead to better disease control and minimize patients' associated morbidity related to disease.

Relevance

Knowledge of vulvoperineal hidradenitis is necessary for gynecologists and primary care physicians to ensure early diagnosis, management, and referral for optimal patient outcomes.