Differences Between Children and Adults With Hidradenitis Suppurativa

A Review of Hidradenitis Suppurativa in Special Populations: Considerations in Children, Pregnant and Breastfeeding Women, and the Elderly

Hidradenitis suppurativa (HS) is a chronic skin condition that significantly impacts patients' quality of life. HS is often challenging to treat. In this review, we discuss the unique characteristics of HS in four special populations: children, the elderly, pregnant individuals, and breastfeeding mothers. In children, diagnosis may be delayed due to atypical and early HS disease presentations. HS management plans must take into consideration the lack of rigorous efficacy and safety data of HS treatments in this population. However, it is important to weigh the risk of treatments against the risk of untreated HS and the morbidity and mortality risk that having HS confers. Pregnancy poses unique challenges for women with HS, with their condition possibly worsening during pregnancy and increased risk of fetal death. Management strategies during pregnancy must consider both maternal and fetal safety. Similarly, breastfeeding mothers require thoughtful medication selection to balance symptom management with infant safety. In the elderly, HS may present more severely and is often complicated by comorbidities. Treating HS in this population should safely accommodate patients' additional health conditions. Furthermore, this review highlights the overall paucity of primary literature addressing management in these populations, underscoring the need for further research to optimize HS care across all stages of life.

Setting the Stage for Standardized Reporting of Clinical and Demographic Information in Laboratory-Based Studies of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a complex inflammatory skin condition affecting 0.1-4% of the population that leads to permanent scarring in the axilla, inframammary region, groin, and buttocks. Its complex pathogenesis involves genetics, innate and adaptive immunity, microbiota, and environmental stimuli. Specific populations have a higher incidence of HS, including females and Black individuals and those with associated comorbidities. HS registries and biobanks have set standards for the documentation of clinical data in the context of clinical trials and outcomes research, but collection, documentation, and reporting of these important clinical and demographic variables are uncommon in HS laboratory research studies. Standardization in the laboratory setting is needed because it helps to elucidate the factors that contribute mechanistically to HS symptoms and pathophysiology. The purpose of this article is to begin to set the stage for standardized reporting in the laboratory setting. We discuss how clinical guidelines can inform laboratory research studies, and we highlight what additional information is necessary for the use of samples in the wet laboratory and interpretation of associated mechanistic data. Through standardized data collection and reporting, data harmonization between research studies will transform our understanding of HS and lead to novel discoveries that will positively impact patient care.

The prevalence of comorbid mental health difficulties in young people with chronic skin conditions: A systematic review and meta-analysis

Chronic skin conditions can have psychosocial and somatic implications, influencing well-being and quality of life. This systematic review and meta-analysis aimed to synthesise evidence on the prevalence of comorbid mental health difficulties in 0-25-year-olds with chronic skin conditions. A secondary aim included identifying factors associated with resilience. The narrative synthesis included 45 studies. Four meta-analyses were performed with moderate-high quality studies, one for each outcome: diagnosed mental disorders; mental health symptoms; suicidal behaviour; socio-emotional and behavioural difficulties. The pooled prevalence of diagnosed mental disorders was 1.2% (95% CI = 0.2-6.1); of mental health symptoms was 22.6% (95% CI = 18.9-26.7); of suicidal behaviour was 7.8% (95% CI = 1.4-3.1); of socio-emotional and behavioural difficulties was 20.9% (95% CI = 14.7-28.8). Findings demonstrate the pooled prevalence of comorbid mental health difficulties in youth with chronic skin conditions.

The management of pediatric hidradenitis suppurativa differs between dermatologic and non-dermatologic providers: A retrospective review

BACKGROUND/OBJECTIVES

There is a paucity of pediatric hidradenitis suppurativa (HS) literature. The objective of this study was to characterize differences in management of pediatric HS patients by dermatology versus non-dermatology clinicians.

METHODS

We examined a retrospective cohort of 195 pediatric patients with HS seen at our institution (3/1/19-3/1/20). Two-sample t-tests and two-proportion z-tests were performed.

RESULTS

A total of 76.1% of subjects were seen by dermatology at least once, and of these, 79.1% were referred. HS diagnosis was most often made by dermatology (36.6%), followed by pediatrics (21.6%). Patients managed by dermatology were significantly more likely to have used standard of care therapies (p < .001). Of dermatology-managed patients, 19.7% were currently prescribed a biologic, as compared with zero patients not managed by dermatology. Those managed by dermatology were less likely to undergo surgical excision (13.3% vs. 25.5%, p = .04).

CONCLUSIONS

Our results support increased likelihood of treatment escalation with medical management by dermatologists. Relatively high utilization of referral to dermatology exists, but with only moderate patient adherence. There is a need for improved access to dermatologic care and prospective studies to determine whether differences in specialty management translate to improved patient outcomes.

Unraveling the Epigenetic Tapestry: Decoding the Impact of Epigenetic Modifications in Hidradenitis Suppurativa Pathogenesis

Hidradenitis suppurativa (HS) is a chronic autoinflammatory skin disorder, which typically occurs during puberty or early adulthood. The pathogenesis of HS is complex and multifactorial; a close interaction between hormonal, genetic, epigenetics factors, host-specific aspects, and environmental influences contributes to the susceptibility, onset, severity, and clinical course of this disease, although the exact molecular mechanisms are still being explored. Epigenetics is currently emerging as an interesting field of investigation that could potentially shed light on the molecular intricacies underlying HS, but there is much still to uncover on the subject. The aim of this work is to provide an overview of the epigenetic landscape involved in HS. Specifically, in this in-depth review we provide a comprehensive overview of DNA methylation/hydroxymethylation, histone modifications, and non-coding RNAs (such as microRNA-miRNA-132, miRNA-200c, miRNA-30a-3p, miRNA-100-5b, miRNA-155-5p, miRNA-338-5p) dysregulation in HS patients. An interesting element of epigenetic regulation in HS is that the persistent inflammatory milieu observed in HS lesional skin could be exacerbated by an altered methylation profile and histone acetylation pattern associated with key inflammatory genes. Deepening our knowledge on the subject could enable the development of targeted epigenetic therapies to potentially restore normal gene expression patterns, and subsequentially ameliorate, or even reverse, the progression of the disease. By deciphering the epigenetic code governing HS, we strive to usher in a new era of personalized and effective interventions for this enigmatic dermatological condition.

Hidradenitis suppurativa tarda: defining an understudied elderly population

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, devastating, multifactorial skin disease. Patients generally develop HS after puberty and the prevalence of the disease is assumed to decrease with higher age. Data outside the usual age range are limited, especially for elderly patients.

OBJECTIVES

To investigate the prevalence, clinical characteristics and associated comorbidities among the elderly HS population.

METHODS

Data were collected through a population-wide survey-based study within the Lifelines Cohort Study in the Netherlands. The clinical characteristics of elderly patients with HS (≥ 60 years) were compared with an adult population (< 60 years) with HS. The comorbidities in elderly patients with HS were compared with those of a non-HS sex- and age-matched elderly population in a 1 : 4 ratio. HS in the elderly was defined as active HS in patients aged 60 years and older. Within the HS elderly group, two subgroups were defined, late-onset HS (HS developed after 60 years of age) and persistent HS (HS developed from a younger age but continuing after 60 years of age).

RESULTS

Within the Lifelines cohort 209 elderly patients with HS were identified as well as an adult (< 60 years) group with HS (n = 793) and a non-HS sex- and age-matched control elderly group (n = 810). The prevalence of HS among the elderly bootstrap analysis population was 0.8% [95% confidence interval (CI) 0.4-1.2]. A significantly higher age of HS symptom onset was found compared with the adult HS group: respectively, 40 vs. 23 years (odds ratio 1.056, 95% CI 1.05-1.07). Among the elderly HS cohort (in the Discussion, the HS tarda cohort) a female : male ratio of 1.7 : 1.0 and a higher family history for HS were found. Moreover, elderly patients with HS had a significantly higher risk of having HS-associated comorbidities compared with the sex- and age-matched controls.

CONCLUSIONS

The prevalence of HS in the elderly is not rare. Among the elderly a shift from female predominance towards a lower female : male ratio in HS is observed. In addition, HS in the elderly showed significant variation in age of onset and involved body areas. Moreover, elderly patients with HS were more susceptible to multimorbidity. Finally, we propose defining HS in the elderly as 'HS tarda' and subdividing it as late-onset and persistent HS tarda.

The presentation of anxiety and depression among children and youth diagnosed with hidradenitis suppurativa: A review

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition with painful lesions in friction-prone areas, impacting patients' physical and mental well-being. Adults with HS experience higher rates of depression, anxiety, and reduced quality of life. Children with HS may also face these challenges, but a comprehensive review of their mental health implications is lacking. A narrative review was conducted using PubMed and Ovid Medline databases to investigate the association between HS and anxiety or depression in pediatric populations. A total of 4498 pediatric patients from six studies were included in this study: six examined depression alone, and three also studied anxiety. Two studies found a significant correlation between HS and depression in pediatric patients (p < .001), while two reported statistical significance for anxiety (p < .001). Two studies comparing pediatric and adult populations also reported a higher prevalence and incidence of depression among pediatric populations (p < .05). Another study found no incidences of depression or anxiety in HS or control patients. Despite heterogeneity in control groups, methodologies, and health system databases, the included studies suggest that pediatric patients with HS have a higher likelihood of developing depression compared to healthy pediatric patients and exhibit higher depression rates and lower anxiety rates compared to adults. These findings and the limited availability of data regarding this topic underscore the imperative for increased screening, evaluation, and reporting of psychiatric disorders among pediatric populations. This can help understand the connection between HS and depression or anxiety and ultimately enhance the mental well-being and quality of life for affected children.

Characteristics and treatment pathways in pediatric and adult hidradenitis suppurativa: An examination using real world data

Background

Hidradenitis suppurativa (HS) is a chronic, debilitating, inflammatory disease. Contemporaneous real-world data can be used to elucidate the clinical treatment of pediatric patients and how treatment strategies compare with adult hidradenitis suppurativa patients.

Objective

The objective of this study is to evaluate clinical and treatment characteristics of pediatric and adult HS patients.

Methods

HS adult and pediatric patients were identified in 3 the United States administrative claims databases during the study period between 2016 to 2021. Patients were required to have 2 diagnostic codes for HS and have at least 365 days of prior observation time to the first HS diagnosis.

Results

Pediatric and adult HS treatments were similar. The proportions of subjects treated with topical and oral antibiotic or oral antibiotic alone or topical medication alone or surgery alone covered 90% of the treated pediatric subjects and 91% of treated adult subjects. The remaining proportion of subjects received other treatment combinations.

Limitations

The databases represent subjects with commercial or government insurance coverage and thus do not necessarily represent the broader US population. The databases do not capture information about medications obtained without insurance.

Conclusions

Although subtle differences exist, this study confirms that topical and systemic therapeutic treatment of HS in adults and adolescents is very similar.

Disorders in Children

Pediatric dermatoses can present at birth or develop over time. When managing dermatology conditions in children, caregiver involvement is important. Patients may have lesions that need to be monitored or need assistance with therapeutic administration. The following section provides a subset of pediatric dermatoses and notable points for presentation in skin of color patients. Providers need to be able to recognize dermatology conditions in patients of varying skin tones and provide therapies that address the condition and any associated pigmentary alterations.

Case report: Acne vulgaris treatment with 5-Aminolaevulinic acid photodynamic therapy and adalimumab: a novel approach

Acne vulgaris is a common skin condition that affects a large proportion of teenagers and young adults. Despite the availability of various treatment options, many patients experience inadequate relief or intolerable side effects. Photodynamic therapy (PDT) is a growing interest in the treatment of acne vulgaris, with 5-Aminolaevulinic acid (ALA) being one of the most commonly used photosensitizers. Adalimumab is a biologic medication used to treat inflammatory skin conditions such as Psoriasis and Hidradenitis suppurativa (HS), which targets TNF-α. Combining different therapies, such as ALA-PDT and adalimumab, can often provide more effective and longer-lasting results. This report presents the case of a patient with severe and refractory acne vulgaris who was treated with a combination of ALA-PDT and adalimumab, resulting in significant improvement in the condition. The literature review highlights the significant comorbidity associated with acne, emphasizing the need for potential of TNF-α inhibitors for its effective treatments that address physical symptoms and ALA-PDT is known to treat scar hyperplasia, and to prevent or minimize the formation of post-acne hypertrophic scars. The combination of TNF inhibitors and ALA-PDT or adalimumab has shown promising results in treating inflammatory skin conditions, including severe and refractory acne vulgaris, as per recent studies.

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.

A bibliometric analysis of hidradenitis suppurativa literature over the past 50 years

BACKGROUND

We aimed to describe the existing literature on hidradenitis suppurative (HS) in the last 50 years and the key processes made over time.

METHODS

On July 27, 2022, we searched for HS studies published in the last 50 years (from 1972 to 2022) using Web of Science. The search was made using the keywords "Hidradenitis Suppurativa" and "Acne Inversa." The data are subdivided according to publications and citations rate, country, publication year, journal and impact factor, keywords analysis of top 100 cited papers study design, and pediatric versus adults.

RESULTS

In total, 5072 documents were retrieved. The annual number of HS publications has increased over the years. The manuscript with the highest citation number was by Zouboulis et al., a total of 552 citations from 2015. The manuscript with the highest citation rate per year was by Mantovani et al., with a citation rate of 70.7/year. According to keywords analysis among the top 100 cited papers, most of the articles focused on management, followed by the pathogenesis of HS. Only 805 out of 5072 (15.8%) HS articles described the disease among children.

CONCLUSIONS

In the current analysis, we shed light on HS's transformations over the last 50 years. In addition, we described the 100 top cited papers and other essential characteristics not examined before, such as HS research in children, gender bias research, specific pharmacological therapy with keyword analysis, comorbidities, preventative care, and publications per country after controlling for population.

Evaluation of Hidradenitis Suppurativa Diagnostic Criteria in Pediatric Patients

Importance

Hidradenitis suppurativa (HS) is associated with considerable diagnostic delay. Although most patients report adolescent onset, existing HS diagnostic criteria may not adequately capture disease in pediatric populations.

Objectives

To determine the proportion of physician-diagnosed pediatric patients with HS who met diagnostic criteria, and describe demographics, disease characteristics, and diagnostic patterns among pediatric patients with HS.

Design, Setting, and Participants

In this retrospective, cross-sectional study, electronic medical records from 2 sites of a single academic tertiary care center were included. Eligible patients were those born after January 1, 1993, and assigned International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/10) codes for HS (ICD-9 705.83/ICD-10 L73.2) between January 1, 2012, and July 1, 2021. Patients were excluded if they were older than 18 years at diagnosis, had inaccessible diagnostic visit notes, or were unintentionally assigned an HS ICD code.

Exposures

Pediatric patients with HS.

Main Outcomes and Measures

Fulfillment of diagnostic criteria in pediatric patients with HS.

Results

A total of 297 adolescents with HS were included in the study; 123 patients were female (78.1%), 78 self-identified as Black (26.3%), and 116 self-identified as Hispanic (39.1%). The median (IQR) age at diagnosis was 14.0 (13.0-16.0) years. Documentation from the diagnostic visit demonstrated that 127 (42.8%) patients did not meet all 3 major HS diagnostic criteria. Of these patients, 122 (96.1%) did not meet the recurrence interval criterion (≥2 lesions within 6 months). Overall, 96 patients who did not meet the recurrence interval criterion had documentation from additional visits in the health system; 59 (61.5%) had documentation of 1 or more additional lesions consistent with HS. Review of these additional records demonstrated that 26 of these 59 (44.1%) patients met the recurrence interval criterion after diagnosis, and 44 (74.6%) had recurrent lesions within a 1-year interval (median, 6.5 months; interquartile range, 3.5-12.2 months). Medical chart review was conducted from November 22, 2021, to January 12, 2022. Analysis was conducted from January 12, 2022, to January 15, 2022.

Conclusions and Relevance

Overall, 118 (40%) of 297 pediatric patients with HS in this retrospective cross-sectional study did not meet all major diagnostic criteria at the time of diagnosis, largely due to failure to fulfill the 6-month recurrence interval criterion. Future studies are needed to determine the appropriate recurrence interval to facilitate timely diagnosis and promote clinical trial eligibility for pediatric patients with HS.

Factors Associated With Dermatologic Follow-up vs Emergency Department Return in Patients With Hidradenitis Suppurativa After an Initial Emergency Department Visit

Importance

Emergency department (ED) visitation is common for the treatment of hidradenitis suppurativa (HS), whereas dermatology outpatient care is low. The reasons underlying this differential follow-up have not been elucidated.

Objective

To assess the interventions and patient factors associated with ED return following an initial ED visit for HS.

Design, Setting, and Participants

This retrospective cohort study used data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases (trademark symbols retained per database owner requirement). An HS cohort was formed from patients who had 2 or more claims for HS during the study period of 2010 to 2019 and with at least 1 ED visit for their HS or a defined proxy. Data were analyzed from November 2021 to May 2022.

Exposures

Factors analyzed included those associated with the ED visit and patient characteristics.

Main Outcomes and Measures

Primary outcomes were return to the ED or dermatology outpatient follow-up for HS or related proxy within 30 or 180 days of index ED visit.

Results

This retrospective cohort study included 20 269 patients with HS (median [IQR] age, 32 [25-41] years; 16 804 [82.9%] female patients), of which 7455 (36.8%) had commercial insurance and 12 814 (63.2%) had Medicaid. A total of 9737 (48.0%) patients had incision and drainage performed at the index ED visit, 14 725 (72.6%) received an oral antibiotic prescription, and 9913 (48.9%) received an opioid medication prescription. A total of 3484 (17.2%) patients had at least 1 return ED visit for HS or proxy within 30 days, in contrast with 483 (2.4%) who had a dermatology visit (P < .001). Likewise, 6893 (34.0%) patients had a return ED visit for HS or proxy within 180 days, as opposed to 1374 (6.8%) with a dermatology visit (P < .001). Patients with Medicaid and patients who had an opioid prescribed were more likely to return to the ED for treatment of their disease (odds ratio [OR], 1.48; 95% CI, 1.38-1.58; and OR, 1.48; 95% CI, 1.39-1.58, respectively, within 180 days) and, conversely, less likely to have dermatology follow-up (OR, 0.16; 95% CI, 0.14-0.18; and OR, 0.81; 95% CI, 0.71-0.91, respectively, within 180 days).

Conclusions and Relevance

This cohort study suggests that many patients with HS frequent the ED for their disease but are not subsequently seen in the dermatology clinic for ongoing care. The findings in this study raise the opportunity for cross-specialty interventions that could be implemented to better connect patients with HS to longitudinal care.

Hidradenitis Suppurativa: Diagnosis and Management in the Emergency Department

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic immune-mediated inflammatory skin disease characterized by abscesses and inflammatory nodules, and occasionally tunnels and scars, in the axillae, groin, and inframammary areas.

OBJECTIVE

HS can be challenging to diagnose because it mimics localized soft-tissue infection. The process of differentiating HS from soft-tissue infection is discussed. Patients with HS frequently visit emergency departments (EDs) for acute management of pain and drainage from HS lesions. This review updates emergency and urgent care physicians on how to educate and initiate treatment for patients with HS, and to coordinate care with dermatologists and other physicians early in their disease course.

DISCUSSION

Recent updates on the epidemiology, diagnosis, and management of HS are reviewed.

CONCLUSIONS

Practice variations between how care for HS is provided in the ED setting and what HS treatment guidelines recommend are identified.