Hidradenitis suppurativa in the pediatric population

Hidradenitis Suppurativa in Children and Adolescents: An Update on Pharmacologic Treatment Options

Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory skin condition that manifests as painful, deep-seated, inflamed nodules and abscesses in the axillary, groin, perianal, perineal, and inframammary regions. The associated pain, malodour, and disfigurement contribute to its profound negative impact on psychosocial spheres and overall quality of life in affected individuals. Although the symptoms of HS classically begin in the second or third decade of life, HS affects children and adolescents as well. Despite this, there are limited pediatric data on treatment, which are largely based on expert opinion, extrapolation of efficacy data in adults with HS, and safety information from medication use in other pediatric diseases. On this basis, there exist several pharmacological modalities in the treatment of children and adolescents with HS including topical therapies, systemic therapies, and biologics. The goals of this review article are to: (1) review the efficacy of different pharmacological treatment modalities in children and adolescents with HS, and (2) review the safety and monitoring considerations of the different treatment options in children and adolescents with HS.

Efficacy of medical treatments for pediatric hidradenitis suppurativa: A systematic review

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition that has been insufficiently studied in the pediatric population. Timely and effective medical treatments may improve quality of life, mitigate disease burden, and prevent the need for invasive procedural interventions such as surgical excisions. However, there is a paucity of research on the efficacy of medical management strategies for HS in children and adolescents. The aim of this study was to perform a systematic review of the literature on the efficacy and safety of medical treatments for HS in patients <18 years of age. In April 2022, MEDLINE and EMBASE databases were searched for articles on the efficacy of medical treatments for HS in the pediatric population. Between 1984 and 2022, 35 articles (101 patients) met the inclusion criteria. Most patients had Hurley Stage II disease (46.7%, 35/75) followed by Stage I (36%, 27/75), and Stage III (17.3%, 13/75). 100% (23/23) of patients responded to antibiotics, 100% (8/8) to finasteride, 93.9% (31/33) to biologics, 80% (4/5) to oral retinoids, and 50% (6/12) to metformin. Overall, this study demonstrates that medical treatment regimens can improve HS symptoms in pediatric patients, but the extent of improvement is unclear, and the results were largely based on case reports or case series. Prospective studies are warranted to better understand the efficacy and safety of medical treatments for pediatric HS. Clinical trials of HS therapies need to be inclusive of pediatric patients to help define the optimal timing of treatment initiation and guide patient selection.

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.

A Case of Psoriatic Disease and Hidradenitis Suppurativa in a Child with Chromosome 17q21.31 Microduplication Syndrome

Psoriatic disease is a chronic, relapsing inflammatory disorder, characterized mostly by cutaneous erythematous scaly plaques sometimes associated with arthritis. Hidradenitis suppurativa (HS) is a chronic relapsing inflammatory disease of the apocrine glands, characterized clinically by painful abscesses, sinus tracts and scars. It typically occurs after puberty, affecting mainly intertriginous areas of the body. There is a strong association between HS and psoriasis since they share the same pathogenic inflammatory pathway. The patient presented: low birthweight, microcephaly, facial dysmorphisms, lumbar hyperlordosis, walking difficulties, global psychomotor developmental delay and learning disabilities. A genetic evaluation revealed a 2.5 Mb de novo microduplication in the 17q21.31 chromosomal region. Dermatological examination revealed HS (Hurley stage II-HS) distributed in the genital area and inguinal folds, psoriatic plaques on the retroauricolar folds, on the elbows bilaterally and on the lateral aspect of the right ankle and psoriatic arthritis. The patient was treated with adalimumab, with a marked improvement of both conditions. To our best knowledge, we report the first case of coexisting Psoriatic Arthritis Disease and Hidradenitis Suppurativa in a child with chromosome 17q21.31 microduplication syndrome. We hypothesize that gene CRHR1 duplication included in the 17q21.31 chromosomal region might be involved in the pathogenesis of both diseases.

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.

Diagnosing and Managing Hidradenitis Suppurativa in Pediatrics

Hidradenitis suppurativa (HS) is a debilitating chronic inflammatory skin disease that presents as exquisitely tender abscesses, draining fistulae, and sinus tracts. HS can lead to significant impairments in patients' quality of life, especially for children and adolescents who face challenges related to self-esteem and physical and emotional development. Severe long-term physical sequelae of inadequately treated HS include extensive scarring, urogenital strictures, immobility, and squamous cell carcinoma; emotional sequelae include depression, anxiety, and suicidal ideation. Many of the devastating long-term sequelae associated with HS can be prevented with early recognition and proper collaborative management. This article reviews strategies to aid pediatricians in early diagnosis of HS and provides clinical pearls for management and prevention of disease flares. [Pediatr Ann. 2022;51(3):e123-e127.].

Biologic Use in Pediatric Patients With Hidradenitis Suppurativa: A Systematic Review

BACKGROUND

There is currently at least 1 biologic (adalimumab) approved in North America for treatment of Hidradenitis Suppurativa in the pediatric population. However, no reviews or clinical trials have specifically analyzed the effectiveness and safety data of biologic use in this population. The objective of this systematic review is to identify and summarize the outcomes of biologic therapy in pediatric patients with HS.

METHODS

MEDLINE and EMBASE databases were used to conduct the search on Sept 18, 2020.

RESULTS

The 15 included studies consisted of 26 patients, with the mean age of 15 ± 2.3 years. Females accounted for 53.8% (n = 14/26) of cases. The mean duration of HS prior to biologic initiation was 3.5 ± 2.9 years, with the majority having Hurley Stage II. The 26 patients received 34 biologics in total: 85.3% treated with TNF alpha inhibitors (adalimumab n = 17, infliximab n = 10, etanercept n = 1, unspecified n = 1), 5.9% with IL-12/23 inhibitors (ustekinumab n = 2), 5.9% with IL-1 inhibitors (i.e., anakinra n = 2) and 2.9% received IL-23 inhibitors (i.e., guselkumab n = 1) biologics. Of the 26 patients, 23.1% (n = 6/26) experienced complete resolution (CR), 73.1% (n = 19/26) experienced partial resolution (PR), and 3.8% (n = 1/26) had no resolution outcomes reported. The time to resolution of HS lesions after biologic initiation ranged from 10 days to 11.5 months (mean: 5.1 months). No adverse events were reported in the studies.

CONCLUSION

Although anti-TNF alpha were the most common biologics used for HS in pediatric cases, large-scale trials specific to pediatric patients with HS are needed to confirm these findings.

Hidradenitis Suppurativa in the Pediatric Population: An International, Multicenter, Retrospective, Cross-sectional Study of 481 Pediatric Patients

Importance

Hidradenitis suppurativa (HS) in pediatric patients has been understudied. Increased awareness and recognition of HS prevalence in children demand efforts to better understand this condition.

Objective

To describe the demographics, clinical features, treatment, associated comorbidities, and outcomes in a large cohort of pediatric patients with HS.

Design, Setting, and Participants

International, multicenter, retrospective medical record review of pediatric patients (aged 1-18 years) with a clinical diagnosis of HS carried out in 10 dermatology clinics across the US, Canada, Israel, Australia, and Italy from January 1996 to January 2017.

Main Outcomes and Measures

Patient demographics, clinical features, severity, associated comorbidities, and treatments in pediatric patients with HS.

Results

This cross-sectional study included 481 patients diagnosed with HS. Overall, 386 (80%) were girls. The mean (SD) age of disease onset was 12.5 (2.9) years, and the mean (SD) age at diagnosis was 14.4 (3.5) years. Family history of HS was present in 111 of 271 (41%) patients. First signs/symptoms reported at disease onset were cyst/abscess in 229 of 481 (48%), pain/tenderness in 118 of 481 (25%), and papules/pustules in 117 of 481 (24%). At initial dermatologic assessment, 233 of 481 (48%) patients already had evidence of skin scarring. Disease severity (Hurley staging) was documented in 288 of 481 (60%) patients (47% stage 1, 45% stage 2 and 8% stage 3). Comorbid conditions were reported in 406 of 481 (85%) patients, the most common being obesity (263/406 [65%]) and acne vulgaris (118/406 [29%]). Complications occurred in 378 of 481 (79%) patients, the most common of which were scars or contractures (301/378 [80%]).

Conclusions and Relevance

The findings of this study indicate that there is a gap in recognizing and diagnosing pediatric HS. Pediatric patients with HS are likely to present with other comorbidities. Prospective observational and interventional studies are needed to better understand clinical course and optimal treatments for pediatric HS.

Differences Between Children and Adults With Hidradenitis Suppurativa

Importance

Up to 50% of patients may have hidradenitis suppurativa (HS) onset between age 10 and 21 years. To our knowledge, little is known about how adolescents with HS utilize health care during their journey to receiving a diagnosis.

Objective

To assess the clinical characteristics and health care utilization patterns of pediatric vs adult patients with HS.

Design, Setting, and Participants

This retrospective cohort study included adult and pediatric patients with HS claims from the MarketScan medical claims database during the study period, January 1, 2012, to December 31, 2016. The data were analyzed between March 1 and March 31, 2021.

Exposures

Clinical characteristics and health care utilization patterns of pediatric vs adult patients with HS.

Main Outcomes and Measures

Health care utilization patterns were examined and included concurrent diagnoses, outpatient care by discipline, and emergency/urgent care and inpatient claims.

Results

This study included 8727 members, comprising 1094 pediatric (155 male [14.2%] and 939 female patients [85.8%]; mean [SD] age, 14.3 [2.47] years) and 7633 adult patients (1748 men [22.9%] and 5885 women [77.1%]; mean [SD] age, 37.2 [12.99] years). Pediatric patients were likely to see pediatricians, dermatologists, emergency department (ED) staff, and family physicians before diagnosis and commonly received diagnoses of folliculitis and comedones. Pediatric patients with HS had high rates of comorbid skin and general medical conditions, including acne vulgaris (558 [51.0%]), acne conglobata (503 [45.9%]), obesity (369 [33.7%]), and anxiety disorders (367 [33.6%]). A higher percentage of pediatric than adult patients had HS-specific claims for services rendered by emergency and urgent care physicians (35.6% vs 28.2%; P < .001; and 18.1% vs 13.4%; P < .001; respectively). However, adult patients were more likely to have inpatient stays (2.38% vs 4.22%; P = .002). Pediatric patients had 2.24 ED claims per person, while adults had 3.5 claims per person. The mean cost per ED claim was similar between groups ($413.27 vs $682.54; P = .18). The largest component of the total 5-year disease-specific cost was the cost of inpatient visits for pediatric and adult patients with HS.

Conclusions and Relevance

This cohort study suggests that pediatric patients utilize high-cost ED care when HS can often be treated as an outpatient. These data suggest that there are opportunities to improve recognition of HS in pediatric patients by nondermatologists and dermatologists.

Prevalence of Hidradenitis Suppurativa: A Systematic Review and Meta-regression Analysis

Importance

Hidradenitis suppurativa/acne inversa (HS) is a chronic inflammatory skin disease characterized by occlusion of hair follicles as a primary pathogenic factor. There are scarce data regarding the prevalence of HS.

Objective

To estimate overall HS prevalence.

Data Sources

This review and meta-regression analysis was conducted using the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline. The academic search included PubMed, Cochrane registry, ClinicalTrials.gov, and evidence by NHS UK and Trip databases from inception through May 2020. To analyze HS prevalence, only cross-sectional studies or baseline assessments of longitudinal cohorts using census-based surveys or probabilistic and nonprobabilistic epidemiologic methods were considered. The search terms were (prevalence OR incidence OR epidemiology) AND (hidradenitis suppurativa OR acne inversa OR Verneuil's disease). No language restriction was applied.

Study Selection

Original investigations that reported HS prevalence were included. After exclusion criteria were applied, 17 studies qualified for qualitative analysis, but only 16 studies were quantitatively assessed.

Data Extraction and Measures

Two reviewers extracted data by age, diagnostic criteria, presence of any comorbidity, sample sizes, continent/location, sex, and other characteristics. Assessment of bias risk used the Joanna Briggs Institute Critical Appraisal Instrument for Studies Reporting Prevalence Data using random-effects models to synthesize available evidence.

Main Outcomes and Measures

Hidradenitis suppurativa prevalence (with 95% CI) among the overall population and among subgroups. Between-study heterogeneity was assessed (Cochran Q statistic) and quantified (I2 statistic).

Results

In 16 quantitatively assessed studies included, prevalence estimates were reported only from Western European and Scandinavian countries, the US, and Australia. Meta-analysis with random effects, after adjusting for publication bias in the prevalence estimates, revealed a 0.40% prevalence (95% CI, 0.26%-0.63%) for HS. Studies based on clinical samples revealed a higher pooled prevalence of HS (1.7%) than population-based studies (0.3%).

Conclusions and Relevance

The findings of this systematic review and meta-regression analysis may help facilitate policy formulation, channeling funding and guiding principles for better disease diagnosis using universal valid tools and management.

The association between hidradenitis suppurativa and male and female infertility: A population-based study

BACKGROUND

Endocrine and metabolic associations have been recently reported in patients with hidradenitis suppurativa (HS); however, fertility was only rarely investigated in women and not at all in men.

OBJECTIVE

To evaluate the association of HS with male and female infertility.

METHODS

A cross-sectional, matched controlled, population-based study was designed. The association between HS and male and female infertility was evaluated in patients with HS (n = 4191) and age- and gender-matched controls (n = 20 941), while utilising the Clalit Health Services databases, the largest community-based health maintenance organisation in Israel.

RESULTS

Hidradenitis suppurativa was associated with infertility in males and females over all reproductive-age groups, especially among individuals aged 36-45 years (OR 4.50, 95%CI 2.55-7.93, P < 0.001), and in female patients (OR 3.10, 95%CI 2.57-3.74, P < 0.001). After adjustment for demographic and clinical factors, the association remained significant only in females (OR 1.26 95%CI 1.04-1.55, P < 0.05).

CONCLUSION

Patients with HS are at increased risk of infertility, particularly females and patients in the 36- to 45-year age group. Physicians should take the additional physiological and psychological burden of infertility among HS patients into account, primarily among female patients at procreative age.

Acne in the first three decades of life: An update of a disorder with profound implications for all decades of life

Acne vulgaris is a chronic, inflammatory, skin condition that involves the pilosebaceous follicles and is influenced by a variety of factors including genetics, androgen-stimulation of sebaceous glands with abnormal keratinization, colonization with Cutibacterium acnes (previously called Propionibacterium acnes), and pathological immune response to inflammation. Acne can occur at all ages and this discussion focuses on the first three decades of life. Conditions that are part of the differential diagnosis and/or are co-morbid with acne vulgaris are also considered. Acne in the first year of life includes neonatal acne (acne neonatorum) that presents in the first four weeks of life and infantile acne that usually presents between 3 and 6 months of the first year of life with a range of 3 to 16 months after birth. Acne rosacea is a chronic, inflammatory, skin condition that is distinct from acne vulgaris, typically presents in adults, and has four main types: erythemato-telangiectatic, papulopustular, phymatous and ocular. Treatment options for acne vulgaris include topical retinoids, topical benzoyl peroxide, antibiotics (topical, oral), oral contraceptive pills, isotretinoin, and others. Management must consider the increasing impact of antibiotic resistance in the 21st century. Psychological impact of acne can be quite severe and treatment of acne includes awareness of the potential emotional toll this disease may bring to the person with acne as well as assiduous attention to known side effects of various anti-acne medications (topical and systemic). Efforts should be directed at preventing acne-caused scars and depigmentation on the skin as well as emotional scars within the person suffering from acne.

Hidradenitis suppurativa in pediatric patients

Interest in and research on hidradenitis suppurativa (HS) have increased during the past decade, resulting in expanded knowledge about associated comorbidities and treatment efficacy. Knowledge about pediatric-onset HS is still limited, based on case studies, small case series, and extrapolation from adult studies. With increasing prevalence of childhood obesity, decreasing pubertal age, and increasing awareness of HS, physicians may start encountering younger HS patients. This review presents an updated discussion on the epidemiology, pathophysiology, and associated comorbidities in HS, with a focus on pediatric and adolescent patients. It also suggests recommendations for investigation and treatment based on current evidence.

Hidradenitis suppurativa in paediatric patients: a retrospective monocentric study in Germany and review of the literature

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle affecting apocrine glands-rich areas of the body. The disease usually occurs after puberty leading to painful nodules, abscesses, tunnels and scarring. Although uncommonly, HS can also occur in children and adolescents.

OBJECTIVE

Our objective was to describe the epidemiology, characteristics, predisposing factors and clinical course of HS in paediatric patients.

METHODS

The retrospective cohort study included patients with HS, who have been diagnosed in Dessau Medical Center and reported development of HS during childhood or adolescence, fulfilled the diagnostic criteria for HS and had a follow-up period of at least one year. A systematic review was conducted on MEDLINE, EMBASE and CENTRAL on 19 March 2020 using the terms 'hidradenitis' or 'acne inversa' together with the terms 'children', 'paediatric' and 'adolescence'.

RESULTS

Twenty paediatric patients [1 child (0.22%), 19 adolescents (4.25%)] were detected out of 447 patients evaluated (4.5%) with a male to female ratio of 1.86 : 1. The median age at diagnosis was 17 years [interquartile range (IQR) 16-18] and the median age at onset 15 years (IQR: 14-16.5). The majority of the patients suffered from moderate disease were overweight or obese and non-smokers. The most common comorbid disorder was acne vulgaris. The systematic review revealed reports with data heterogeneity and lack of systematic documentation of specific demographic characteristics. Most paediatric patients were female, obese and non-smokers, with considerable comorbid disorders.

CONCLUSIONS

Hidradenitis suppurativa in Germany may affect children and adolescents exhibiting a particular phenotype of mainly male non-smokers.

Pleiotropic Role of Notch Signaling in Human Skin Diseases

Notch signaling orchestrates the regulation of cell proliferation, differentiation, migration and apoptosis of epidermal cells by strictly interacting with other cellular pathways. Any disruption of Notch signaling, either due to direct mutations or to an aberrant regulation of genes involved in the signaling route, might lead to both hyper- or hypo-activation of Notch signaling molecules and of target genes, ultimately inducing the onset of skin diseases. The mechanisms through which Notch contributes to the pathogenesis of skin diseases are multiple and still not fully understood. So far, Notch signaling alterations have been reported for five human skin diseases, suggesting the involvement of Notch in their pathogenesis: Hidradenitis Suppurativa, Dowling Degos Disease, Adams-Oliver Syndrome, Psoriasis and Atopic Dermatitis. In this review, we aim at describing the role of Notch signaling in the skin, particularly focusing on the principal consequences associated with its alterations in these five human skin diseases, in order to reorganize the current knowledge and to identify potential cellular mechanisms in common between these pathologies.

Weight counseling in pediatric hidradenitis suppurativa patients

BACKGROUND/OBJECTIVES

Hidradenitis suppurativa is a chronic, painful, debilitating disease that may present in the pediatric years. Overweight and obesity are believed to worsen disease severity, but many patients do not receive counseling regarding weight control. The objective of this study is to examine the percentage of hidradenitis suppurativa patients who receive weight counseling as a part of their disease management and which specialties primarily care for these patients.

METHODS

We performed a retrospective chart review of pediatric hidradenitis suppurativa patients between January 2011 and October 2018. Demographic data, height, weight, body mass index, body mass index percentiles, number of visits per department, referrals to the Center for Healthy Weight and Nutrition, and referring provider department data were collected.

RESULTS

A total of 535 pediatric hidradenitis suppurativa patients were reviewed; 79.6% were female, and the mean age at diagnosis was 14.5 years. 11.6% of patients were overweight, and 54.2% were obese. 32.1% of overweight and obese hidradenitis suppurativa patients received a referral to the Center for Healthy Weight and Nutrition. The majority of referrals were placed by Primary Care. Dermatology placed 7.1% of the referrals to the Center for Healthy Weight and Nutrition for these patients.

CONCLUSIONS

The results suggest that there is a need for increased awareness, education, and counseling on weight management and nutrition for pediatric hidradenitis suppurativa patients. Further studies are needed to determine the success of counseling on weight control and disease severity.

Pediatric Endoscopic Hidradenitis Treatment: A New Minimally Invasive Treatment for Pediatric Patients with Hidradenitis Suppurativa

Background: Hidradenitis suppurativa (HS) is infrequent in the pediatric population. When indicated, surgery is often invasive, painful, and with significant recurrence rate. We aimed to report our preliminary experience using a new endoscopic technique to treat this pathology. Materials and Methods: We reported the data of 11 patients (9 girls and 2 boys) with average age of 15.7 years (range 14-17) with HS, who were operated using endoscopic procedure for a 15-month period. Six patients presented axillary, inguinal, and inframammary localizations, 3 patients presented axillary and inguinal localizations, and 2 patients presented only inguinal localization. Pediatric endoscopic hidradenitis treatment (PEHT) followed the same principles of pediatric endoscopic pilonidal sinus treatment (PEPSiT). The fistuloscope was introduced into the different holes, and after using an endobrush, all tracts were cauterized using monopolar electrode or laser energy, and finally the granulation tissues were removed using graspers. At the end of the procedure, all the holes were filled with oxygen-enriched oil-based gel and covered with fat gauze. Results: The average operative time was 47 minutes (range 30-80). All procedures were performed in a day surgery setting or with an overnight hospitalization. All patients reported no pain postoperatively and performed a local dressing with silver sulfadiazine spray and oxygen-enriched oil-based gel two times per day for 1 month postoperatively. At the longest follow-up of 1 year, the lesions were completely healed in all cases. Two patients (18%) developed further lesions in different untreated localizations that were successfully treated using PEHT. Conclusions: PEHT is a minimally invasive, effective, and safe treatment option for pediatric patients with HS. All patients reported a painless postoperative period and excellent results. Postoperative local dressings using oxygen-enriched oil-based gel and silver sulfadiazine spray are fundamental to achieve the complete healing. However, a further evidence with larger series and longer follow-up is required to confirm these preliminary results.

Management of adolescents with hidradenitis suppurativa

Hidradenitis suppurativa (HS) can have devastating impacts on quality of life (QoL), especially during adolescence when patients face unique challenges related to self-esteem, body-image, and sexual maturation. Many teenage HS patients also experience social challenges related to school, relationships, and employment that may require physician intervention. Strategies for comprehensive management of this special group include addressing low medication adherence, screening for comorbidities, and recommending practical lifestyle modifications to reduce disease flares. Herein, we review the impact of HS on adolescent patients and provide practical recommendations to minimize effects on the adolescent life course.

Hidradenitis suppurativa in a cohort of overweight and obese children and adolescents

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory, and recurring disease mainly observed in adults. Obesity is considered an important independent factor in HS development and is associated with a higher prevalence of HS in children. We aimed to characterize the clinical presentation of HS in overweight and obese children and adolescents.

METHODS

We performed a cross-sectional observational study during January 2007-April 2015. Overweight and obese patients (5-17 years of age, BMI> 90th percentile) referred to The Children's Obesity Clinic, Department of Paediatrics, Copenhagen University Hospital Holbaek, Denmark, underwent screening for dermatological conditions. A dermatologist ascertained the diagnosis of HS, and disease severity was assessed using Hurley staging and Sartorius score. Tobacco smoke exposure, body mass index (BMI) standard deviation score (SDS), and psychiatric comorbidities were recorded. Our cohort was compared with a reference cohort recruited in a previous study.

RESULTS

A total of 195 children and adolescents underwent screening for dermatological conditions. Nine patients screened positive, and six of these patients were available for examination of whom five presented with HS. All HS cases were mild (median Sartorius score of 9). Four of the five patients (with varying constellations) reported tobacco exposure, a positive family history of HS, and exhibited psychiatric comorbidities.

CONCLUSION

Our findings support that the presence of pediatric HS is correlated with familial disposition to HS and psychiatric comorbidities.

Metabolic syndrome and inflammatory skin conditions

PURPOSE OF REVIEW

Several chronic inflammatory skin disorders have been linked to metabolic syndrome (MetS) and an increased risk for cardiovascular disease. In this review, we will summarize the recent evidence on the association between psoriasis, hidradenitis suppurativa (HS), and atopic dermatitis (AD) and metabolic syndrome with careful attention to this association among the pediatric population.

RECENT FINDINGS

Historically, psoriasis has exhibited the most robust association with MetS in the literature. Recent studies show that the prevalence of MetS appears to be higher among patients with HS and can be associated with MetS even in mild disease. A relationship between AD and MetS is still under debate, but research has shown a clear link between pediatric AD and being overweight or obese.

SUMMARY

There are no current consensus guidelines for metabolic syndrome in the pediatric population, and its clinical implications in children are still unclear. Nevertheless, providers should be aware of the shared underlying inflammatory state and link between several cutaneous disorders and metabolic syndrome. Early diagnosis and proper disease management of these at risk populations has the potential to assist in disease control and mitigate future cardiovascular disease.

Disseminate Recurrent Folliculitis and Hidradenitis Suppurativa Are Associated Conditions: Results From a Retrospective Study of 131 Patients With Down Syndrome and a Cohort of 12,351 Pediatric Controls

Background

Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent skin disease of the pilosebaceous unit characterized by protean manifestations. Several studies have found an increased incidence and earlier presentation of this disease in patients carrying trisomy 21. Patients with Down syndrome (DS) have a higher risk of developing a wide range of cutaneous manifestations, including HS and chronic folliculitis. Recently, disseminate recurrent folliculitis (DRF) has been reported as an atypical monosymptomatic feature of HS at its onset.

Objective

To assess the prevalence of HS and DRF by comparing a cohort of patients carrying trisomy 21 vs pediatric controls.

Methods

A retrospective 2-year monocentric clinical study was performed by collecting clinical data of 131 patients with DS, aged 4-36 years, followed at the Dermatology Unit and Down Syndrome Regional Center of Bologna University. Data were matched with those coming from 12,351 pediatric controls.

Results

In DS patients, DRF and HS showed a prevalence of, respectively, 6.8% and 24.4%, while 5.3% of patients presented both diseases. In the control group the prevalence for HS+ and DRF+ was 0.5% and 1.2%, respectively, with a 0.14% of overlap cases. The association between HS and DRF proved to be statistically significant in both groups (P < 0.05). In the DS cohort the mean age of symptoms onset was 15.67 (SD: 2.29) years for HS and 13.11 (SD: 4.93) years for DRF. Buttocks were the most frequently affected body area for DRF followed by the inguinocrural area, while in HS buttocks were less frequently involved than groins and upper thighs.

Conclusions

Because of the later onset of HS, patients with DRF at an early age should be monitored for the possible onset of HS in the apocrine-bearing areas.

Model-Informed Drug Development Approach Supporting Approval of Adalimumab (HUMIRA) in Adolescent Patients with Hidradenitis Suppurativa: a Regulatory Perspective

On October 16, 2018, FDA expanded the adalimumab dosing regimen to adolescent hidradenitis suppurativa (HS) patients 12 years and older, weighing at least 30 kg without new clinical data. This approval was mainly supported by the model-informed drug development approach. Population pharmacokinetic simulations suggest body weight-tiered dosing regimens in adolescent patients will achieve similar exposure to adult patients across all weight range. Adalimumab has a well-established, 16-year long-term safety profile in various diseases in adult and pediatric populations. Current data of adalimumab in the pediatric population demonstrate no exposure-response relationship for adverse events. The effectiveness in adolescent patients was extrapolated from two adequate and well-controlled phase 3 studies in adult patients, assuming similar positive exposure-efficacy relationships in adults and adolescents. This article provides the insight of the application of MIDD on the adalimumab approval in adolescent HS patients and its implication on drug development and regulatory decision especially for pediatrics or rare diseases.

Diagnosis and treatment of dermatologic diseases in inflammatory bowel disease

PURPOSE OF REVIEW

Dermatologic manifestations in patients with inflammatory bowel disease (IBD) are increasingly recognized as related disorders, secondary to specific therapies used to treat IBD, or complications of IBD itself. These dermatologic manifestations can be difficult to manage.

RECENT FINDINGS

We summarize three categories of dermatologic manifestations in this review: extraintestinal cutaneous disorders, paradoxical manifestations to biologic therapies, and other drug-induced cutaneous manifestations. In particular, we provide current data surrounding clinical characteristics, epidemiology, and treatment modalities for individual cutaneous manifestations.

SUMMARY

Many extraintestinal cutaneous manifestations can be managed by optimized treatment of IBD itself, as shared treatment pathways exist. Paradoxical reactions to biologic agents may be driven by the individual biologic therapy. In these instances, if topical therapies or immunomodulators are not effective in treating the paradoxical cutaneous reaction, a change of class may be required. Nonmelanoma and melanoma skin cancers have been linked to specific therapies for IBD (including thiopurines and antitumor necrosis factor alpha agents, respectively). Therefore, optimizing preventive efforts towards skin cancer is warranted. Recognition of these cutaneous disorders by the practicing gastroenterologist is important, as is collaboration with dermatology for management of many cutaneous disorders.

Proceeding report of the third symposium on Hidradenitis Suppurativa advances (SHSA) 2018

The 3rd Annual Symposium on Hidradenitis Suppurativa Advances (SHSA) took place on 12-14 October 2018 at the Women's College Hospital in Toronto, Ontario, Canada. This symposium was a joint meeting of the Hidradenitis Suppurativa Foundation (HSF) founded in the USA and the Canadian Hidradenitis Suppurativa Foundation (CHSF). This cross-disciplinary meeting with experts from around the world was an opportunity to discuss the most recent advances in the study of hidradenitis suppurativa pathogenesis, epidemiology, classification, scoring systems, radiologic diagnosis, treatment approaches and psychologic assessment. Two special sessions this year were HS as a systemic disease and HS management guidelines. There were focused workshops on wound healing and ultrasound. There were two sessions primarily for patients and their families in the HS School programme: One workshop focused on mindfulness, and the second involved discussion among clinicians and patients about various disease aspects and the latest management. To facilitate networking between clinical and research experts and those early in their career, a mentoring breakfast was held.

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part II: Topical, intralesional, and systemic medical management

Hidradenitis suppurativa is a severe and debilitating dermatologic disease. Clinical management is challenging and consists of both medical and surgical approaches, which must often be combined for best outcomes. Therapeutic approaches have evolved rapidly in the last decade and include the use of topical therapies, systemic antibiotics, hormonal therapies, and a wide range of immunomodulating medications. An evidence-based guideline is presented to support health care practitioners as they select optimal medical management strategies and is reviewed in this second part of the management guidelines. A therapeutic algorithm informed by the evidence available at the time of the review is provided.

Consensus on the treatment of hidradenitis suppurativa - Brazilian Society of Dermatology

Hidradenitis suppurativa is a chronic immune mediated disease of universal distribution that causes great damage to the quality of life of the affected individual, whose prevalence is estimated at 0.41% in the Brazilian population. The objective of this work was update on physiopathogenesis, diagnosis and classification of hidradenitis suppurativa and to establish therapeutic recommendations in the Brazilian reality. It was organized as a work group composed of eight dermatologists from several institutions of the country with experience in the treatment of hidradenitis suppurativa and carried out review on the topic. Recommendations were elaborated and voted by modified Delphi system and statistical analysis of the results was performed. The Brazilian consensus on the clinical approach of hidradenitis suppurativa had the support of the Brazilian Society of Dermatology.

Association Between Hidradenitis Suppurativa and Metabolic Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

Recent studies have shown a relationship between hidradenitis suppurativa (HS) and metabolic syndrome (MS), but the literature offers no meta-analysis restricted to studies that have been adjusted for confounders.

OBJECTIVE

To determine the association between HS and MS.

METHODS

A systematic review and meta-analysis of observational studies on HS and MS in adults. We searched MEDLINE, SCOPUS, SCIELO, Google Scholar, Science Direct, and LILACS from the inception of the databases to January 2016. We performed a random effects model meta-analysis for studies reporting adjusted and crude odds ratios (ORs) with 95% CIs. A subgroup analysis was related to the type of HS patient (general patients vs hospital patients) and age group (adults vs children and adults).

RESULTS

Five studies including 3950 HS patients were analyzed. We found that MS was pres-ent in 9.64% of HS patients (OR, 1.82; 95%, CI 1.39-2.25). Studies from tertiary care hospital dermatology clinics (OR, 2.82; 95% CI, 0.58-5.06) reported a greater risk for MS than studies carried out in patients treated outside hospitals (OR, 1.78; 95% CI, 1.34-2.22). Studies that included pediatric populations reported a significant association (OR, 2.10; 95% CI, 1.58-2.62).

LIMITATION

Few of the included studies reported adjusted ORs.

CONCLUSIONS

HS patients have an increased risk for MS. Clinicians should consider screening HS patients for metabolic risk factors.

Photobiomodulation therapy promotes in vitro wound healing in nicastrin KO HaCaT cells

Mutations in NCSTN gene (encoding for nicastrin protein) are associated with hidradenitis suppurativa (HS), a chronic inflammatory disease involving hair follicles. HS is clinically handled with drugs but the most severe cases are treated with surgery. Photobiomodulation (PBM) therapy, already used in the treatment of skin diseases such as acne, herpes virus lesions, ultraviolet damage, vitiligo, hypertrophic scar, keloid, burn, psoriasis and diabetic chronic wounds, could be beneficial as an adjuvant supportive treatment to promote and foster the healing process after skin excision in HS. The effects of PBM therapy in promoting the wound closure are evaluated in a HaCaT cells NCSTN-/-, assessing cell metabolism, migration rate, proliferation and cell cycle progression. In our experimental model, PBM exerts a potent action on metabolism of mutated keratinocytes, incrementing adenosine triphosphate (ATP) production at 2 hours, while after 24 hours an increase of metabolism with a decrement of intracellular ATP levels were recorded. Moreover, PBM speeds up the wound closure, inducing cells' migration without affecting their proliferation.Based on our findings, we suggest the use of PBM in HS patients, who undergo major surgery with large skin excision.

Long-Term Outcome of Adalimumab in a Young Girl with Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, burdensome inflammatory skin disorder mainly affecting adults with an infrequent onset during childhood or adolescence. Guidelines regarding the therapeutic drugs in pediatric HS patients are lacking. We describe the case of a 16-year-old girl affected by HS with a massive impact of the disease on her daily activities. She underwent antibiotics, estroprogestinics, isotretinoin, and drainage procedures with partial and short-term improvement. We treated the patient with adalimumab and assessed disease severity using BMI, pain VAS, Hurley, m-Sartorius, and HS-PGA. The treatment has been continued for 4 years with a strong improvement of clinical and psychological outcome. No side effects were recorded throughout the treatment period.

A retrospective study of the characteristics of patients with early-onset compared to adult-onset hidradenitis suppurativa

BACKGROUND

The mean age of onset of hidradenitis suppurativa (HS) is between 20 and 24 years. Very few data about patients with early-onset HS exist.

OBJECTIVE

To investigate the association of early-onset HS with the clinical characteristics: age, gender, body mass index (BMI), smoking, family history of HS, Hurley stage, and number of areas affected.

METHODS

This was a retrospective study of the reported early age at HS onset (≤17 years old) with clinical characteristics and with the severity of HS at first consultation visit.

RESULTS

In 166 patients, 42 patients (25.3%) reported early-onset HS. Compared to adult-onset HS, patients with early-onset HS were younger (mean age: 37 years vs. 27 years, P < 0.0001), had a significantly younger mean age of onset (28.2 years old vs. 14.5 years old, respectively, P < 0.0001), longer mean disease duration (8.8 years vs. 12.6 years, respectively, P = 0.011) and were less frequently smokers (P < 0.001), whereas there was no association with gender (P = 0.177) or BMI (0.086). Patients with a family history had increased risk for early-onset HS (OR: 2.45, 95% CI: 1.08-5.56). Early-onset HS was not associated with Hurley stage (OR: 1.12, 95% CI: 0.33-3.74) or with the number of body areas affected (OR: 1.54, 95% CI: 0.49-4.83).

CONCLUSION

Early-onset HS was frequent and associated with a family history of HS. There was no difference in the severity of HS in adult life for patients with an onset of HS at ≤17 years, compared to patients with adult-onset, which may be reassuring information for these younger patients.

Hidradenitis suppurativa, a review of pathogenesis, associations and management. Part 1

Hidradenitis suppurativa is a chronic, painful, autoinflammatory condition resulting in nodules, abscesses and sinus tracts. We present an evidence-based review providing new understanding of the pathogenesis of hidradenitis suppurativa and associated comorbidities. By the nature of their speciality, dermatologists are uniquely positioned to investigate and treat patients with this condition. Data collected from a subspecialty hidradenitis suppurativa clinic (N = 106) and experiences thereof are discussed in this review.

The impact of pediatric skin disease on self-esteem

Background

Pediatric skin disorders can affect children's self-esteem, relationships with caregivers and peers, and performance in school and activities.

Objective

This review describes common pediatric congenital and acquired dermatologic disorders and the impact that these disorders can have on children's self-esteem.

Methods

A review of current, English-language literature was conducted with use of the PubMed database. Search terms included atopic dermatitis, acne, infantile hemangiomas, port wine stains, congenital melanocytic nevi, hidradenitis suppurativa, and self-esteem.

Results

During infancy and toddlerhood, skin disorders such as infantile hemangiomas primarily affect the attachment between child and caregiver. School-aged children with port wine stains and atopic dermatitis report increased bullying, teasing, and social isolation. Acne and hidradenitis typically affect older children and teens and these conditions are associated with increased risks of depression and suicidal ideation. Effective management of these conditions has been shown to increase patients' self-esteem.

Conclusion

Pediatric dermatologic disorders impact self-esteem throughout childhood. In addition to the surgical and medical management of these disorders, clinicians can also take an active role in the assessment and improvement of the psychosocial impact of these skin disorders.

Hidradenitis suppurativa and the metabolic syndrome

The association of the metabolic syndrome (MetS) and its components with immune-mediated chronic inflammatory disorders has attracted much interest within the last two decades. In addition to the well-established association of psoriasis with MetS, recent data point to an association between MetS and hidradenitis suppurativa, as well. The association of hidradenitis suppurativa with MetS and its components, such as diabetes, obesity, and dyslipidemia, has been consistently identified in controlled studies. This relationship is not only limited to older individuals but also applicable to younger patients and those with mild disease. This review documents the link between these disorders and discusses its practical implications, mainly highlighting the importance of prevention and routine screening for early diagnosis to prevent cardiovascular-related morbidity.