Hidradenitis Suppurativa Is Associated with Polycystic Ovary Syndrome: A Population-Based Analysis in the United States

Comorbidities, Clinical Presentation, Subtypes, and Treatment of HS Patients in Lithuania

Background: Hidradenitis suppurativa (HS) is a persistent, recurring skin inflammatory condition linked to various comorbidities. Management involves antibiotics, hormone therapy, immune-modulating drugs, surgery, and treatment of comorbidities. The objectives of the study were to assess the comorbidities, clinical presentation subtypes, and applied treatment of patients with HS. Methods: Patients with HS who visited the Centre of Dermatovenereology at Vilnius University Hospital Santaros Klinikos in Lithuania underwent evaluation based on the guidelines of the European Hidradenitis Suppurativa Foundation Registry questionnaire. Results: The study included 49 patients, and 61.22% (n = 30) had comorbidities. A strong positive correlation was found between a family history of inflammatory diseases (69.38% (n = 34)) and the severity of HS according to Hurley stage (r = 0.71 p < 0.05). A statistically significant correlation (r = 0.944, p = 0.02) was found between metabolic comorbidities and Hurley stage. Patients on biologic treatment had a mean IHS4 of 7.38 at the beginning of treatment and 3.22 at follow-up (p < 0.05). For patients not on biologics, the initial IHS4 score was 6.21 and 5.42 at follow-up (p > 0.05). Conclusions: A family history of inflammatory diseases and metabolic comorbidities showed a strong correlation with HS severity. Treatment with biologics showed significant improvement in HS scores compared to systemic antibiotics.

Prevalence and association of polycystic ovary syndrome and hidradenitis suppurativa in underrepresented groups

Hidradenitis suppurativa (HS) is an inflammatory disorder of follicular biology; androgens are believed to be involved in its pathogenesis. Polycystic ovary syndrome (PCOS) is similarly characterized by hyperandrogenism. Previous studies have found a lasting association of HS and PCOS. Socioeconomic status (SES) has been described as a comorbidity for both HS and PCOS that has not been accounted for in prior studies; we sought to investigate this association while adjusting for this. We also analyzed the prevalence of PCOS among HS patients. Using the All of Us database, female HS patients were stratified by PCOS diagnosis and compared by age, race, and ethnicity. Female HS patients were also nearest-neighbor propensity-score matched to controls at a 4:1 ratio, selecting for race, ethnicity, age, ever smoker, alcohol use disorder, obesity, type II diabetes, Medicaid status, and community deprivation index. Univariable and multivariable logistic regression was conducted to estimate the effect of HS on the presence of PCOS. The distribution of race among HS patients with PCOS was significantly different than HS patients without PCOS. A total of 1,022 female HS patients and 4,088 matched female controls were included. Significantly more patients carried a diagnosis of PCOS compared to controls (8.8% versus 4.3%, p < .001). In multivariable logistic regression, PCOS was significantly associated with HS [OR 1.71 (95% CI 1.34-2.17)]. This is the first study investigating the association of HS and PCOS within the All of Us database. We found that females with HS had a 1.34- to 2.17-fold increased odds of having PCOS, which is consistent with previous analyses. However, our analysis, in addition to controlling for common medical co-morbidities found in both HS and PCOS, also accounts for markers of SES at an individual and community level, further strengthening the association of HS with PCOS.

Hidradenitis suppurativa disease control associated with type of hormonal contraceptive use

Hidradenitis suppurativa (HS) is a painful chronic skin condition of apocrine gland regions. This retrospective cohort study aimed to assess the impact of hormonal contraception type on HS disease control in adult women. In total, 160 patients were included, with the majority identifying as Black or African American (73.1%). Multivariate logistic regression showed that oestrogen-progesterone users were 3.14 times more likely to experience stable or improved HS than progesterone-only users (adjusted odds ratio 3.14, 95% CI 1.18-8.35; P = 0.02). Further investigation is needed to elucidate the antiandrogenic mechanisms affecting HS symptom response to hormonal contraceptives.

[Translated article] Glucagon-Like Peptide-1 Agonists for Treating Obesity in Patients With Immune-Mediated Skin Diseases

Psoriasis and hidradenitis suppurativa are often associated with obesity. Because chronic low-grade inflammation underlies these 2 diseases, they can progress to more severe forms in patients with obesity if weight-reduction measures are not taken. This review covers pharmacologic alternatives for treating obesity, with emphasis on the benefits associated with the novel use of glucagon-like peptide-1 (GLP-1) agonists that act on satiety receptors. These drugs have led to greater weight loss in clinical trials and real-world settings than orlistat, which until recently was the only drug approved for treating obesity in the European Union. Although experience with GLP-1 agonists in patients with obesity and inflammatory skin diseases is currently scarce, the promising results reported suggest they may offer a useful tool for managing obesity.

Haptoglobin is an independent marker for disease severity and risk for metabolic complications in hidradenitis suppurativa: A prospective study

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease that is highly correlated with obesity. Haptoglobin serum levels have recently been recognized as an important biomarker linking obesity with chronic inflammation.

OBJECTIVE

To compare haptoglobin with previously proposed serum biomarkers for the determination of disease severity in HS patients. For this purpose, disease severity of HS patients was determined by a panel of clinical scores as well as several risk factors, such as weight and smoking habits.

METHODS

A prospective, diagnostic accuracy study was performed at the International Centre for Hidradenitis suppurativa/Acne inversa Bochum (ICH). The study included a total of 263 patients, including 131 who had a confirmed diagnosis of HS in Hurley I (n = 16), II (n = 56) and III (n = 59) HS, and 132 healthy controls. The main outcome was to identify serological inflammatory markers for HS disease severity [severe (III) vs. moderate/mild (II/I)] as assessed by Hurley classification.

RESULTS

The serum levels of acute phase proteins haptoglobin and CRP, as well as the number of neutrophils in peripheral blood, number of monocytes, the systemic immune-inflammation index and the pan-immune-inflammatory value correlated with disease severity according to established clinical scores (mHSS, SAHS, Hurley, DLQI). HS patients had significantly higher haptologlobin levels compared to healthy controls. Logistic regression analysis revealed haptoglobin as the only independent marker predicting severe HS.

CONCLUSION

In this prospective study, we discovered that the serum levels of the acute phase protein haptoglobin levels serve as an independent marker of disease severity in HS. While this presents the first study in the context of HS. Thus, the present data not only yield a highly promising serum marker to be further validated.

Glucagon-Like Peptide-1 Agonists for Treating Obesity in Patients With Immune-Mediated Skin Diseases

Psoriasis and hidradenitis suppurativa are often associated with obesity. Because chronic low-grade inflammation underlies these 2 diseases, they can progress to more severe forms in patients with obesity if weight-reduction measures are not taken. This review covers pharmacologic alternatives for treating obesity, with emphasis on the benefits associated with the novel use of glucagon-like peptide-1 (GLP-1) agonists that act on satiety receptors. These drugs have led to greater weight loss in clinical trials and real-world settings than orlistat, which until recently was the only drug approved for treating obesity in the European Union. Although experience with GLP-1 agonists in patients with obesity and inflammatory skin diseases is currently scarce, the promising results reported suggest they may offer a useful tool for managing obesity.

Taiwanese Dermatological Association (TDA) consensus recommendations for the definition, classification, diagnosis, and management of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory follicular disease characterized by painful, recurrent, inflamed lesions most commonly occurring in the axillary, inguinal, and anogenital regions. HS can inflict immense physical and psychological impact on patients who suffer from this distressing disease. Management of HS generally requires combining various medical and procedural treatment modalities; however, the disease is often recalcitrant to conventional treatments. In light of recent evidence supporting the effectiveness of biologic agents in the treatment of HS, the Taiwanese Dermatological Association established an expert panel of nine dermatologists to develop consensus statements aimed to provide up-to-date evidence-based guidance in optimizing HS patient management in Taiwan. The recommendations described in the statements were summarized in a management algorithm in terms of general care, topical treatment, systemic treatment, and procedural treatment.

What should a surgeon know about hidradenitis suppurativa?

Otherwise known as Verneuil's disease, hidradenitis suppurative (HS) is a severe dermatosis of heterogeneous appearance affecting 1% of the population. Its pathophysiology is multifactorial, involving genetic predisposition, inflammatory disorder and environmental elements. Its diagnosis is based on the association of three clinical characteristics: characteristic lesions, typical localizations, and the chronic and recurrent nature of the lesions. Given its diversified aspects, diagnosis can be difficult to achieve. As its manifestations often include abscesses, it is important for the surgeon to know how to detect this pathology. The development of biologics has improved treatment of this disease, treatment that necessitates a multidisciplinary medical and surgical approach involving dermatologists and proctologists as well as surgeons. The objective of this report is to synthesize what a surgeon will need to know so as effectively treat HS patients.

Epidemiology of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent skin disease affecting hair follicles in predominantly intertriginous areas, characterized by deep, painful nodules and abscesses, fistulas, sinus tracts, and scarring. The estimated global prevalence of HS is highly variable, as revealed in a growing body of published literature, and ranges from 0.053% to 4.1%. In North American and European patients, HS is three times more common in women than men, whereas in South Korea and Japan, male predominance is found. The disease most frequently manifests itself between the ages of 18 and 29. Numerous published studies have reported the association between smoking, obesity, and HS, although there are limitations in confirming the causal relationship due to the retrospective design of the available studies. Case-control studies have frequently evaluated the association between HS, metabolic syndrome, and other systemic comorbidities. Due to increased mental health problems, a higher risk of suicide in patients with HS has been reported. We provide up-to-date evidence about the epidemiology, genetic and environmental risk factors, comorbidities, and quality of life of patients with HS. The divergence in HS frequency, possibly due to differences in populations and methodologies, remains to be explained in future worldwide studies.

Clinical and Ultrasonographic Characterization of Hidradenitis Suppurativa in Female Patients: Impact of Early Recognition of the Disease

Hidradenitis suppurativa (HS) is considered a post-pubertal disease; however, earlier onset is not infrequent. The burden of HS on the female population is very relevant, and early identification might reduce the quality of life impairment and improve the therapeutic approach. In this study, we investigated clinical biomarkers of HS that could impact the management of patients affected by HS. Female patients affected by stable HS were prospectively included in this study. Anamnestic data, clinical and ultrasonographic features were collected and analyzed. Overall, 53 patients were included in this study. The median age of onset was 19 (IQR: 14-25). Early onset was reported by 22/53 patients (median age of onset: 14; IQR: 11-16). Four patients had pre-menstruation occurrence. Early-onset patients had an earlier first-menstrual-cycle age and more frequent genital localization of HS, and were more often treated with biologics. Patients with early-onset-HS and genital localization had more severe disease with a higher number of areas affected, Hurley, and IHS4 scores. Genital involvement might be prevalent in patients with early-onset HS, leading to a worse impact on the global severity of the disease and tailored treatment protocols, including multidisciplinary approaches, in order to improve the early recognition of hidden lesions.

Patient Perspectives on Hidradenitis Suppurativa and Infertility: A Survey Study

BACKGROUND

Hidradenitis suppurativa (HS) is an inflammatory skin condition which predominantly affects women of childbearing age in the USA. There is a lack of research on the association between HS and fertility.

OBJECTIVES

The aim of this study was to understand the perspectives of females with HS regarding the impact of their disease on reproductive health, the impact of fertility treatments on HS, and the impact of HS treatments on fertility.

METHODS

An anonymous, online survey was disseminated through HS support groups from June to July 2022. Respondents aged 18-50 who were assigned female sex at birth were eligible for participation. Comparative statistics were performed using t tests/χ2 tests to assess associations between respondents' demographics and survey responses.

RESULTS

Among the 312 respondents (80.8% White, mean age 35.7 ± 7.4 [range 18-50]), two-thirds of respondents (66.6%, 207/311) had been pregnant before and 79.5% (248/312) had ever tried to conceive. 41.5% (103/248) had unsuccessfully tried to conceive for 12 months or more. Of the 59 respondents who had never attempted to conceive, 39% reported that HS had impacted this decision. Amongst respondents who experienced fertility challenges but did not pursue fertility treatments, top barriers to fertility treatments include concerns about financial support/insurance coverage (47.5%, 29/61) and fertility treatments worsening HS (21.3%, 13/61). Most respondents who used fertility treatments reported either no change (73.7%, 28/38 or 77.8%, 14/18) or improvement (15.8%, 6/38 or 11.1%, 2/18) in their HS symptoms with oral or injectable medications. Respondents were most concerned about the effects of oral antibiotics (44.9%, 140/312), followed by hormonal medications (38.8%, 121/312) and biologics (35.9%, 112/312) on fertility.

CONCLUSION

Females with HS reported high rates of infertility compared to the general population. The majority reported no change in HS symptoms with fertility treatments, and clinicians can use this finding to help counsel patients during family planning discussions. Further research in the field of HS and fertility is needed.

Metformin Treatment of Hidradenitis Suppurativa: Effect on Metabolic Parameters, Inflammation, Cardiovascular Risk Biomarkers, and Immune Mediators

Hidradenitis suppurativa (HS) is a common cutaneous and systemic inflammatory disease with a significant impact on mental health and quality of life. It is associated with obesity, insulin resistance, metabolic syndrome, cardiovascular (CV) disease, and increased all-cause mortality. Metformin is used frequently in HS treatment and is effective for some patients. The mechanism of action of metformin in HS is unknown. A case-control study of 40 patients with HS (20 on metformin and 20 controls) was conducted to assess differences in metabolic markers, inflammation (C-reactive protein [CRP], serum adipokines, and CV risk biomarkers), and serum immune mediators. Body mass index (BMI), insulin resistance (77%), and metabolic syndrome (44%) were high overall, but not significantly different between the groups. This highlights the need for co-morbidity screening and management. A significant reduction in fasting insulin and a trend towards a reduction in insulin resistance were identified in the metformin group compared with pre-treatment levels. CV risk biomarkers were significantly favourable in the metformin group (lymphocytes, monocyte-lymphocyte ratio, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio). CRP was lower in the metformin group but was not statistically significant. Adipokines were dysregulated overall but were not different between the two groups. Serum IFN-γ, IL-8, TNF-α, and CXCL1 trended lower in the metformin group but did not reach significance. These results suggest that metformin improves CV risk biomarkers and insulin resistance in patients with HS. When the results of this study are considered alongside other studies in HS and related conditions, it is likely that metformin also has beneficial effects on metabolic markers and systemic inflammation in HS (CRP, serum adipokines, and immune mediators), warranting further research.

Establishing an Association between Polycystic Ovarian Syndrome and Pilonidal Disease in Adolescent Females

STUDY OBJECTIVE

We sought to determine whether pilonidal disease (PD) is associated with polycystic ovarian syndrome (PCOS) in adolescent females.

DESIGN

Retrospective cohort study SETTING: Urban tertiary children's hospital PARTICIPANTS: All girls aged 12 to 21 who received a diagnosis of PD and/or PCOS from 2012 to 2019 INTERVENTIONS: Treatment for PCOS and PD MAIN OUTCOME MEASURES: The variables analyzed included age, race/ethnicity, body mass index, age at menarche, tobacco use, payer status, treatment of PCOS and PD, and serum markers of hyperandrogenism and metabolic syndrome.

RESULTS

During the study period, 100,043 patients presented to an urban tertiary medical center. Of these patients, 966 were diagnosed with PD, and 219 were diagnosed with both PD and PCOS. Compared with patients with only PD, patients with both diagnoses had a higher body mass index (31.4 vs 27.4 kg/m²; P < .01) and were older (18.76 vs 18.30 years; P = .003). The prevalence ratio for patients with PD having PCOS per the original Rotterdam criteria was 26.1 (CI, 22.0-31.0) and 28.7 (CI, 24.3-33.9) for having PCOS per the modified Rotterdam criteria. Patients with both diagnoses were less likely to receive intervention for PD (OR = 0.22; CI, 0.13-0.37; P < .001).

CONCLUSIONS

Adolescent females diagnosed with PD are likely to demonstrate features of PCOS. PCOS treatment could positively alter the disease course of PD. As such, surgical providers should consider referring adolescent females with PD to endocrinologists, gynecologists, and adolescent medicine specialists for evaluation of PCOS.

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.

Current Medical and Surgical Treatment of Hidradenitis Suppurativa-A Comprehensive Review

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease presenting with recurrent inflammatory lesions in intertriginous body regions. HS has a pronounced impact on patients' quality of life and is associated with a variety of comorbidities. Treatment of HS is often complex, requiring an individual approach with medical and surgical treatments available. However, especially in moderate-to-severe HS, there is an urgent need for new treatment approaches. In recent years, increased research has led to the identification of new potential therapeutic targets. This review aims to give a comprehensive and practical overview of current treatment options for HS. Furthermore, the clinically most advanced novel treatment approaches will be discussed.

The Role of Hormones in Hidradenitis Suppurativa: A Systematic Review

Hidradenitis suppurativa (HS) is a chronic inflammatory disease manifesting in inverse body regions. In a systematic review, the role of hormones in HS will be presented to better understand the pathomechanisms of HS. The review is based on the PRISMA criteria. Systematic research was carried out using keywords. Subsequently, the data were analyzed based on the clinical response and other relevant information. The main focus of our systematic review was on HS manifestation, exacerbation, sex hormones, antiandrogen therapy, thyroid function, polycystic ovary syndrome, insulin resistance, and adipokines. In HS, there appears to be a dysregulated adipokine release that is shifted towards pro-inflammatory adipokines. Insulin resistance is significantly more common in HS than in healthy patients regardless of BMI, age, and gender. Insulin resistance in HS patients leads to further cardiovascular disease. The mechanism of insulin resistance and role of adipokines should be investigated in future studies to better provide the pathomechanisms of HS. The role of androgens seems to be important in a certain subgroup of female patients. Anti-androgenic therapy can be useful and helpful in some patients. However, further studies are needed to better understand the hormonal relationship in HS.

Comorbid diseases of hidradenitis suppurativa: a 15-year population-based study in Olmsted County, Minnesota, USA

BACKGROUND

Like other chronic, inflammatory skin disorders, hidradenitis suppurativa (HS) is increasingly recognized to be associated with various medical disorders.

OBJECTIVE

Using the Rochester Epidemiology Project (REP), we sought to conduct the first American population-based study examining the association between HS and various comorbid conditions.

METHODS

From the REP database, we identified patients diagnosed with HS from 2003 through 2018 who were residents of Olmsted County, Minnesota, USA, along with age- and gender-matched controls. The frequency of a wide variety of comorbid conditions was compared between the groups.

RESULTS

A total of 1160 patients with HS were identified during the study period. Compared with age- and gender-matched controls, patients with HS had a significantly higher frequency of several medical conditions, including depression, anxiety, hyperlipidemia, acne conglobata, dissecting cellulitis, pilonidal cysts, polycystic ovary syndrome, diabetes, chronic kidney disease, psoriasis, atopic dermatitis, obesity, and disordered substance use, among others.

LIMITATIONS

Our study was limited by its retrospective design.

CONCLUSIONS

Providers caring for patients with HS should consider these results, along with those of similar studies, and obtain a thorough history, comprehensive physical examination, and, potentially, laboratory testing and referral to other specialists.

Is Polycystic Ovary Syndrome a Predisposing Factor for Pilonidal Sinus Disease?

BACKGROUND

The incidence of pilonidal sinus may be increased in women with polycystic ovary syndrome.

OBJECTIVE

This study aimed to compare the prevalence and risk factors of pilonidal sinus disease in women with and without polycystic ovary syndrome in the same population.

DESIGN

This was a case-control study.

SETTINGS

This study was conducted in a Turkish rural district state hospital.

PATIENTS

This study included 40 female patients with polycystic ovary syndrome and 120 female patients without polycystic ovary syndrome.

MAIN OUTCOME MEASURES

The prevalence of pilonidal sinus, age, BMI, number of baths per week, daily sitting time, and family history of pilonidal sinus were recorded.

RESULTS

Pilonidal sinus was detected in 22.5% (12.5% asymptomatic pits, 10% symptomatic) of patients with polycystic ovary syndrome and 1.7% of the control group ( p < 0.001). No difference was noted between the 2 groups in terms of BMI ( p = 0.219). Family history was similar between the case and control groups ( p = 0.520). No significant difference was noted between the 2 groups in terms of insufficient hygiene and daily sitting time ( p = 0.763, p = 0.706). Multivariate analysis showed that the risk of pilonidal sinus was significantly higher in patients with a positive family history ( p = 0.008).

LIMITATIONS

The number of patients in the case and control groups in the study was limited. In addition, the control group may not fully reflect the general population because it was composed of only patients who presented to the general surgery and gynecology outpatient clinic for other reasons. The control group was not age matched.

CONCLUSIONS

In our study, we found that the prevalence of pilonidal sinus was significantly higher in patients with polycystic ovary syndrome. See Video Abstract at http://links.lww.com/DCR/B945 .

ES EL SNDROME DE OVARIO POLIQUSTICO UN FACTOR PREDISPONENTE PARA LA ENFERMEDAD DEL SENO PILONIDAL

ANTECEDENTES:La incidencia de enfermedad del seno pilonidal puede aumentar en mujeres con síndrome de ovario poliquístico.OBJETIVO:El objetivo fue comparar la prevalencia y los factores de riesgo de la enfermedad del seno pilonidal en una misma poblacion de mujeres con y sin síndrome de ovario poliquístico.DISEÑO:Este fue un estudio de casos y controles.ENTORNO CLÍNICO:Se llevó a cabo en un hospital estatal de un distrito rural turco.PACIENTES:Este estudio incluyó a 40 pacientes mujeres con síndrome de ovario poliquístico y 120 pacientes mujeres sin síndrome de ovario poliquístico.PRINCIPALES MEDIDAS DE VALORACIÓN:Se registraron la prevalencia del seno pilonidal, la edad, el IMC, el número de duchas por semana, el tiempo diario para sentarse y los antecedentes familiares de seno pilonidal.RESULTADOS:El seno pilonidal se detectó en el 22,5 % (12,5 % fosas asintomáticas, 10 % sintomáticas) de las pacientes con síndrome de ovario poliquístico y en el 1,7 % del grupo control ( p < 0,001). No se observaron diferencias entre los dos grupos en términos de IMC ( p = 0,219). Los antecedentes familiares fueron similares entre los grupos de casos y controles ( p = 0,520). No se observaron diferencias significativas entre los dos grupos en términos de higiene insuficiente y tiempo de sedentarismo diario ( p = 0,763, p = 0,706). El análisis multivariante mostró que el riesgo de seno pilonidal fue significativamente mayor en pacientes con antecedentes familiares positivos ( p = 0,008).LIMITACIONES:El número de pacientes en los grupos de casos y controles en el estudio fue limitado. Además, es posible que el grupo de control no refleje completamente a la población general, ya que está compuesto solo por pacientes que acudieron a la consulta externa de cirugía general y ginecología por otras razones. El grupo de control no fue emparejado por edad.CONCLUSIONES:En nuestro estudio encontramos que la prevalencia de seno pilonidal fue significativamente mayor en pacientes con síndrome de ovario poliquístico. Consulte Video Resumen en http://links.lww.com/DCR/B945 . (Traducción-Dr. Ingrid Melo ).

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.

Women with polycystic ovary syndrome are burdened with multimorbidity and medication use independent of body mass index at late fertile age: A population-based cohort study

INTRODUCTION

This population-based follow-up study investigated the comorbidities, medication use, and healthcare services among women with polycystic ovary syndrome (PCOS) at age 46 years.

MATERIAL AND METHODS

The study population derived from the Northern Finland Birth Cohort 1966 and consisted of women reporting oligo/amenorrhea and hirsutism at age 31 years and/or a PCOS diagnosis by age 46 years (n = 246) and controls without PCOS symptoms or diagnosis (n = 1573), referred to as non-PCOS women. The main outcome measures were self-reported data on symptoms, diagnosed diseases, and medication and healthcare service use at the age of 46 years.

RESULTS

Overall morbidity risk was increased by 35% (risk ratio [RR] 1.35, 95% confidence interval [CI] 1.16-1.57) and medication use by 27% [RR 1.27, 95% CI 1.08-1.50) compared with non-PCOS women, and the risk remained after adjusting for body mass index. Diagnoses with increased prevalence in women with PCOS were migraine, hypertension, tendinitis, osteoarthritis, fractures, and endometriosis. PCOS was also associated with autoimmune diseases and recurrent upper respiratory tract infections and symptoms. Interestingly, healthcare service use did not differ between the study groups after adjusting for body mass index.

CONCLUSIONS

Women with PCOS are burdened with multimorbidity and higher medication use, independent of body mass index.

Unraveling the Role of Sex Hormones on Keratinocyte Functions in Human Inflammatory Skin Diseases

The skin exerts several fundamental functions that are the first physical, chemical and immune barriers to the human body. Keratinocytes, the main cell type of the epidermis, provide mechanical defense, support skin integrity and actively endorse cutaneous immune responses. Not surprisingly, considering these crucial activities, alterations in keratinocyte functions are associated with different inflammatory skin diseases. Recent findings indicate that the skin should not only be regarded as a target for hormones but that it should also be considered as an endocrine peripheral organ that is directly involved in the synthesis and metabolism of these chemical messengers. Sex hormones have multiple effects on the skin, attributed to the binding with intracellular receptors expressed by different skin cell populations, including keratinocytes, that activate downstream signaling routes that modulate specific cellular functions and activities. This review is aimed at reorganizing the current knowledge on the role exerted by sex hormones on keratinocyte function in five different inflammatory skin diseases: Hidradenitis suppurativa; Acne vulgaris; Atopic dermatitis; progesterone hypersensitivity; psoriasis. The results of our work aim to provide a deeper insight into common cellular mechanisms and molecular effectors that might constitute putative targets to address for the development of specific therapeutic interventions.

Impact of Pregnancy on Hidradenitis Suppurativa Disease Course: A Systematic Review and Meta-Analysis

BACKGROUND

Hormones are thought to play a role in hidradenitis suppurativa (HS). However, data on the HS disease course during pregnancy and the postpartum period has not been well established. The objective of this study is to analyze the available literature to determine HS disease activity during pregnancy and the postpartum period.

METHODS

The PubMed and Embase databases were systematically searched for relevant articles from database inception until November 22, 2020. The inclusion criteria were a study population with the diagnosis of HS and discussion of pregnancy impact on the HS disease course or postpartum flare. Study characteristics, patient demographics, HS severity, and HS disease course during pregnancy and the postpartum period were extracted by 2 independent reviewers. The quality of included studies was assessed using the Newcastle-Ottawa Scale for observational studies. Heterogeneity was assessed using Cochran's Q statistic and I2 index. The random-effects meta-analytical model was used. The primary study outcome was the pooled odds ratio of improvement or of worsening of HS disease activity during pregnancy.

RESULTS

The systematic search identified 8 studies for analysis. There was a total of 672 cases for which data on the patient-reported HS disease course during pregnancy were available, and 164 cases for which data on patient-reported postpartum flare were available. In the meta-analyses, the rate of HS disease improvement was 24% (95% CI 0.13-0.40) and the rate of HS disease worsening was 20% (95% CI 0.11-0.34). Sixty percent (99/164) of patients experienced a postpartum flare.

CONCLUSION

While about a quarter of women will experience an improvement in HS during pregnancy, the majority will have a stable or worsened disease course, and over half of patients will experience a postpartum flare. Close monitoring of HS patients is needed during pregnancy and postpartum periods, as patients may need continued, or even escalated, disease management.

Clinico-Epidemiological Characteristics of Hidradenitis Suppurativa: A Retrospective Cohort Study from a Tertiary Care Centre in Northern India

Background:

Hidradenitis suppurativa (HS) is a chronic debilitating disease with a relapsing and remitting course. Due to delay in diagnosis, patients are often referred when the disease is very severe. Management strategies vary across multiple guidelines.

Aims:

The aim of this study was to analyze the demographic and clinical characteristics of patients with HS among our outpatient attendees and to study the outcomes of various treatments offered.

Methodology:

This was a retrospective cohort study analyzing case files and photographic records of all patients diagnosed with HS, presenting to our tertiary care institute over 18 months.

Results:

A total of 22 patients (10 males and 12 females) of HS were studied with majority having Hurley stage 2 and 3 diseases. The most common site affected was axilla. Overweight and obese patients were 45.4% and 18.1%, respectively. Rifampicin–clindamycin combination or doxycycline was the first line therapy offered. Adalimumab was given in only two patients but could not be continued for long term due to financial issues. Surgery was performed in six patients. Procedures included wide local excision and deroofing which is left to heal by secondary intention. Least number of remissions and most satisfactory improvement was seen with a combination of antibiotics and surgery compared to medical treatment alone.

Limitations:

Retrospective nature and a single center study were the major drawbacks.

Conclusion:

Patients undergoing procedural intervention in addition to pharmacotherapy have best overall outcomes and involvement of a multidisciplinary team plays a key role, however a larger follow-up study is required.

Clinical Epidemiology and Management of Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic immune-mediated inflammatory skin disease with a prevalence of 0.1-1%, characterized by nodules and abscesses in the axillae, groin, and inframammary areas, sometimes developing into tunnels (or fistulas) and scars. Because hidradenitis suppurativa is more common in women and in those aged 18-40 years, obstetrician-gynecologists (ob-gyns) have the opportunity to diagnose, educate, initiate treatment, and coordinate care with ancillary health care professionals. The recently published North American treatment guidelines, along with management information for patients with hidradenitis suppurativa who are pregnant or breastfeeding, are summarized. By diagnosing and optimizing hidradenitis suppurativa treatment early in the disease course, ob-gyns can reduce morbidity, with the potential to favorably alter disease trajectory.

Adverse pregnancy and maternal outcomes in women with hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) disproportionately affects women of childbearing age. However, pregnancy and maternal outcomes for women with HS are unknown.

OBJECTIVE

To compare risk of adverse pregnancy and maternal outcomes among women with and without HS and to evaluate the influence of comorbid conditions.

METHODS

Retrospective cohort analysis between January 1, 2011, and September 30, 2015.

RESULTS

Compared to control pregnancies (n = 64,218), HS pregnancies (n = 1862) had a higher risk of spontaneous abortion (15.5% vs 11.3%), preterm birth (9.1% vs 6.7%), gestational diabetes mellitus (11.6% vs 8.4%), gestational hypertension (6.1% vs 4.4%), preeclampsia (6.6% vs 3.8%), and cesarean section (32.4% vs 27.1%). Relative risk of some pregnancy and maternal outcomes were attenuated after comorbidity adjustment. In the fully adjusted model, HS pregnancies were independently associated with spontaneous abortion (odds ratio, 1.20; 95% CI, 1.04-1.38), gestational diabetes mellitus (odds ratio, 1.26; 95% CI, 1.07-1.48), and cesarean section (odds ratio, 1.09; 95% CI, 1.004-1.17).

LIMITATIONS

We could not evaluate potential influences of disease duration, activity, or severity. Newborn outcomes could not be evaluated.

CONCLUSION

HS appears to be an independent risk factor for adverse pregnancy and maternal outcomes. This risk is influenced by comorbidities that may be modifiable with early identification and management.

Comorbidity screening in hidradenitis suppurativa: Evidence-based recommendations from the US and Canadian Hidradenitis Suppurativa Foundations

Background:

Hidradenitis suppurativa (HS) is associated with comorbidities that contribute to poor health, impaired life quality, and mortality risk.

Objective:

To provide evidence-based screening recommendations for comorbidities linked to HS.

Methods:

Systematic reviews were performed to summarize evidence on the prevalence and incidence of 30 comorbidities in patients with HS relative to the general population. The screening recommendation for each comorbidity was informed by the consistency and quality of existing studies, disease prevalence, and magnitude of association, as well as benefits, harms, and feasibility of screening. The level of evidence and strength of corresponding screening recommendation were graded by using the Strength of Recommendation Taxonomy (SORT) criteria.

Results:

Screening is recommended for the following comorbidities: acne, dissecting cellulitis of the scalp, pilonidal disease, pyoderma gangrenosum, depression, generalized anxiety disorder, suicide, smoking, substance use disorder, polycystic ovary syndrome, obesity, dyslipidemia, diabetes mellitus, metabolic syndrome, hypertension, cardiovascular disease, inflammatory bowel disease, spondyloarthritis, and sexual dysfunction. It is also recommended to screen patients with Down syndrome for HS. The decision to screen for specific comorbidities may vary with patient risk factors. The role of the dermatologist in screening varies according to comorbidity.

Limitations:

Screening recommendations represent one component of a comprehensive care strategy.

Conclusions:

Dermatologists should support screening efforts to identify comorbid conditions in HS.

Clinical and demographic features of hidradenitis suppurativa: a multicentre study of 1221 patients with an analysis of risk factors associated with disease severity

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, relapsing and debilitating inflammatory disease associated with profound morbidity.

AIM

In this multicentre study, we investigated the demographic and clinical features of HS, and determined risk factors of disease severity.

METHODS

In total, 1221 patients diagnosed with HS from 29 centres were enrolled, and the medical records of each patient were reviewed.

RESULTS

The mean age of disease onset was 26.2 ± 10.4 years, and almost 70% (n = 849) of patients were current or former smokers. Mean disease duration was 8.9 ± 8.4 years with a delay in diagnosis of 5.8 ± 3.91 years. Just over a fifth (21%; n = 256) of patients had a family history of HS. The axillary, genital and neck regions were more frequently affected in men than in women, and the inframammary region was more frequently affected in women than in men (P < 0.05 for all). Acne (40.8%), pilonidal sinus (23.6%) and diabetes mellitus (12.6%) were the most prevalent associated diseases. Of the various therapies used, antibiotics (76.4%) were most common followed by retinoids (41.7%), surgical interventions (32.0%) and biologic agents (15.4%). Logistic regression analysis revealed that the most important determinants of disease severity were male sex (OR = 2.21) and involvement of the genitals (OR = 3.39) and inguinal region (OR = 2.25). More severe disease was associated with comorbidity, longer disease duration, longer diagnosis delay and a higher number of smoking pack-years.

CONCLUSIONS

Our nationwide cohort study found demographic and clinical variation in HS, which may help broaden the understanding of HS and factors associated with disease severity.

Diagnosis and management of hidradenitis suppurativa in women

Hidradenitis suppurativa is a chronic inflammatory disease that disproportionately affects women of childbearing age. Hidradenitis suppurativa is characterized by painful nodules, abscesses, draining dermal tunnels, and scarring with a predilection for intertriginous sites, such as the axilla, groin, and breast regions. Delay in diagnosis and treatment of hidradenitis suppurativa often results in long-term sequelae leading to significant morbidity, and rarely mortality, in these patients. This clinical opinion suggests that obstetrician-gynecologists are uniquely poised to recognize early signs of hidradenitis suppurativa during routine well-woman examinations and initiate treatment or referral to dermatology. Herein, we provide clinical pearls for obstetrician-gynecologists caring for female patients with hidradenitis suppurativa, including strategies for comprehensive management and recommendations to improve the comfort of patients with hidradenitis suppurativa during examinations.

A Molecular Perspective on the Potential Benefits of Metformin for the Treatment of Inflammatory Skin Disorders

Due to its anti-hyperglycemic effect, metformin is the first-line medication for the treatment of type 2 diabetes, particularly in people who are obese. However, metformin is a drug with a very wide range of pharmacological properties and reports of its therapeutic effect on diseases including inflammation and cancer are increasing. Numerous research groups have reported that metformin has beneficial effects on a variety of inflammatory skin disorders including psoriasis, acanthosis nigricans, acne, hidradenitis suppurativa, and allergic contact dermatitis. According to these reports, in addition to the well-known action of metformin, that is, its anti-hyperglycemic effect, NF-kB inhibition and the resulting alteration to the cytokine network may be the potential targets of metformin. Its anti-hyperandrogenism effect has also been confirmed as the major action of metformin in some inflammatory skin diseases. Moreover, novel regulatory mechanisms, including autophagy and antioxidant processes, have been suggested as promising mechanisms of action for metformin in inflammatory skin disorders.

The epidemiology of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease defined clinically by multiple, painful inflammatory lesions occurring predominantly in flexural sites. Onset is typically soon after puberty; however, it remains unknown whether the menopause induces remission. In North American and European patients with HS the female-to-male ratio is approximately 3 : 1 but the ratio is 1 : 2 in South Korean patients. It may be that some elements of HS epidemiology cannot be generalized across all populations. Elements of HS epidemiology in the USA and Europe are well established, including strong associations with obesity and smoking, which may increase disease severity. There are associations between HS and other cardiovascular disease (CVD) risk factors, including type 2 diabetes and metabolic syndrome. People with HS have double the risk of death from CVD compared with those without HS and 1·5 times the risk compared with patients with psoriasis. Depression and anxiety are associated with HS and completed suicide rates in those with HS are more than double the rates in controls. Associations exist between HS and other chronic inflammatory conditions, particularly inflammatory bowel disease and inflammatory arthritis. Case-control studies demonstrate associations with pilonidal sinus, polycystic ovary syndrome, Down syndrome, obstructive sleep apnoea and pyoderma gangrenosum. Population-based studies using routinely collected healthcare data from the USA estimate a prevalence of 0·1%, suggesting HS is relatively uncommon. European studies include undiagnosed patients and typically estimate prevalence of 1% or more, suggesting a common condition. Resolving the controversy surrounding a greater than 10-fold difference in HS prevalence estimates remains a high priority.

Comparative Overall Comorbidity Burden Among Patients With Hidradenitis Suppurativa

Importance

The overall comorbidity burden among patients with hidradenitis suppurativa (HS) has not been systematically evaluated.

Objectives

To investigate the standardized overall comorbidity burden among patients with HS and to compare it with the comorbidity burden in patients with psoriasis and a control group.

Design, Setting, and Participants

A cross-sectional analysis was conducted of 5306 patients with HS, 14 037 patients with psoriasis, and 1 733 810 controls identified using electronic health records data from October 1, 2013, through October 1, 2018.

Main Outcome and Measure

The primary outcome was the mean Charlson Comorbidity Index (CCI) score.

Results

Each matched cohort had 3818 patients (2789 women and 1029 men; mean [SD] age, 45.7 [15.0]). Before matching, the overall mean (SD) CCI score was highest among the psoriasis cohort (2.33 [3.13]), followed by the HS cohort (1.80 [2.79]) and control cohort (1.26 [2.35]). In matched analyses, the overall mean (SD) CCI score was highest among the HS cohort (1.95 [2.96]), followed by the psoriasis cohort (1.47 [2.43]; P < .001) and control cohort (0.95 [1.99]; P < .001) patients. A total of 516 patients with HS (13.5%) had an overall mean CCI score of 5 or greater. Mean CCI score was highest for patients with HS across all sex, race, and age groups. The most common comorbidities among patients with HS were chronic pulmonary disease (1540 [40.3%]), diabetes with chronic complications (365 [9.6%]), diabetes without chronic complications (927 [24.3%]), and mild liver disease (455 [11.9%]). Patients with HS with a CCI score of 5 or greater had 4.97 (95% CI, 1.49-16.63) times the adjusted risk of 5-year mortality compared with patients with HS with a CCI score of zero.

Conclusions and Relevance

Patients with HS have a higher overall comorbidity burden compared with patients with psoriasis and a control group. A significant proportion of patients with HS have CCI scores of 5 or greater, which are associated with increased mortality. This degree of comorbidity burden may warrant multidisciplinary implementation of routine screening measures.

Prevalence and cutaneous comorbidities of hidradenitis suppurativa in the German working population

The association of hidradenitis suppurativa with other skin diseases has not yet been investigated in larger studies based on dermatological exams. The objectives of this study are to determine the prevalence and cutaneous comorbidities of hidradenitis suppurativa in the German working population. Between 2014 and 2017, 20,112 people in 343 German companies were examined for the presence of clinical features of hidradenitis suppurativa within the framework of a cross-sectional epidemiological study based on whole-body examinations. In addition, all cutaneous comorbidities were recorded. Point prevalence was calculated and the differences between individuals with and without hidradenitis suppurativa were determined by bivariate analysis. All statistical procedures were performed using SPSS 23.0 for Windows. Of 20,112 people examined, mean age was 43.6 ± 10.5 years; 52.3% were male. In total, n = 57 people (0.3%) with hidradenitis suppurativa were identified; 61.4% (n = 35) being male. In addition, non-inflammatory hidradenitis suppurativa-related lesions were found in 674 other individuals. In a bivariate comparison, patients with hidradenitis suppurativa showed significantly more frequently the following cutaneous comorbidities: acne vulgaris, psoriasis, seborrhoeic dermatitis, excoriations, and folliculitis. We determined a point prevalence of hidradenitis suppurativa of 0.3%. Since we have examined the working population, the healthy worker effect, which could have led to underestimation of prevalence, cannot be ruled out. The point prevalence of 0.3% for employed people in Germany and a prevalence of 3.0% for inflammatory and non-inflammatory hidradenitis suppurativa-related lesions show that hidradenitis suppurativa is an important disease for the whole health system.

Integrating complement into the molecular pathogenesis of Hidradenitis Suppurativa

Complement inhibition has been identified as a potential therapeutic target for multiple inflammatory disorders including Hidradenitis Suppurativa (HS). It is currently unclear how complement integrates into our current model of molecular pathogenesis in HS and whether it represents a central component of pathogenesis, or a neutrophil-associated bystander. Levels of C5a in serum and tissue correlate with disease activity and degree of neutrophilic infiltrates in HS. C5a has been associated with Th17 immune axis activation in psoriasis, rheumatoid arthritis and Crohn's disease with strong similarities to TH17 activation in HS. Porphyromonas species (which are identified in the HS microbiome) are able to cleave inactive C5 into C5a implicating the cutaneous microbiome as an activator of complement. C3a and C5a are associated with activation of the NLRP3 inflammasome, implicated in the inflammatory drive in HS. Complement receptors are present upon dendritic cells, monocytes, fibroblasts and adipocytes, which may broaden the potential contribution of complement to multiple aspects of HS pathogenesis. Dysregulation of complement receptor pathways has been documented in obesity, insulin resistance and polycystic ovarian syndrome leading to the possibility that complement may explain the epidemiological associations between these conditions and HS. The therapeutic potential of complement inhibitors in HS may be related to the therapeutic target (complement receptor or complement subunit) and the presence of alternate receptors (such as C5aR2) or ligands (including C3a, PAMPs and DAMPs). Integrating complement into the known pathogenesis of HS may aid in explaining the contradictory results between Phase 2 studies of C5a antagonists. It also allows for the identification of existing knowledge gaps to target further clinical investigation and research.

Dietary and metabolic factors in the pathogenesis of hidradenitis suppurativa: a systematic review

Hidradenitis suppurativa (HS) is a systemic recalcitrant inflammatory condition characterized by debilitating lesions with high morbidity. Its known association with obesity and smoking indicate correlation with other environmental factors, such as diet, suggesting a larger role for lifestyle modifications in disease treatment. This study seeks to assess the contribution of weight loss and dietary intake in HS management. A primary literature search was conducted using PubMed, Web of Science, and CINAHL in November 2018 to include association and intervention studies on the influence of diet and weight on HS. Twenty-five articles were included. Meta-analysis of nine case-control studies across Asia, Europe, and the United States showed that HS patients are four times more likely to be obese compared to the general population; random effects pooled odds ratio 4.022 (2.667-6.065), P < 0.001. Five articles assessed weight-loss interventions and revealed mixed findings. The remaining articles included three association studies on micronutrient levels, eight dietary intervention studies, and one article analyzing both micronutrient association and dietary intervention. Included articles in this systematic review reveal that low serum zinc and vitamin D levels are associated with increased lesion count in HS. Supplementation of zinc, vitamin D, vitamin B12, or exclusion of dairy or brewer's yeast can be effective in partial or complete lesion resolution. Reviewed data show that weight loss from bariatric surgery may lead to HS improvement but often results in more severe malnutrition that worsens or even leads to new onset HS post bariatric surgery. Future reporting is needed to conclusively determine the role of diet in HS.

Undergarment and Fabric Selection in the Management of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory condition manifesting as recurrent and exquisitely painful nodules in intertriginous regions. The role of mechanical stress in HS pathogenesis is gaining attention, as factors including intertriginous distribution of lesions, obesity, sweating, and suboptimal clothing contribute to increased friction and exacerbation of disease. Undergarment and clothing selection are often-overlooked components of HS management and should be addressed with patients as practical lifestyle changes that can decrease the frequency of disease flares and reduce symptoms of pain and irritation at involved sites. Selection of breathable and absorbent fabrics can also aid in reducing microbial colonization, sweat retention, and odor. This discussion is based on expert recommendations and aims to provide practitioners with the rationale for appropriate undergarment and clothing selection for HS patients. We propose practical principles for choosing undergarment design and fabrics for breathability, absorbency, and skin pressure reduction.

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

BACKGROUND

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

OBJECTIVE

To evaluate unmet needs from the perspective of HS patients.

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Comorbidities of hidradenitis suppurativa: A review of the literature

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

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

Hidradenitis suppurativa and polycystic ovarian syndrome: Systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Hidradenitis suppurativa has been associated with a number of pathologies, including various endocrine and autoimmune disorders. Although signs of hyperandrogenism are common in hidradenitis suppurativa, few formal studies have assessed the relationship between hidradenitis suppurativa and polycystic ovarian syndrome. Therefore, we performed a systematic review and meta-analysis to assess the association between hidradenitis suppurativa and polycystic ovarian syndrome.

METHODS

We performed a systematic review and meta-analysis according to PRISMA guidelines. Odds ratio was used as the effect size, with random-effects meta-analysis.

RESULTS

We identified five case-control studies for inclusion. From pooled data, we found a significantly higher proportion of polycystic ovarian syndrome in hidradenitis suppurativa cases compared with controls (OR 2.64; 95% CI 1.69-4.11; P < 0.00001). There was significant heterogeneity noted (I²  = 88%, P < 0.00001). Limitations included that studies reviewed were observational by design which are susceptible to bias, and lack of randomisation.

CONCLUSIONS

In summary, pooled analysis of existing case-control studies supports a significant association between hidradenitis suppurativa and polycystic ovarian syndrome. Our results imply that hidradenitis suppurativa patients with signs of hyperandrogenism may benefit from screening for polycystic ovarian syndrome, and may potentially benefit from anti-androgen therapy.

Hidradenitis suppurativa and metabolic syndrome - systematic review and adjusted meta-analysis

BACKGROUND

Hidradenitis suppurativa (HS) is a debilitating and distressing chronic systemic inflammatory skin disease. There have been several prior observational studies which reported a possibility link between HS and metabolic syndrome, however the current evidence is not definitive. It is unclear in HS whether this possible relationship is independent or driven by underlying risk factors and comorbidities.

OBJECTIVE

To determine whether HS is independently associated with metabolic syndrome via adjusted meta-analysis of case-control studies.

METHODS

A systematic review and meta-analysis was performed according to PRISMA guidelines. Electronic searches were performed using six electronic databases (Ovid Medline, PubMed, CCTR, CDSR, ACP Journal Club, and DARE) from their inception until September 2018. Data were extracted and analyzed according to predefined clinical endpoints.

RESULTS

We identified six case-control studies included for meta-analysis. Based on unadjusted analysis, we found a significant association between adult cases of HS and metabolic syndrome (OR 1.95, 95% CI 1.31-2.89, P = 0.001). Adjusted meta-analysis, after adjustment for age, sex, other cardiovascular risk factors, and comorbidities, found a significant association (OR 2.19, 95% CI 1.70-2.81, I²  = 32%, P < 0.00001).

LIMITATIONS

Studies reviewed were observational by design which are susceptible to bias, and there was lack of randomization. The quality of the current systematic review is also limited by the quality of available evidence which was predominantly observational in nature.

CONCLUSIONS

This pooled analysis of existing case-control studies supports an association between HS and metabolic syndrome. Clinicians treating patients with HS should be aware of this potential association.

Topical, systemic and biologic therapies in hidradenitis suppurativa: pathogenic insights by examining therapeutic mechanisms

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin, manifesting in chronic, recurrent painful pustules, nodules, boils and purulent draining abscesses. Our current understanding of the pathogenesis of the disease is incomplete. This review aims to identify available treatment options in HS and discuss the pharmacological mechanisms through which such agents function. Identifying common pathways may inform our understanding of the pathogenesis of HS as well as identify future therapeutic targets. The pharmacological mechanisms implicated in topical therapies, antibiotic, hormonal, systemic immunomodulatory and biologic therapies for HS are discussed. Significant differences exist between agents and implicated pathways in therapy for mild and severe disease. This is an expression of the possible dichotomy in inflammatory pathways (and treatment responses) in HS. Studies involving monoclonal antibodies provide the greatest insight into what these specific mechanisms may be. Their variable levels of clinical efficacy compared with placebo bolsters the suggestion that differential inflammatory pathways may be involved in different presentations and severity of disease. Nuclear factor kappa B (NF-κB), tumor necrosis factor (TNF)-α and other innate immune mechanisms are strongly represented in treatments which are effective in mild to moderate disease in the absence of scarring or draining fistulae, however complex feed-forward mechanisms in severe disease respond to interleukin (IL)-1 inhibition but are less likely to respond to innate immune inhibition (through NF-κB or TNF-α) alone. It is unclear whether IL-17 inhibition will parallel TNF-α or IL-1 inhibition in effect, however it is plausible that small molecule targets (Janus kinase1 and phosphodiesterase 4) may provide effective new strategies for treatment of HS.

Hidradenitis suppurativa and diabetes mellitus: updated systematic review and adjusted meta-analysis

BACKGROUND

Hidradenitis suppurativa (HS) is a debilitating and distressing chronic inflammatory skin disease. There is also evolving evidence supporting the association between HS and cardiovascular risk factors, including smoking, obesity, hyperlipidaemia and metabolic syndrome. Notably, these are clinical features and risk factors that are closely associated with type 2 diabetes mellitus (DM).

AIMS

We performed a pooled adjusted meta-analysis of comparative studies to investigate the relationship between HS and DM.

METHODS

A systematic review and meta-analysis was performed according to recommended Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. OR was used as the summary effect size.

RESULTS

From pooled analysis of unadjusted data from 12 studies, we found a significantly higher proportion of DM in HS cases compared with non-HS healthy controls (16.1% vs. 15.7%; OR = 2.17; 95% CI 1.85-2.55; P < 0.001). Adjusted effect sizes from five studies were also pooled. A significantly higher proportion of DM was found for HS compared with healthy controls, although the effect size was attenuated compared with unadjusted analyses (OR 1.69; 95% CI 1.50-1.91; P < 0.001).

CONCLUSIONS

To our knowledge, our systematic review and meta-analysis is the first to pool adjusted effect sizes. We found that HS was associated with a 1.69-fold increased odds of diabetes; however, the absolute risk difference was small (16.1% vs. 15.7%) and is probably not clinically relevant. Treating clinicians should be aware of this association, but there may not be an urgent need to perform screening for impaired glucose tolerance or diabetes.

Overall and subgroup prevalence of acne vulgaris among patients with hidradenitis suppurativa

BACKGROUND

Evidence establishing a link between acne vulgaris (AV) and hidradenitis suppurativa (HS) is limited, and the burden of AV in adults with HS is unknown.

OBJECTIVE

To determine the prevalence of AV among adults with HS and determine the strength of this association.

METHODS

Cross-sectional analysis identifying adults with AV among patients with and without HS by using electronic health record data from a population-based sample of more than 55 million patients.

RESULTS

The prevalence of AV among adults with HS was 15.2% (7315 of 48,085) compared with 2.9% (497,360 of 16,899,470) for adults without HS (P < .001). The prevalence was greatest among patients with HS who were female (5870 of 35,790 [16.4%]), were 18 to 44 years old (5260 of 28,870 [18.2%]), were nonwhite (3120 of 17,825 [17.5%]), were obese (5430 of 35,135 [15.5%]), and had polycystic ovarian syndrome (685 of 2385 [28.7%]). Patients with HS had 4.51 [95% confidence interval, 4.40-4.63] times the odds of having AV than did patients without HS, with the higher likelihood of having AV persisting across all subgroups of patients with HS. The association between HS and AV was generally stronger for patients who were male, and 65 years of age or older.

LIMITATIONS

Influence of disease severity in HS, or in acne, on the strength of the association could not be assessed.

CONCLUSION

Patients with HS may benefit from assessment of acne status and optimization of comanagement strategies.