Psychiatric comorbidities in 3207 patients with hidradenitis suppurativa

Stigmatization and perceived health status in patients with hidradenitis suppurativa: an observational multicenter study in Europe

INTRODUCTION

Hidradenitis suppurativa (HS) can severely affect the quality of life (QoL) and is linked to psychological distress, including anxiety, depression, and reduced self-esteem. Stigmatization due to physical appearance may significantly contribute to the psychological burden and impact on QoL for HS patients. This study investigates the association between stigmatization, depression, anxiety, and health- and disease-related variables among HS patients in Europe.

PATIENTS AND METHODS

This observational cross-sectional multicenter study was conducted across 22 dermatological outpatient clinics in 17 European countries. Data collected included sociodemographic variables, general health variables, disease-related variables, perceived stigmatization (PSQ), and mental health (PHQ-2, GAD-2).

RESULTS

Of the 5487 dermatological patients, 142 (2.6%) were diagnosed with HS, and data from 135 patients (70.1% women, mean age 38.2 years) who completed the PSQ questionnaire were analyzed. Scores on the stigmatization measure indicated that significant stigmatization levels were present in the sample. Linear regression models revealed a significant relationship between stigmatization and both the duration of HS and the presence of itch. Similar findings were noted for the PSQ "confused/staring behavior" scale with depression. The PSQ "absence of friendly behavior" scale was inversely associated with general health status, whereas the "hostile behavior" scale was positively linked to depression.

CONCLUSION

HS patients experience significant stigmatization linked to disease duration, itch, and depression. Comprehensive management, including screening for psychosocial co-morbidity, is essential, as is providing access to psychological interventions that support patients to both manage internal distress and the potential reactions of others.

Incidence of anxiety disorder in adults with hidradenitis suppurativa

BACKGROUND

There are limited data on the risk of new-onset anxiety disorders in patients with hidradenitis suppurativa (HS).

OBJECTIVES

To compare the risk of new-onset anxiety disorder in patients with HS and controls, and to describe risk factors for the development of anxiety in patients with HS.

METHODS

We carried out a retrospective cohort analysis of a US electronic health records database between 2011 and 2020. Adults newly diagnosed with HS at a dermatology or primary care visit and control participants were included. The primary outcome was a new diagnosis of generalized anxiety disorder, phobic disorders, panic disorder or unspecified anxiety. Cox proportional hazards regression was used to compare the crude risk of any anxiety disorder between groups and to assess the independent association with HS while controlling for potential demographic, clinical and healthcare-related confounders.

RESULTS

Among 9597 patients with HS and 959 493 controls, the incidence rate (IR) of anxiety was 5.74 and 3.86 per 100 person-years (PY), respectively. The crude risk among all patients was 48% higher for those with HS vs. controls [hazard ratio (HR) 1.48, 95% confidence interval (CI) 1.40-1.55]. When stratified by index encounter type, patients with HS had 2.43 (95% CI 2.13-2.77) times the risk of anxiety disorder than dermatology controls and 1.46 (95%CI 1.38-1.55) times the risk than primary care controls. The adjusted HR for patients with HS vs. controls was 1.11 (95% CI 1.05-1.17) overall, 1.26 (95% CI 1.07-1.48) in the dermatology subgroup and 1.07 (95% CI 1.01-1.13) in the primary care subgroup. Risk factors for an incident anxiety diagnosis among patients with HS included depression (HR 1.69, 95% CI 1.48-1.93), female sex (HR 1.41, 95% CI 1.23-1.60), younger age (HR 0.87 per 10-year increase, 95% CI 0.84-0.90), White race, in the Medicaid insurance programme (HR 1.22, 95% CI 1.07-1.40), tobacco smoking (HR 1.16, 95% CI 1.03-1.31) and having one or more emergency department visits in the year before a HS diagnosis. Absolute IRs of anxiety disorders were highest among patients with HS who were aged 18-29 years (7.10 per 100 PY), female (6.34 per 100 PY) and White (6.79 per 100 PY).

CONCLUSIONS

HS is independently associated with an increased risk of anxiety disorders. An increased risk remains but is attenuated when confounders are controlled for. The relative risk may be particularly high in patients managed by dermatologists.

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

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

Topical and Intralesional Therapies for Hidradenitis Suppurativa: A Systematic Literature Review

BACKGROUND AND OBJECTIVE

Topical and intralesional (IL) treatments may be considered the first-line therapy in patients with hidradenitis suppurativa (HS); however, the evidence supporting their use is limited. The aim of our review is to evaluate the efficacy and safety profile of topical and IL treatments in patients with HS.

MATERIALS AND METHODS

We designed a systematic review of the current medical literature available following the PICO(T) method. And including all types of studies (Study type [T]) of individuals with HS of any sex, age, and ethnicity (Population [P]) who received any topical or IL treatment for HS (Intervention [I]) compared to placebo, other treatments, or no treatment at all (Comparator [C]), and reported efficacy and/or safety outcomes (Outcomes [O]). Two outcomes were defined: quality of life and the no. of patients with, at least, one adverse event. The search was conducted in the Cochrane Library, MEDLINE, and Embase databases; study selection was performed based on pre-defined criteria. The risk of bias was determined in each study.

RESULTS

We obtained a total of 11,363 references, 31 of which met the inclusion criteria. These studies included 1143 patients with HS, 62% of whom were women. A total of 10, 8, 6, 2, and 5 studies, respectively, evaluated the use of photodynamic therapy (PDT), glucocorticoids, resorcinol, topical antibiotics, and other interventions. Most articles were case series (n=25), with only five randomized clinical trials (RCTs) and one cohort study. RCTs showed improvement in disease activity with topical clindamycin and botulinum toxin (BTX) vs placebo, and PDT with methylene blue (MB) niosomal vs free MB; however, intralesional triamcinolone acetonide was not superior to placebo. The risk of bias was low in three RCTs and high in two RCTs.

CONCLUSION

The quality of evidence supporting the use of topical, or IL treatments is low. However, it supports the use of topical clindamycin, PDT, and BTX. Well-designed RCTs with standardized outcomes and homogeneous populations of patients and lesions are needed to support decision-making in the routine clinical practice.

Autoimmune, Autoinflammatory Disease and Cutaneous Malignancy Associations with Hidradenitis Suppurativa: A Cross-Sectional Study

BACKGROUND

Hidradenitis suppurativa (HS) is a debilitating cutaneous disease characterized by severe painful inflammatory nodules/abscesses. At present, data regarding the epidemiology and pathophysiology of this disease are limited.

OBJECTIVE

To define the prevalence and comorbidity associations of HS.

METHODS

This was a cross-sectional study of EPICTM Cosmos© examining over 180 million US patients. Prevalences were calculated by demographic and odds ratios (OR) and identified comorbidity correlations.

RESULTS

All examined metabolism-related, psychological, and autoimmune/autoinflammatory (AI) diseases correlated with HS. The strongest associations were with pyoderma gangrenosum [OR 26.56; confidence interval (CI): 24.98-28.23], Down syndrome (OR 11.31; CI 10.93-11.70), and polycystic ovarian syndrome (OR 11.24; CI 11.09-11.38). Novel AI associations were found between HS and lupus (OR 6.60; CI 6.26-6.94) and multiple sclerosis (MS; OR 2.38; CI 2.29-2.48). Cutaneous malignancies were largely not associated in the unsegmented cohort; however, among Black patients, novel associations with melanoma (OR 2.39; CI 1.86-3.08) and basal cell carcinoma (OR 2.69; CI 2.15-3.36) were identified.

LIMITATIONS

International Classification of Diseases (ICD)-based disease identification relies on coding fidelity and diagnostic accuracy.

CONCLUSION

This is the first study to identify correlations between HS with melanoma and basal cell carcinoma (BCC) among Black patients as well as MS and lupus in all patients with HS.

Topical and Intralesional Therapies for Hidradenitis Suppurativa: A Systematic Literature Review

BACKGROUND AND OBJECTIVE

Topical and intralesional (IL) treatments may be considered the first-line therapy in patients with hidradenitis suppurativa (HS); however, the evidence supporting their use is limited. The aim of our review is to evaluate the efficacy and safety profile of topical and IL treatments in patients with HS.

MATERIALS AND METHODS

We designed a systematic review of the current medical literature available following the PICO(T) method. And including all types of studies (Study type [T]) of individuals with HS of any sex, age, and ethnicity (Population [P]) who received any topical or IL treatment for HS (Intervention [I]) compared to placebo, other treatments, or no treatment at all (Comparator [C]), and reported efficacy and/or safety outcomes (Outcomes [O]). Two outcomes were defined: quality of life and the no. of patients with, at least, one adverse event. The search was conducted in the Cochrane Library, MEDLINE, and EMBASE databases; study selection was performed based on pre-defined criteria. The risk of bias was determined in each study.

RESULTS

We obtained a total of 11,363 references, 31 of which met the inclusion criteria. These studies included 1143 patients with HS, 62% of whom were women. A total of 10, 8, 6, 2, and 5 studies, respectively, evaluated the use of photodynamic therapy (PDT), glucocorticoids, resorcinol, topical antibiotics, and other interventions. Most articles were case series (n=25), with only five randomized clinical trials (RCTs) and one cohort study. RCTs showed improvement in disease activity with topical clindamycin and botulinum toxin (BTX) vs placebo, and PDT with methylene blue (MB) niosomal vs free MB; however, intralesional triamcinolone acetonide was not superior to placebo. The risk of bias was low in three RCTs and high in two RCTs.

CONCLUSION

The quality of evidence supporting the use of topical, or IL treatments is low. However, it supports the use of topical clindamycin, PDT, and BTX. Well-designed RCTs with standardized outcomes and homogeneous populations of patients and lesions are needed to support decision-making in the routine clinical practice.

Increased cancer incidence among patients with hidradenitis suppurativa - a Danish nationwide register study 1977-2017

BACKGROUND

The chronic, inflammatory skin disease hidradenitis suppurativa (HS) (prevalence: 0.5%-1%, diagnostic delay: 7-10 years) primarily arises in younger adults and frequently coincides with autoimmune comorbidities and unhealthy life-styles (smoking and obesity). These factors are known to increase cancer risk, but despite this, information on cancer occurrence among HS patients is scarce.

MATERIALS AND METHODS

A nationwide retrospective register-based study assessing relative risk of cancer - overall and by anatomical site - following HS diagnosis expressed as standardized incidence ratios (SIRs), which is ratios between observed cases among all Danes diagnosed with HS since 1977 and expected cases based on cancer incidence rates of the entire Danish population during the same period.

RESULTS

Participants consisted of a cohort of 13,919 Danes with HS, who during an average of 14.2 years of follow-up developed a total of 1,193 incident cancers, corresponding to a 40% increased risk (SIR = 1.4, 95% CI: 1.3 to 1.4, p < 0.001). Increased risks were observed for cancers of the respiratory system, oral cavity and pharynx, digestive organs and peritoneum, urinary tract, and the lymphatic tissues.

INTERPRETATION

These findings underline an unmet need for health monitoring, lifestyle interventions and cancer screening if and when relevant.

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

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

Navigating the Multidimensional Impact of Living with Hidradenitis Suppurativa: An In-Depth Netnographic Study on Social Media Platforms

INTRODUCTION

Hidradenitis suppurativa (HS) is a chronic skin condition causing considerable distress. It impacts mobility, social interaction, and quality of life. In Brazil, there is a notable gap in epidemiological data and patient experiences regarding HS.

METHODS

This study, spanning 2019 to 2022, employed netnography to probe the experiences of Brazilian patients with HS. This approach gleans insights from online interactions, offering a direct view into patients' lives.

RESULTS

Notably, the data illuminated the challenges patients face, such as difficulties in obtaining a diagnosis and the complexities involved in managing a chronic, and often debilitating, condition. Furthermore, patients' experiences with various treatments, encompassing antibiotics, biologic agents, lifestyle alterations, surgical procedures, and alternative remedies, were also examined.

CONCLUSION

By undertaking a longitudinal analysis of patient interactions, the study aimed to offer a richer understanding of HS, from its diagnosis to its treatment. It underscores the necessity for a more patient-centered approach when managing this condition. We hope that this enhanced understanding can facilitate better care for those affected by HS.

The Influence of Pain on Reduced Quality of Life in Patients with Hidradenitis Suppurativa: A Single-Center Retrospective Study

BACKGROUND

Pain and itch are impactful and burdensome symptoms of hidradenitis suppurativa (HS). Elucidating factors associated with pain and itch severity may identify groups disproportionally affected by HS-related pain and itch and further our understanding of how pain and itch impact quality of life (QoL) in patients with HS.

OBJECTIVE

The objective of the study was to determine factors associated with pain severity, itch severity, and reduced QoL in patients with HS.

METHODS

This is a retrospective cross-sectional study of 257 adults with HS who received care in an HS Specialty Clinic from January 2019 to August 2021. Multivariable mixed-effects linear regression was used to determine the relationships between clinical and demographic patient factors and the outcomes of pain severity, itch severity, and skin-specific QoL.

RESULTS

Factors associated with reduced QoL were Hurley stage II (β = 19.66, 95% CI: 1.40-37.93) and III (β = 21.98, 95% CI: 1.57-42.39) disease as well as severity of pain (β = 13.74, 95% CI: 11.93-15.55), itch (β = 4.57, 95% CI: 2.59-6.55), anxiety (β = 2.55 95% CI: 1.29-3.81), and depression (β = 1.43, 95% CI: 0.30-2.56). Increasing HS pain severity was associated with Hurley stage III disease (β = 2.04, 95% Cl: 0.99-3.09), black race (β = 1.23, 95% Cl: 0.40, 2.06), depression severity (β = 0.08, 95% Cl: 0.02, 0.14), and anxiety severity (β = 0.10 95% Cl: 0.04, 0.17). Factors associated with HS itch severity were Hurley stage III disease (β = 2.23, 95% Cl: 1.19, 3.27), black race (β = 0.92, 95% Cl: 0.07, 1.78), depression severity (β = 0.09, 95% Cl: 0.04, 0.14), and anxiety severity (β = 0.07, 95% Cl: 0.01, 0.13).

CONCLUSION

Pain is one of the largest contributors to QoL in patients with HS; on a 0-10 numeric rating scale, a 2-point increase in HS pain had a similar independent effect on QoL as having Hurley stage III disease compared to Hurley stage I.

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.

Requirements for Brazilian Outpatient Centers of Excellence in Hidradenitis Suppurativa: Consensus Co-Creative Study

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic skin condition. Its complexity and impact on patients highlight the need for multidisciplinary care that can address the physical, psychological, and social aspects. Centers of excellence can ideally provide the necessary infrastructure, resources, and expertise to effectively treat HS. However, there are still no consolidated models of centers of excellence in HS, and establishing their foundations is an intricate research challenge. Purposely, design and co-creation as innovation techniques are helpful approaches to this type of research.

METHODS

In this study, we conducted a co-creation with consensus among HS specialists to propose the criteria and requirements to establish outpatient centers of excellence of HS in Brazil. We followed a linear process with mixed methods in 6 stages.

RESULTS

The process resulted in 10 categories for establishing outpatient centers, including their respective requirements, rationale, and classification. The categories include onboarding and welcoming; infrastructure and procedures; infusion therapy; flows and referrals; staffing; disease management; metrics during diagnosis; metrics during treatment; awareness and advocacy; research and education.

DISCUSSION

The idealized outpatient centers can play a role in the complete multidisciplinary treatment for HS and advancing the science of healthcare services by providing a focus for research, training, and translation of findings into practice.

Real-world safety and effectiveness of adalimumab in patients with hidradenitis suppurativa: A 52-week analysis of a postmarketing surveillance study in Japan

Adalimumab is a human monoclonal antibody against tumor necrosis factor-α that was approved in Japan for the treatment of hidradenitis suppurativa (HS), a chronic recurrent inflammatory skin disease. We report the results of the final analysis of the postmarketing surveillance (PMS) study (ClinicalTrials.gov: NCT03894956), which evaluated the 52-week safety and efficacy of adalimumab for HS treatment in real-world clinical practice in Japan. This multicenter, prospective, open-label, observational study (March 2019 to May 2021) included patients with HS treated with subcutaneous adalimumab at doses following the package insert. The primary endpoint was safety, and the secondary endpoints were effectiveness, including HS clinical response (HiSCR), C-reactive protein (CRP), skin pain, and Dermatology Life Quality Index (DLQI). Of the 84 patients registered at 65 sites, 83 patients were included in the analyses. Adverse drug reactions (ADRs) were reported by 10 (12.0%) patients; two patients reported a serious ADR, including one patient with serious infection. Other safety events of special interest reported were liver disorder and dermatitis psoriasiform (one patient each). Almost all patients with ADRs were recovering or had recovered, except for one patient who experienced a serious ADR of liver disorder and died. At 12 weeks, 55.4% of patients achieved HiSCR; this increased to 60.5% and 62.8% at 24 and 52 weeks of adalimumab treatment, respectively. Significant reductions from baseline in CRP (P < 0.05), skin pain (P < 0.0001), and DLQI (P < 0.0001) were observed at all time points. The results from this PMS study demonstrated that long-term adalimumab treatment is well tolerated and effective in patients with HS in real-world clinical practice in Japan.

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

BACKGROUND

Hidradenitis suppurativa (HS) is characterised by inflamed lesions that typically appear in apocrine-rich flexural areas. Although studies have reported clinical and epidemiological data from western countries, data from the Middle East are scarce. The aim of this study is to characterise the differences in the clinical characteristics of patients with HS of Arab and Jewish ancestry and review the clinical characteristics, the course of the disease, the comorbidities, and the response to treatment.

METHODS

This is a retrospective study. We collected clinical and demographic data from patient files between 2015-2018 at the Rambam Healthcare Campus dermatology clinic-a tertiary hospital located in the north of Israel. Our results were compared to those of a previously published Israeli control group registered in Clalit Health Services.

RESULTS

Of the 164 patients with HS, 96 (58.5%) were men and 68 (41.5%) were women. The average age at diagnosis was 27.5 years and the average latency between the onset and diagnosis of the disease was 4 years. We found a higher adjusted prevalence of HS in Arab patients (56%) than in their Jewish counterparts (44%). Gender, smoking, and obesity, as well as axilla and buttock lesions, were risk factors for severe HS, with no differences between ethnicities. No differences were documented in comorbidities and in response to adalimumab, with a high overall response rate of 83%.

CONCLUSIONS

Our findings revealed differences between Arab and Jewish patients with HS in terms of incidence and gender predominance, while no differences were documented in comorbidities and response to adalimumab.

Cutaneous body image in patients with hidradenitis suppurativa: a hospital-based cross-sectional study

Hidradenitis suppurativa (HS) has been linked with body image (BI) impairment and reduced quality of life (QoL). We sought to evaluate the associations between Cutaneous Body Image Scale (CBIS) and disease severity in HS patients.Between July 2020 and January 2022, a cross-sectional study was carried out including consecutive HS patients above the age of 16 who attended a Tertiary Referral Hospital in Greece. Disease Severity was graded with the Hurley stage, HS-Physician's Global Assessment (HS-PGA) scale, and the Modified Sartorius scale (MSS). Patients completed at their first visit ten survey instruments including Patients' Severity of disease, pain and pruritus scale, CBIS, Multidimensional Body-Self Relations Questionnaire (MBSRQ) including 5 subscales: Appearance Evaluation (AE), Appearance Orientation (AO), Body Areas Satisfaction Scale (BASS), Overweight Preoccupation (OWP), and Self Classified Weight (SCW) , Dermatology Quality of Life Index (DLQI), Skindex-16, EQ5D 5L, EQ- visual analogue scale (VAS), PHQ9, and GAD7. In total, 70 HS patients above 16 years old participated, mean [SD] age, 34.44 [11.64] years; 49/70 (70%) males and 21/70 (30%) females. Mean ± SD CBI, DLQI, Skindex-16 total, EQ-5D-5L, EQ VAS, PHQ9 and GAD7 were 5.59 ± 1.58, 11.70 ± 8.88, 52.90 ± 27.75, 0.75 ± 0.21, 62.48 ± 21.12, 7.64 ± 5.56, 7.87 ± 5.23 respectively. Moderate to severe CBI dissatisfaction was reported by 36/70 (51.42%) patients. CBI was correlated with appearance evaluation (AE) (p < 0.01, r = 0.544), body areas satisfaction (BASS) (p < 0.01, r = 0.481), and overweight preoccupation subscale (OWPS) (p < 0.01, r =  - 0.267), and Skindex-16 (p < 0.01, r =  - 0.288). HS patients with affected genital areas scored higher in disease patient's severity score (p = 0.015), and male patients scored higher in Skindex-16 than females(p < 0.01). Our study found that the mean of CBI in HS patients was 5.59 ± SD 1.58. Predictors for CBI dissatisfaction were low scores of MBSRQ Appearance Evaluation (AE) and Body Areas Satisfaction Subscale (BASS).

Hidradenitis suppurativa and the risk of myocardial infarction, cerebrovascular accident, and peripheral vascular disease: a population-based study

Previous studies have identified an association between myocardial infarction (MI), cerebrovascular accident (CVA), and peripheral vascular disease (PVD) in patients with hidradenitis suppurativa (HS). To evaluate the risk and prognostic outcomes of MI, CVA, and PVD in patients with HS. A population-based retrospective cohort study using the computerized database of Clalit Health Services (CHS), the largest managed care organization in Israel, was conducted to compare the incidence of MI, CVA, and PVD among patients with HS (N = 6779) with age-, sex- and ethnicity-matched control subjects (N = 33,260). Adjusted hazard ratios (HRs) were estimated by multivariate Cox regression analysis. The overall incidence rates of MI, CVA, and PVD were estimated at 2.9 (2.3-3.4), 1.3 (0.9-1.7), and 0.8 (0.6-1.1) per 1000 person-year, respectively. Patients with HS were at an increased risk of developing MI (fully-adjusted HR 1.33; 95% CI 1.04-1.68; P = 0.021), but the risk of CVA (fully-adjusted HR 0.82; 95% CI 0.59-1.14; P = 0.245) and PVD (fully-adjusted HR 1.22; 95% CI 0.80-1.87; P = 0.355) was comparable relative to controls. Compared to other patients with HS, increased risk of all-cause mortality was observed among patients with HS and comorbid MI (HR 12.56; 95% CI 7.59-20.80; P < 0.001), CVA (HR 13.33; 95% CI 7.29-24.37; P < 0.001), and PVD (HR 7.11; 95% CI 2.61-19.32; P < 0.001). Patients with HS are at an increased risk of MI, but not CVA and PVD. Awareness of these epidemiological findings is of importance for clinicians managing patients with HS.

Neutrophilic granulocyte-derived B-cell activating factor supports B cells in skin lesions in hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by painful inflamed nodules, abscesses, and pus-draining tunnels appearing in axillary, inguinal, and perianal skin areas. HS lesions contain various types of immigrated immune cells.

OBJECTIVE

This study aimed to characterize mediators that support lesional B/plasma cell persistence in HS.

METHODS

Skin samples from several cohorts of HS patients and control cohorts were assessed by mRNA sequencing, quantitative PCR on reverse-transcribed RNA, flow cytometry, and immunohistofluorescence. Blood plasma and cultured skin biopsy samples, keratinocytes, dermal fibroblasts, neutrophilic granulocytes (neutrophils), monocytes, and B cells were analyzed. Complex systems biology approaches were used to evaluate bulk and single-cell RNA sequencing data.

RESULTS

Proportions of B/plasma cells, neutrophils, CD8+ T cells, and M0 and M1 macrophages were elevated in HS lesions compared to skin of healthy and perilesional intertriginous areas. There was an association between B/plasma cells, neutrophils, and B-cell activating factor (BAFF, aka TNFSF13B). BAFF was abundant in HS lesions, particularly in nodules and abscesses. Among the cell types present in HS lesions, myeloid cells were the main BAFF producers. Mechanistically, granulocyte colony-stimulating factor in the presence of bacterial products was the major stimulus for neutrophils' BAFF secretion. Lesional upregulation of BAFF receptors was attributed to B cells (TNFRSF13C/BAFFR and TNFRSF13B/TACI) and plasma cells (TNFRSF17/BCMA). Characterization of the lesional BAFF pathway revealed molecules involved in migration/adhesion (eg, CXCR4, CD37, CD53, SELL), proliferation/survival (eg, BST2), activation (eg, KLF2, PRKCB), and reactive oxygen species production (eg, NCF1, CYBC1) of B/plasma cells.

CONCLUSION

Neutrophil-derived BAFF supports B/plasma cell persistence and function in HS lesions.

Employing Adalimumab in Treatment of Moderate-to-Severe Hidradenitis Suppurativa: Real-Life Multicenter Data from the Czech Republic

Adalimumab is the only approved biologic treatment for moderate-to-severe hidradenitis suppurativa, nonetheless, long-term data from real-life setting are still limited. The objective of this observational multicenter study was to evaluate the effectiveness, safety, and drug survival of adalimumab in patients with hidradenitis suppurativa included in the BIOREP registry. A total of 299 patients who initiated adalimumab therapy for hidradenitis suppurativa from 2011 to November 2021 were included. The Dermatology-Life-Quality-Index (DLQI), pain scale, the number of abscesses, inflammatory nodules and draining tunnels, and International Hidradenitis Suppurativa Severity Score System (IHS4) were recorded in the 0th, 3rd, and 6th months; then every 6 months during the ongoing adalimumab treatment. Studied patients underwent treatment for up to 48 months, with the average duration of treatment lasting 2.3 years. The mean age of the patients was 44.9 years, 79% were smokers or ex-smokers, 54.8% were obese, and 26.4% were overweight, the mean BMI was 30.8. The mean time from diagnosis to initiation adalimumab therapy was 9.1 years. The number of patients with severe IHS4 dropped from the initial 249 (83.3%) to 65 (30.1%) after 12 months and this trend was maintained up to the 48th month. A decreasing number of inflammatory lesions were rapid and sustained and correlated to the improvement of patients’ quality of life, the mean DLQI score dropped from 17.6 to 8.5 after 3 months and to 5, 7 after 48 months. No unexpected risk signals were observed. Our long-term study demonstrates the effectiveness and safety of adalimumab in a real-life setting.

Measuring Quality of Life in Hidradenitis Suppurativa: Development and Validation of a Disease-specific Patient-reported Outcome Measure for Practice and Research

Hidradenitis suppurativa is a chronic disease that disrupts patients' physical and psychological well-being. A disease-specific measure was developed and validated for assessing health-related quality of life in hidradenitis suppurativa. After qualitative item development, the quality of life in hidradenitis suppurativa instrument was tested in 101 patients, applying convergent measures and a usability questionnaire. Descriptive and validation-specific analyses were conducted. There was no ceiling, but moderate floor effects (scores between 0 and 3.13 on a scale of 0-4). Few missing values were observed (21 of 23 items < 5%). Internal consistency was satisfying: 2 subscales with 6 and 16 items were identified (Cronbach's alpha=0.95 and 0.88). The quality of life in hidradenitis suppurativa instrument correlated significantly with all convergent criteria (including change in convergent patient-reported outcomes; p < 0.05) except for Hurley stage (p = 0.490). In conclusion, the quality of life in hidradenitis suppurativa questionnaire is an internally consistent, valid, responsive, and usable instrument to assess quality of life in patients with hidradenitis suppurativa.

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.

Pain and Late-Onset of Hidradenitis Suppurativa Can Have a Negative Influence on Occupational Status and Educational Level. A Cross-Sectional Study

BACKGROUND AND OBJECTIVES

Hidradenitis suppurativa is a chronic and painful condition with negative impact on daily activity. Little information on the impact of disease-specific factors on educational level and occupational status in hidradenitis suppurativa patients has been reported. We sought to identify how disease-specific factors could influence occupational status and educational level in patients with hidradenitis suppurativa.

METHODS

Cross-sectional study of patients with hidradenitis suppurativa seen between September 2017 and September 2018. Disease-specific variables were analyzed to find associations in patients with different educational levels and occupational status.

RESULTS

Ninety-eight patients were included. Patients with non-university studies had more frequently≥3 affected areas (22.5% [16/73] vs 4.8% [1/22], p=0.049), a higher number of painful days (8.5 [SD 8.8] vs 4.6 [SD 4.8], p=0.048) and a higher score on the VAS scale (6.7 [SD 2.8] vs 5.0 [3.3], p=0.031). Patients from the inactive group had a significantly increased number of painful days (11.2 [SD 10.4] vs 5.7 [SD 6.2], p=0.004). This group had a greater number of patients with a history of depression (61.3% [19/31] vs 27.4% [17/62], p=0.002) and a higher mean BMI (32.3 [9.1] vs 28.4 [6.4], p=0.016). Late disease onset was significantly associated with being "inactive" (26.7% [8/31] vs 6.5% [4/62], p=0.026). No significant differences between severity scales of hidradenitis suppurativa and educational level or occupational status were found.

LIMITATIONS

cross-sectional and single center study.

CONCLUSIONS

Pain, ≥3 affected areas, history of depression, higher mean BMI, and late onset of hidradenitis suppurativa, are associated with low education level and inactive occupational status.

Pain and late-onset of hidradenitis suppurativa can have a negative influence on occupational status and educational level. A cross-sectional study

BACKGROUND AND OBJECTIVES

Hidradenitis suppurativa (HS) is a chronic and painful condition with negative impact on daily activity. Little information on the impact of disease-specific factors on educational level and occupational status in hidradenitis suppurativa patients has been reported. We sought to identify how disease-specific factors could influence occupational status and educational level in patients with HS.

METHODS

Cross-sectional study of patients with HS seen between September 2017 and September 2018. Disease-specific variables were analyzed to find associations in patients with different educational levels and occupational status.

RESULTS

Ninety-eight patients were included. Patients with non-university studies had more frequently ≥ 3 affected areas (22.5% [16/73] vs. 4.8% [1/22], p = 0.049), a higher number of painful days (8.5 [SD 8.8] vs. 4.6 [SD 4.8], p = 0.048) and a higher score on the VAS scale (6.7 [SD 2.8] vs. 5.0 [3.3], p = 0.031). Patients from the inactive group had a significantly increased number of painful days (11.2 [SD 10.4] vs. 5.7 [SD 6.2], p = 0.004). This group had a greater number of patients with a history of depression (61.3% [19/31] vs. 27.4% [17/62], p = 0.002) and a higher mean BMI (32.3 [9.1] vs. 28.4 [6.4], p = 0.016). Late disease onset was significantly associated with being «inactive» (26.7% [8/31] vs. 6.5% [4/62], p = 0.026). No significant differences between severity scales of HS and educational level or occupational status were found.

LIMITATIONS

cross-sectional and single center study.

CONCLUSIONS

Pain, ≥ 3 affected areas, history of depression, higher mean BMI, and late onset of HS, are associated with low education level and inactive occupational status.

Sexual Dysfunction and Quality of Life in Patients with Hidradenitis Suppurativa and Their Partners

Hidradenitis suppurativa (HS) is a chronic skin disease that profoundly affects patients' quality of life (QoL) and sexuality. Few data are available on the impact of HS on patients' partners. We aimed to explore the QoL and sexual function of patients' partners and the factors associated with their impairment and to compare the QoL and sexual function of single patients and those in a stable relationship. We conducted a cross-sectional study at Hospital Universitario Virgen de las Nieves (Granada, Spain) and at the Wroclaw Medical University (Wroclaw, Poland). Patients over the age of 16 years attending their scheduled follow-up and their partners, if any, were included. The Dermatology Life Quality Index (DLQI) and the Family Dermatology Life Quality Index (FDLQI) were used to estimate the QoL of patients and partners, respectively. The FSFI-6 was used to determine sexual dysfunction in women and the IIEF-5 for erectile dysfunction in men. Thirty-four single patients and twenty-eight patients in a stable relationship and their partners were included. Patients had a very large impact (DLQI 12.5 ± 7.5) and their partners a moderate impact (FDLQI 10.3 ± 7.1) in their QoL due to HS. Women with HS had a high prevalence of sexual dysfunction (13/32, 40.6%) and men of erectile dysfunction (19/30, 63.3%). Male partners also had a high prevalence of erectile dysfunction (10/17, 58.8%), while only one female partner had sexual dysfunction (1/11, 9.1%). Factors related to disease severity, intensity of symptoms and body mass index were associated with poorer QoL in partners and time of disease evolution with greater erectile dysfunction in male partners. In conclusion, HS not only profoundly affects the QoL and sexuality of patients but also of their partners. Several risk factors have been identified, which should be taken into account in the holistic approach of the disease.

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

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

Unmet Medical Needs in Chronic, Non-communicable Inflammatory Skin Diseases

An estimated 20-25% of the population is affected by chronic, non-communicable inflammatory skin diseases. Chronic skin inflammation has many causes. Among the most frequent chronic inflammatory skin diseases are atopic dermatitis, psoriasis, urticaria, lichen planus, and hidradenitis suppurativa, driven by a complex interplay of genetics and environmental factors. Autoimmunity is another important cause of chronic skin inflammation. The autoimmune response may be mainly T cell driven, such as in alopecia areata or vitiligo, or B cell driven in chronic spontaneous urticaria, pemphigus and pemphigoid diseases. Rare causes of chronic skin inflammation are autoinflammatory diseases, or rheumatic diseases, such as cutaneous lupus erythematosus or dermatomyositis. Whilst we have seen a significant improvement in diagnosis and treatment, several challenges remain. Especially for rarer causes of chronic skin inflammation, early diagnosis is often missed because of low awareness and lack of diagnostics. Systemic immunosuppression is the treatment of choice for almost all of these diseases. Adverse events due to immunosuppression, insufficient therapeutic responses and relapses remain a challenge. For atopic dermatitis and psoriasis, a broad spectrum of innovative treatments has been developed. However, treatment responses cannot be predicted so far. Hence, development of (bio)markers allowing selection of specific medications for individual patients is needed. Given the encouraging developments during the past years, we envision that many of these challenges in the diagnosis and treatment of chronic inflammatory skin diseases will be thoroughly addressed in the future.

Insights into hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, debilitating, inflammatory skin disorder with a prevalence of around 1% and a profound impact on patients' quality of life. Characteristic lesions such as inflammatory nodules, abscesses, and sinus tracts develop in the axillae, inguinal, and gluteal areas, typically during or after puberty. A complex interplay of genetic predisposition, hormonal factors, obesity, and smoking contributes to development and maintenance of the disease. HS is considered to arise from an intrinsic defect within the hair follicle, leading to follicular plugging, cyst formation, and subsequent rupture that in turn induce an acute inflammatory response characterized by elevated levels of IL-1β, IL-17, and TNF. Over time, acute lesions transition into chronic disease, with active draining sinus tracts accompanied by extensive fibrosis. HS is associated with other immune-mediated inflammatory diseases, metabolic and cardiovascular disorders, and psychiatric comorbidities. Treatment of HS often requires a combination of antibiotic or immunosuppressing therapies and surgical intervention. Nonetheless, the currently available treatments are not universally effective, and many drugs, which are often repurposed from other inflammatory diseases, are under investigation. Studies into the early stages of HS may yield treatments to prevent disease progression; yet, they are hampered by a lack of appropriate in vitro and animal models.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of psychiatric comorbidities in psoriasis, hidradenitis suppurativa and atopic dermatitis: the importance of a psychodermatological approach

Background

There is a strong interaction between the immunological and nervous system in the skin. Lesions that are physically disfiguring and chronically relapsing have a high impact on quality of life (QoL) and can result in the emergence of psychiatric disorders. The literature data confirm a higher prevalence of psychiatric disorders in patients with psoriasis, hidradenitis suppurativa (HS) and atopic dermatitis (AD), but such data are compromised by low‐quality evidence due to methodological heterogeneity.

Objectives

The primary aim was to analyse the prevalence of psychiatric comorbidities in a group of psoriasis, AD and HS patients compared with a control group. The secondary aims were to evaluate the impact of psychiatric comorbidities on the disease development, severity, flare‐ups and QoL.

Methods

A total of 59 cases and 64 controls were included.

Results

Generalized anxiety disorder and depressive disorder with anxious distress were found to be risk factors for AD. Age, smoking and substance‐related disorder showed a specific association with HS. Major depressive disorder showed a specific association with dermatology life quality index (DLQI) and all the above disease flare‐ups.

Conclusions

Atopic dermatitis, psoriasis and HS are associated with psychiatric disorders. A psychodermatological approach improves outcomes in terms of QoL, disease flare‐ups and long‐term management.

Neurological Complications of Biological Treatment of Psoriasis

In the available literature, little attention has been paid to the assessment of psoriasis and the biological therapy used for it and the nervous system. The purpose of this article is to discuss the relationship between psoriasis and the nervous system as well as to analyze the mechanisms that lead to neurological complications during anticytokine therapies in psoriasis. However, this connection requires further analysis. The use of biological drugs in psoriasis, although it yields positive therapeutic results, is not without numerous side effects. Serious neurological side effects of the therapy are most often visible with the use of anti-TNF-alpha, which is why patients should be monitored for their potential occurrence. Early detection of complications and rapid discontinuation of treatment with the drug may potentially increase the patient’s chances of a full recovery or improvement of his/her neurological condition. It also seems reasonable that, in the case of complications occurring during anti-TNF-alpha therapy, some of the drugs from other groups should be included in the therapy.

A systematic review on shared biological mechanisms of depression and anxiety in comorbidity with psoriasis, atopic dermatitis, and hidradenitis suppurativa

BACKGROUND

Mental disorders in comorbidity with chronic skin diseases may worsen disease outcome and patients' quality of life. We hypothesized the comorbidity of depression, anxiety syndromes, or symptoms as attributable to biological mechanisms that the combined diseases share.

METHODS

We conducted a systematic review based on the Preferred Reporting Items for Systematic Review and Meta-Analysis statement searching into PubMed, PsycInfo, and Scopus databases. We examined the literature regarding the comorbidity of psoriasis (Ps), atopic dermatitis (AD), or hidradenitis suppurativa with depression and/or anxiety in adults ≥18 years and the hypothetical shared underlying biological mechanisms.

RESULTS

Sixteen studies were analyzed, mostly regarding Ps and AD. Brain-derived neurotrophic factor/tropomyosin receptor kinase B signaling and nuclear factor kappa-light-chain-enhancer of activated B cells/p38 mitogen-activated protein kinase pathways arose as shared mechanisms in Ps animal models with depression- and/or anxiety-like behaviors. Activated microglia and neuroinflammatory responses emerged in AD depressive models. As to genetic studies, atopic-dermatitis patients with comorbid anxiety traits carried the short variant of serotonin transporter and a polymorphism of the human translocator protein gene. A GA genotype of catechol-O-methyltransferase gene was instead associated with Ps. Reduced natural killer cell activity, IL-4, serotonin serum levels, and increased plasma cortisol and IgE levels were hypothesized in comorbid depressive AD patients. In Ps patients with comorbid depression, high serum concentrations of IL-6 and IL-18, as well as IL-17A, were presumed to act as shared inflammatory mechanisms.

CONCLUSIONS

Further studies should investigate mental disorders and chronic skin diseases concurrently across patients' life course and identify their temporal relation and biological correlates. Future research should also identify biological characteristics of individuals at high risk of the comorbid disorders and associated complications.

LAight® Therapy Significantly Enhances Treatment Efficacy of 16 Weeks of Topical Clindamycin Solution in Hurley I and II Hidradenitis Suppurativa: Results from Period A of RELIEVE, a Multicenter Randomized, Controlled Trial

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory, burdensome skin disease where medical first-line treatment is still limited to long-term, topical and/or systemic antibiotics. The RELIEVE study aimed at evaluating the efficacy of LAight® therapy - a combination of intense pulsed light and radiofrequency - as an adjunct treatment to first-line therapies in Hurley stage I and II HS.

METHODS

The RELIEVE study was performed as a two-period multicenter randomized controlled trial with blinded assessment. For period A from week 0 to week 16, the 88 participating subjects were randomized into either an intervention group (IG) or a control group (CG). The IG received topical clindamycin 1% solution combined with 8 additional bi-weekly treatments with LAight® therapy. The CG was treated with topical clindamycin 1% solution only. After 16 weeks, patients entered open-label period B and both groups were treated exclusively with LAight® therapy for an additional 16 weeks (8 sessions). The primary efficacy endpoint was the change in International Hidradenitis Suppurativa Score System (∆IHS4) at week 16 to baseline. Secondary endpoints were DLQI, HiSCR, Pain-NRS, and HADS.

RESULTS

In total, from the 88 patients enrolled in RELIEVE, 81 patients were included in the endpoint analysis after period A. After 16 weeks of treatment, the ∆IHS4 of the group treated with the combination of LAight® therapy and topical clindamycin 1% solution was -7.2 ± 6.7 (-60.0%), which was significantly higher in magnitude than the ∆IHS4 in the group treated with clindamycin 1% solution alone (-1.8 ± 5.6, -17.8%, p < 0.001). Secondary endpoints, including other clinical scores as well as patient-reported outcomes, confirmed that the efficacy of the combined treatment was superior to monotherapy.

CONCLUSION

The results of the primary endpoint analysis of period A of the RELIEVE study show that the combined therapy with LAight® and topical clindamycin 1% solution, resulted in a significantly higher decrease in disease severity and an improvement of quality of life in comparison to topical clindamycin 1% solution monotherapy. Treatment was well tolerated, and side effects were all mild and transitory. These data speak for the implementation of the combined treatment as a first-line therapy in Hurley stage I and II HS. LAight® therapy as long-term monotherapy (results from period B), will be analyzed in a consecutive paper.

Alterations in mental health and quality of life in patients with skin disorders: a narrative review

The presence of lesions in visible areas of skin may cause emotional troubles in patients, including low self-worth, embarrassment, sorrow, and social isolation. Those alterations may predispose to psychiatric disorders such as anxiety, depression, and even suicidal ideation, severely affecting patients' health state and quality of life (QoL). In this article, we focus on dermatologic patients that present with secondary mental health alterations. Thus, we offer a detailed description of mental disorders observed in patients with acne vulgaris, atopic dermatitis, psoriasis, ichthyosis, vitiligo, and hidradenitis suppurativa. Moreover, we point out the relationship between the severity of the cutaneous symptoms with mental illnesses and QoL decline. Our objective was to highlight the importance of mental health care for patients with skin diseases. The impact of skin alterations on the mental health of dermatological patients should be a central concern. Likewise, the timely identification and treatment of mental disorders are essential for the comprehensive management of these skin diseases.

Identifying Unmet Care Needs and Important Treatment Attributes in the Management of Hidradenitis Suppurativa: A Qualitative Interview Study

Background and Objective

Hidradenitis suppurativa (HS) is an inflammatory skin disease with a profound effect on patients’ quality of life. The patient’s journey to manage HS is often complex and unsuccessful, which motivates the aim of this research to gain insight into unmet needs and relevant treatment considerations from the perspective of patients and healthcare professionals (HCPs).

Methods

Individual semi-structured interviews were conducted with patients and HCPs experienced in treating HS to understand the perceived unmet care needs and to identify important treatment attributes. Prioritization of the five most important treatment attributes allowed elicitation of their relative importance.

Results

Interviews with 12 patients and 16 HCPs revealed 16 areas of unmet needs either related to treatment outcomes or the care process and 13 important treatment attributes. The most frequently reported unmet needs by patients and HCPs were lacking quality-of-life improvement, low treatment effectiveness, inadequate pain control, low disease awareness, and delayed diagnosis. Patients expressed unique concerns relating to pain management, access to HS specialists, and wound care guidance and costs, which HCPs did not. Treatment attributes related to effectiveness were considered most important by patients and HCPs. Patients additionally emphasized a strong preference for improved pain management.

Conclusions

Current HS treatments and care processes leave patients and HCPs with a high level of unmet need. It is critical to consider patients’ and HCPs’ perspectives when designing appropriate HS care as perceived unmet needs differ. Further quantitative preference elicitation studies are needed to assess the trade-offs between important care needs and treatment attributes.

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.

Association of Birth Weight, Childhood Body Mass Index, and Height With Risk of Hidradenitis Suppurativa

Importance

There is a lack of evidence on the association of birth weight, childhood body mass index (BMI), change in BMI during childhood, and childhood height with subsequent risks of hidradenitis suppurativa (HS) in adulthood.

Objective

To investigate the association of birth weight, childhood BMI, change in BMI during childhood, and childhood height with subsequent risks of HS in adulthood in a large Danish population-based cohort.

Design, Setting, and Participants

This cohort study included 347 200 schoolchildren from the Copenhagen School Health Records Register born from 1930 to 1996 who were linked to the Danish National Patient Register of hospital discharge diagnoses to identify cases of HS. Birth weight was reported by parents or guardians, whereas childhood weight and height were measured by school physicians or nurses at ages 7 through 13 years. Cox proportional hazards regressions were used to estimate hazard ratios (HRs) and 95% CIs. Statistical analysis was performed from February 20, 2019, to May 15, 2019.

Main Outcomes and Measures

A diagnosis of HS as recorded in the Danish National Patient Register.

Results

Among the 347 200 children included in the study (175 750 boys) during the follow-up period from 1977 to 2017, 1037 individuals (677 females; median age at diagnosis, 39 years [range, 15-73 years]) received a diagnosis of HS. A nonlinear (U-shaped) association was found between birth weight and HS, such that both the lightest (2.00-2.75 kg; HR, 1.36 [95% CI, 1.10-1.68]) and the heaviest babies (4.26-5.50 kg; HR, 1.39 [95% CI, 1.01-1.93]) had increased risks of HS compared with normal-weight babies (3.26-3.75 kg; P = .04 for deviation from linearity). The risk of HS increased significantly with increasing BMI z score at each age from 7 to 13 years, from an HR of 1.32 (95% CI, 1.24-1.40) per BMI z score at 7 years of age to an HR of 1.50 (95% CI, 1.40-1.61) per BMI z score at 13 years of age. Compared with children with a normal weight at 7 and 13 years of age, those with a normal weight at 7 years of age and overweight at 13 years of age had a significantly increased risk of HS (HR, 2.11 [95% CI, 1.63-2.74]) and children with persistent overweight at both ages also had an increased risk of HS (HR, 2.61 [95% CI, 2.02-3.38]). Children with overweight at 7 years of age but with normal weight at 13 years of age did not have a significantly increased risk of HS (HR, 1.05 [95% CI, 0.67-1.67]). Childhood height at all ages was not associated with risk of HS (children at 7 years had an HR of 1.00 [95% CI, 0.94-1.07], and those 13 years had an HR of 1.06 [95% CI, 0.99-1.13], per z score).

Conclusions and Relevance

This cohort study found that both the lightest and heaviest babies had increased risks of HS. Childhood BMI was positively and significantly associated with risk of HS development in adulthood. These findings suggest that returning to normal weight before puberty reduces risks of HS to levels observed in children who were never overweight. Childhood height was not associated with risk of HS.

Disease Trajectories for Hidradenitis Suppurativa in the Danish Population

Importance

Hidradenitis suppurativa (HS) is a chronic skin disease characterized by recurrent inflamed nodular lesions and is associated with multiple comorbidities; previous studies have been of cross-sectional design, and the temporal association of HS with multiple comorbidities remains undetermined.

Objective

To evaluate and characterize disease trajectories in patients with HS using population-wide disease registry data.

Design, Setting, and Participants

This retrospective registry-based cohort study included the entire Danish population alive between January 1, 1994, and April 10, 2018 (7 191 519 unique individuals). Among these, 14 488 Danish inhabitants were diagnosed with HS or fulfilled diagnostic criteria identified through surgical procedure codes.

Exposures

Citizens of Denmark with a diagnosis code of HS as defined by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) or as identified through surgical procedures.

Main Outcomes and Measures

Disease trajectories experienced more frequently by patients with HS than by the overall Danish population. Strength of associations between disease co-occurrences was evaluated using relative risk (RR). All significant disease pairs were tested for directionality using a binomial test, and pairs with directionality were merged into disease trajectories of 3 consecutive diseases. Numerous disease trajectories were combined into a disease progression network showing the most frequent disease paths over time for patients with HS.

Results

A total of 11 929 individuals were identified by ICD-10 diagnosis codes (8392 [70.3%] female; mean [SD] age, 37.72 [13.01] years), and 2791 were identified by procedural codes (1686 [60.4%] female; mean [SD] age, 37.38 [15.83]). The set of most common temporal disease trajectories included 25 diagnoses and had a characteristic appearance in which genitourinary, respiratory, or mental and behavioral disorders preceded the diagnosis of HS and chronic obstructive pulmonary disease (604 cases [4.2%]; RR, 1.57; 95% CI, 1.55-1.59; P < .001), pneumonia (827 [5.7%]; RR, 1.18; 95% CI, 1.15-1.20; P < .001), and acute myocardial infarction (293 [2.0%]; RR, 1.37; 95% CI, 1.35-1.39; P < .001) developed after the diagnosis.

Conclusions and Relevance

The findings suggest that patients with newly diagnosed HS may have a high frequency of manifest type 1 diabetes and subsequent high risk of acute myocardial infarction, pneumonia, and chronic obstructive pulmonary disease.

Assessment of Overall and Specific Cancer Risks in Patients With Hidradenitis Suppurativa

Importance

Large population-based studies investigating the risks of overall and specific cancers among patients with hidradenitis suppurativa (HS) are limited.

Objective

To assess the overall and specific cancer risks in patients with HS compared with the risks in patients without HS in the Republic of Korea.

Design, Setting, and Participants

A nationwide population-based cohort study, using the Korean Health Insurance Review and Assessment Service database was conducted over a 2-year period from January 1, 2007, to December 31, 2008. Individuals in the control group who were never diagnosed with HS or cancer during the washout period were randomly extracted and matched by age, sex, index year, and insurance type at a case-control ratio of 1:8, and patients with newly diagnosed HS between January 1, 2009, and December 31, 2017, were included. Follow-up data on incident cancer from January 1, 2009, to December 31, 2018, were included.

Main Outcomes and Measures

The overall and specific cancer incidence rates were calculated per 100 000 person-years in patients with HS and in the matched control cohort. The risk for cancers was assessed by multivariable Cox regression models in patients with HS compared with the matched control cohort.

Results

In total, 22 468 patients with HS and 179 734 matched controls were included in the study. The mean (SD) age was 33.63 (17.61) years and 63.7% of the participants in both groups were male. The adjusted hazard ratio (aHR) of overall cancer in patients with HS was 1.28 (95% CI, 1.15-1.42). Patients with HS had significantly higher risk for Hodgkin lymphoma (aHR, 5.08; 95% CI, 1.21-21.36), oral cavity and pharyngeal cancer (aHR, 3.10; 95% CI, 1.60-6.02), central nervous system cancer (aHR, 2.40; 95% CI, 1.22-4.70), nonmelanoma skin cancer (HR, 2.06; 95% CI, 1.12-3.79), prostate cancer (aHR, 2.05; 95% CI, 1.30-3.24), and colorectal cancer (aHR, 1.45; 95% CI, 1.09-1.93).

Conclusions and Relevance

In this study, HS appeared to be associated with a significantly increased risk of overall cancer as well as several specific cancers.

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.

[Psychiatric comorbidities in hidradenitis suppurativa/acne inversa]

BACKGROUND

The findings of most studies suggest that depression and anxiety disorders are the most common psychiatric comorbidities in patients with hidradenitis suppurativa/acne inversa (HS/AI).

METHODS

In a prospective study, 51 patients with HS/AI were further examined for psychiatric comorbidity using a standardized interview and questionnaires.

RESULTS

In psychiatric examination, 29.4% of HS/AI patients had additional mental symptoms, mainly manifested as depressive disorder. The HS/AI patients were rather young and female, and they showed a high incidence of nicotine and alcohol use, and a positive family history of paternal alcohol dependence. In addition, HS/AI patients experienced more severe psychosocial impairments in the form of lack of partnership and lower school attainment.

CONCLUSIONS

Acne inversa is a severe chronic inflammatory skin disease that, like other inflammatory dermatoses, is associated with mental comorbidity and psychosocial impairments. Since especially young patients are affected, a psychiatric-psychotherapeutic cotreatment should be considered already at an early stage.

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.

Prevalence of Neuropathic Pain and Related Characteristics in Hidradenitis Suppurativa: A Cross-Sectional Study

BACKGROUND

Pain is a core symptom of hidradenitis suppurativa (HS) and is of complex, multifactorial origin. HS patients frequently report typical neuropathic pain qualities, but its prevalence has been poorly described.

METHODS

In this cross-sectional study, we examine the prevalence of neuropathic pain (NP) component and related pain-characteristics of a hospital-based cohort of patients with symptomatic HS. We administered the pain-DETECT tool (PDQ), a validated screening tool for NP, collecting clinical and patient-reported data on pain, pruritus and pain-management. We obtained 110 complete datasets from symptomatic HS patients (49.1% females; Hurley I (27.3%])-II (45.5%)-III (27.3%)). According to the PDQ tool, 30% of patients were classified with a high probability (>90%) of neuropathic pain (LNP). LNP status was significantly associated with increased pain severity, disease activity, pruritus intensity and use of pain medication. Regression analysis showed a significant impact of the PDQ score on patient-reported outcomes, including pain severity and the dimensions of activity and affective pain interference. HS patients may present a mixed chronic pain phenotype with a neuropathic component, thus requiring additional pain-assessments. A multi-modal approach to pain management, in combination with disease-specific treatment, should be implemented in future interventional studies.

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.

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.

A Review of Skin Disease in Schizophrenia

BACKGROUND

Schizophrenia is a debilitating neuropsychiatric condition that affects 0.5% of the North American population. Skin disease in schizophrenia has not been well described. Identifying skin diseases that are commonly comorbid with schizophrenia may help clinicians address the burden of skin disease in patients with schizophrenia.

SUMMARY

We conducted a nonsystematic review of the literature to identify skin diseases that may be associated with schizophrenia. We searched MEDLINE, EMBASE, and PsycINFO for articles published in English from December 2000 through April 2020 using the key words "skin disease" or "dermatological" or "dermatology" and "schizophrenia." Based on our results, we further refined the search terms to include more specific skin diseases. Schizophrenia appears to be associated with a number of skin diseases, including inflammatory dermatoses, autoimmune diseases, and certain genodermatoses. Limitations include being a nonsystematic review and the relative paucity of more rigorous clinical research using longitudinal study designs.

Baseline Characteristics from UNITE: An Observational, International, Multicentre Registry to Evaluate Hidradenitis Suppurativa (Acne Inversa) in Clinical Practice

Background

Hidradenitis suppurativa (HS), also known as acne inversa, is a recurring, painful, chronic, and sometimes disfiguring inflammatory skin disease.

Objectives

Our objective was to report the baseline clinical characteristics, natural history, and associated outcomes of patients with HS from the ongoing, prospective, non-interventional UNITE registry that is collecting data regarding the natural history and associated outcomes of HS.

Methods

Patients with inflammatory HS lesions were enrolled, including adolescents (aged 12 to < 18 years) and adults (aged ≥ 18 years). None had participated in previous or current originator-adalimumab studies/registries. Patients received treatment consistent with site-specific, routine clinical practice. HS disease status was assessed by HS lesions and disease flare; treatment and outcomes data were collected at enrolment and every 6 months for ≤ 4 years.

Results

Enrolment (N = 594; 89.1% adults; 10.9% adolescents) occurred from 29 October 2013 to 29 December 2015 at 73 sites in 12 countries. At baseline, the majority were female (69.7%) and White (81.2%), had moderate-to-severe disease (Hurley stage II or III; 93.3%), and had undergone prior procedures/surgery for HS (68.7%). In total, 61.6% of adults and 49.2% of adolescents were obese; 40.2% of patients reported current tobacco use. Scarring due to lesions occurred in 91.2% of patients. The prevalence of comorbidities of interest was as follows: depression (13.3%), other psychiatric disorders (9.6%), inflammatory bowel disease (2.7%), diabetes (9.1%), and polycystic ovary syndrome (5.2%).

Conclusions

In this population from the UNITE HS registry, obesity and smoking were common, and disease burden was high, manifesting as multiple lesions, scarring, surgical history, and considerable comorbidities.

Electronic supplementary material

The online version of this article (10.1007/s40257-020-00504-4) contains supplementary material, which is available to authorized users.