Comparison of clinical and ultrasound scores in patients with hidradenitis suppurativa: results from an Italian ultrasound working group

Doppler ultrasound protocol for patients with hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease that leads to the formation of nodules, abscesses and fistulas, with the formation of scars and fibrosis, causing significant impairment in patient quality of life. The diagnosis is clinical, using scores to classify the severity of the condition; currently the most recommended classification is the International Hidradenitis Suppurativa Severity Scoring System (IHS4). Doppler ultrasound has been used to complement the clinical evaluation of patients with HS. It is possible to observe subclinical lesions that change the staging, the severity of the case, and its treatment, either clinical or surgical. Correct treatment is essential to minimize the consequences of this disease for the patient.

OBJECTIVE

To establish an outpatient protocol for the use of Doppler ultrasound in the care of patients with HS.

METHODS

A narrative review of the literature was carried out on the use of Doppler ultrasound in patients with hidradenitis suppurativa; a referring protocol and technique orientations for imaging assessment in HS were created.

RESULTS

Recommendation to perform ultrasound evaluation of symptomatic areas eight weeks after using antibiotics and four, 12, and 24 weeks after starting immunobiologicals; apply SOS-HS ultrasound severity classification.

STUDY LIMITATIONS

The review did not cover all literature on ultrasound and HS; no systematic review was carried out, but rather a narrative one.

CONCLUSIONS

The correct assessment of patients staging must be carried out using dermatological ultrasound to avoid progression to scars and fibrosis, which compromise patients quality of life.

Role of Color Doppler Ultrasound in Cutaneous Inflammatory Conditions

Inflammatory cutaneous diseases can be challenging to diagnose and manage. Nowadays, the anatomical information provided by ultrasound is critical for detecting subclinical alterations and assessing the severity and activity of these conditions. Many of these entities can be clinically observed in dermatology and other specialties, such as rheumatology, plastic surgery, ophthalmology, and otolaryngology, among others. We review the ultrasonographic patterns of the most common inflammatory cutaneous conditions. In several cases, such as hidradenitis suppurativa, acne, and morphea, there are ultrasonographic staging systems of severity or activity that are pivotal in the management of these diseases. The early ultrasonographic diagnosis of these entities implies a proper management of the patients and, therefore, improve their quality of life. Thus, knowledge of the current use of ultrasound in this field seems essential.

Topical and Systemic Retinoids in the Management of Hidradenitis Suppurativa: A Comprehensive Literature Review

Hidradenitis suppurativa (HS) is a debilitating chronic skin disorder characterized by painful inflammatory nodules, abscesses and sinus tracts involving intertriginous areas and has an adverse impact on patient quality of life. Over the past decade, the therapeutic options of HS have increased significantly to comprise multiple modalities, including topical medication, systemic therapies (mainly antibiotics, retinoids, and biologics), surgical approaches, and lifestyle modifications. Biologics alone or in combination with surgery remain the treatment of choice for moderate to severe disease. However, non-biologic therapies (including retinoids) may be used as monotherapy for mild disease and in combination with biologics and surgical treatment in moderate to severe disease. Retinoids, specifically isotretinoin, acitretin, and alitretinoin, are historically used in the management of HS, supported by anecdotal evidence and with variable treatment response. Although the current American and European guidelines offer different recommendations on the use of retinoids in HS, retinoids remain a valuable ally in HS management. This review provides a comprehensive analysis of the current scientific literature on retinoid therapy (topical and systemic) in HS, highlighting disparities in mechanisms of action, efficacy, and safety to clarify their role in HS treatment.

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

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

New Insight into the Molecular Pathomechanism and Immunomodulatory Treatments of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is an immune-mediated inflammatory disorder characterized by deep-seated nodules, abscesses, sinus tracts and scars localized in the intertriginous areas. It is accompanied by pain, malodourous secretion and a dramatically decreased quality of life. Although the pathogenesis has not been entirely elucidated, the primary event is follicular hyperkeratosis of the pilosebaceous apocrine unit. Since the registration of the tumor necrosis factor-alpha inhibitor Adalimumab in 2015, several cytokines have been implicated in the pathomechanism of HS and the research of novel therapeutic targets has been intensified. We provide an update on the inflammatory cytokines with a central role in HS pathogenesis and the most promising target molecules of future HS management.

Practical applications of ultrasound in dermatology

Ultrasound has evolved in dermatology from an experimental phase to a daily practice imaging technique. Its several advantages include its safety, good balance between penetration and resolution, high definition, and the detection of blood flow in real time. Its applications are growing and include the support of the diagnosis and extent in all axes, including depth, vascularity patterns, staging, and follow up of multiple cutaneous diseases-benign cutaneous tumors, vascular anomalies, nail lesions, skin cancer, inflammatory cutaneous diseases, and aesthetics complications.

Assessment of Inter-rater Reliability of Clinical Hidradenitis Suppurativa Outcome Measures Using Ultrasonography

BACKGROUND

Hidradenitis suppurativa (HS) staging and severity is typically based upon physical examination findings which can result in misclassification of severity based on subclinical disease activity and significant variation between healthcare providers. Ultrasound (US) is an objective tool to help evaluate subclinical disease and more accurately classify severity of disease. The objective of this study was to evaluate inter-rater reliability in HS disease severity assessment using clinical and US techniques.

METHODS

Twenty subjects underwent clinical evaluation of HS using clinical outcome measures including Hurley, Sartorius, HS Physician Global Assessment (HS-PGA), and Hidradenitis Suppurativa Clinical Response (HiSCR) independently by two physicians. US was subsequently performed, and clinical assessments were repeated. Intra-class correlation coefficients (ICC) were obtained to evaluate inter-rater agreement of each outcome measure before and after US.

RESULTS

Pre- to post-US improvement in ICC was seen with the Sartorius, HiSCR nodule and abscess count, and HiSCR draining fistula count. The scores went from having "good" rater agreement for Sartorius and HiSCR nodule and abscess count and "poor" rater agreement for HiSCR draining fistula count to "excellent" rater agreement amongst these scores.

CONCLUSIONS

US improved inter-rater agreement and should be used in conjunction with physical examination findings to evaluate disease severity to ensure uniform staging.

Ultrasound-guided injection of intralesional steroids in acute hidradenitis suppurativa lesions: A prospective study

The management of hidradenitis suppurativa (HS) flares with intralesional steroids lacks strong scientific evidence but limited data suggest that it may be useful. The objective of this study is to assess the clinical and ultrasound responses of HS flares to ultrasound‐guided injections of intralesional triamcinolone (40 mg/ml) with a dilution 1:4 versus 1:2 at 30‐day (t1), 60‐day (t2), and 90‐day (t3) follow‐up. We recruited patients with ≤3 acute lesions, unresponsive to topical therapy. At baseline we assessed lesions clinically and by ultra‐high frequency ultrasound (48 or 70 MHz) and randomly performed an ultrasound‐guided injection of triamcinolone. Assessments were repeated at t1, t2, and t3 follow‐up, re‐injecting the lesion in the case of no or partial response. We treated 49 lesions: 38.8% showed improvements at t1; 46.9% at t2; 6% at t3; and 8.3% showed no clinical and ultrasound improvements. Long‐term follow‐up data confirmed a statistically significant reduction in Visual Analogue Scale (VAS)‐pain, Dermatology Life Quality Index (DLQI), and HS‐Physician Global Assessment (HS‐PGA), as well as edema and vascular signals. No adverse effects were reported. Our study suggests that ultrasound‐injections with a 1:2 dilution are beneficial for HS flares that do not respond to topical treatment and should be included in the therapeutic algorithm.

Should We Scan Hidradenitis Suppurativa Patients? A Systematic Review of Radiologic Findings

OBJECTIVE

To bring awareness and close gaps between dermatologists and radiologists about the contribution of imaging techniques for diagnosis, treatment, and follow-up of hidradenitis suppurativa (HS).

DATA SOURCES

Investigators searched the PubMed database for articles on HS and radiology techniques.

STUDY SELECTION

Databases were searched up to December 2018. The query retrieved 257 publications, of which 103 were unique; of these, 7 were inaccessible. From the remaining 96, 33 were irrelevant (did not discuss HS lesion features). After applying the inclusion criteria, 63 studies were relevant to this study.

DATA EXTRACTION

A standardized form was constructed to extract data from eligible studies by two independent authors.

DATA SYNTHESIS

Imaging techniques are significant and useful tools in HS management. Imaging should be carried out to evaluate disease severity, subclinical features, treatment success, and intraoperative patient assessment. Providers should consider nonconventional radiology techniques, which are underused in clinical management of HS. Further, dermatology and radiology require a shared terminology of disease features to better understand patient status.

CONCLUSIONS

Publications on HS lesion imaging have increased over the years. Imaging techniques have proven useful for determining HS severity and treatment effectiveness, as well as intraoperative patient assessment. These authors strongly recommend the use of these techniques in routine clinical practice for patients with HS.

Clinical and Power-Doppler ultrasound features related with persistence of fistulous tracts under treatment with adalimumab in hidradenitis suppurativa: 4 years of follow-up

Fistulous tracts are the hallmark lesions of hidradenitis suppurativa (HS) and respond poorly to the currently available medical treatments. To evaluate the clinical and ultrasound features related with both healing and persistence of fistulous tracts in patients under treatment with adalimumab, a retrospective analysis of power-Doppler ultrasound (PD-US) images with fistulas in HS patients was performed. The clinical and sonographic staging of HS, body areas involved, and anatomic characteristics of the fistulous tracts were registered and graded. Chi-square test, univariate/multivariate Cox-regression analysis with clustered error, and Kaplan-Meier analysis were computed to analyze data. In total, 151 fistulous tracts from 33 HS patients were included. Age, BMI, length, thickness, subcutaneous pattern, high intensity of PD-US signal, and a high grade of fibrosis/edema were all related to a lower possibility of healing and a high risk of longer persistence at binomial Cox-regressions. Whereas, multivariate regressions showed that high fibrosis, was the variable with the highest risk of poor response and longer survival. Survival-analysis showed that fistulas with high fibrosis or PD-US signal have longer survival time than those with absent/low fibrosis or signal. Limitations include the impossibility to detect with ultrasound lesions less than 0.1 mm and smaller sample size. In conclusion, an accurate assessment of fibrosis may be crucial to define better when a surgical approach-besides the medical treatment-could be required. PD-US may assess the decrease of vascularization in HS lesions and consequently the reduction of inflammation due to immunomodulatory therapies.

Metabolic, pharmacokinetic, and toxicological issues of biologic therapies currently used in the treatment of hidradenitis suppurativa

INTRODUCTION

Hidradenitis suppurativa is a chronic, relapsing, debilitating inflammatory dermatologic disease of the terminal hair follicles at intertriginous sites clinically characterized by painful inflammatory nodules, abscesses, draining sinus tracts, and dermal fibrosis. The management of hidradenitis suppurativa is a challenge and usually consists of both medical and surgical approaches, which must often be combined for best outcome. The introduction of biological therapies, specifically TNFα-inhibitors such as adalimumab, has profoundly changed the therapeutic armamentarium of the disease.

AREAS COVERED

The PubMed database was searched using combinations of the following keywords: hidradentis suppurativa, biologic therapy, TNF-α inhibitors, adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, adverse effects, pharmacodynamics, pharmacology, adverse events, pharmacokinetics, drug interaction. This article reviews and updates the chemistry, pharmacokinetics, mechanism of action, adverse effects, drug interactions of on-label and off-label use of TNF-α inhibitors in HS.

EXPERT OPINION

Biologic agents, particularly adalimumab, exhibit clinical efficacy in patients with hidradenitis suppurativa. Careful patient selection and close monitoring during treatment are mandatory to provide safe and effective use of the TNF-α inhibitor. Familiarity with biologic agents is crucial because these agents could become a consolidated treatment option in the clinician's therapeutic approaches.

Lymecycline vs. clindamycin plus rifampicin in hidradenitis suppurativa treatment: clinical and ultrasonography evaluation

BACKGROUND

Antibiotic therapy remains the first-line treatment for hidradenitis suppurativa (HS). However, literature data on its comparative clinical efficacy and safety are limited.

AIM

To investigate the efficacy of tetracycline (lymecycline 300 mg daily) vs. the combination therapy clindamycin and rifampicin (600 mg plus 600 mg daily) by evaluating and comparing the clinical response at the end of antibiotic treatment (10 weeks).

METHODS

The study retrospectively analysed 52 patients divided in two groups of 26 patients: Group A received lymecycline and Group B received clindamycin plus rifampicin for 10 weeks. Subjects had mild, moderate and severe HS. The clinical and ultrasonography extent of disease was measured by the Hurley Score, Sonographic Score of Hidradenitis Suppurativa, International Hidradenitis Suppurativa Severity Score System (IHS4), pain visual analogue scale (pain VAS) and Dermatology Life Quality Index (DLQI). The primary outcome was the clinical response at the end of the antibiotic treatment period, according to the Hidradenitis Suppurativa Clinical Response measure.

RESULTS

Both groups showed a significant improvement in IHS4, pain VAS and DLQI from baseline, but this was more marked in Group A. Reductions in nodule counts were similar between the two groups, whereas the number of abscesses and draining tunnels decreased more in Group B. Disease-free survival was similar between the two groups.

CONCLUSION

Lymecycline monotherapy and clindamycin plus rifampicin combination are both effective treatments for patients with moderate-severe HS. Nodular-type HS seems to respond better to lymecycline, whereas the abscess/tunnel type seems to respond better to clindamycin plus rifampicin.

Seventy-MHz Ultrasound Detection of Early Signs Linked to the Severity, Patterns of Keratin Fragmentation, and Mechanisms of Generation of Collections and Tunnels in Hidradenitis Suppurativa

OBJECTIVES

To test the capability of 70-MHz ultrasound for detecting initial ultrasound signs of hidradenitis suppurativa (HS) linked to severity.

METHODS

A cross-sectional study of the ultrasound images of patients with HS was conducted and compared with a healthy control group. Detection and identification of early subclinical ultrasound signs in the lesional and perilesional areas of the HS cases in comparison with the control group were performed. Statistical analyses included mean, dispersion measures, the Kruskal-Wallis test, and bivariate and multivariate ordered logistic regression studies. Significance was assessed at P < .05.

RESULTS

A total of 139 patients with HS met the criteria and showed abnormalities of the hair follicles such as a curved shape, ballooning, and protrusion into pseudocysts, collections, or tunnels (donor of keratin sign). Significant increases in the sizes of the hair follicles and hair shafts were found in HS cases. The following ultrasound signs were significantly linked to severity: a connecting band between the base of adjacent hair follicles (bridge sign), a fragment of the hair shaft extruding through a dilated hair follicle (sword sign), and retained cylindrical fragments of keratin in the dermis. Two patterns of fragmentation of the keratin were detected: multifragment and cylindrical.

CONCLUSIONS

Ultrasound can detect early HS signs that are significantly linked to severity and 2 types of fragmentation of the keratin, which could support the generation and perpetuation of the fluid collections and tunnels. These ultrasound signs can help prompt diagnosis and management, the development and testing of medications, and the measure of treatment outcomes in HS.

The patient journey: a voyage from diagnosis to hidradenitis suppurativa multidisciplinary unit

BACKGROUND

Hidradenitis suppurativa (HS) is an inflammatory, recurrent and debilitating chronic skin disease that is often worsened by comorbidities, with a destructive impact on the social and working life of the patient. The low awareness of patients and clinicians regarding HS, together with weak coordination between specialists who manage the clinical care of these patients, may result in a burdening diagnostic and therapeutic delay, lowering efficacy of therapies and worsening prognosis and patients' QoL.

OBJECTIVES

To rule out these critical aspects, a HS-Multidisciplinary Unit with a hierarchical organization is proposed.

METHODS

Based on previously published models of a multidisciplinary unit, a hierarchical structure of a HS-dedicated multidisciplinary unit was designed.

RESULTS

In this model, an operational core constituted by four healthcare professionals constantly working as team, is supported by a large panel of consultants, local dermatologists and general practitioners, helping in HS patient management.

CONCLUSIONS

This standardization would imply an optimization of professional resources, an amelioration of patient's quality of life, and a shortening of patient journey.

Review of imaging technologies used in Hidradenitis Suppurativa

BACKGROUND

Until recently, clinical assessment with manual palpation of the HS lesions was the primary means to detect HS lesions and their borders. In the past decade, there has been increased application of imaging technologies to HS patients, and it is reported that manual palpation consistently underestimates HS. Of the technologies, ultrasound (US) imaging has been the most efficacious and well-studied. In the present review, we will discuss the various imaging modalities that aid in detecting, managing, and treating HS.

MATERIALS AND METHODS

Non-invasive HS imaging technologies including ultrasound (US) imaging, magnetic resonance imaging (MRI), medical infrared thermography (MIT), positron emission topography (PET), and computed tomography (CT) were reviewed and compared through a review of the literature. PubMed, Google, and Google Scholar were utilized.

RESULTS

Of the 4 HS technologies reviewed, US imaging and MRI are the most established and useful non-invasive modalities utilized in HS patients. However, MIT may have potential to aid in the pre-operative and intra-operative surgical excision of HS lesions.

CONCLUSION

For imaging HS lesions, US imaging is the most well-characterized and has the greatest range of use, while MRI has a role in severe, anogenital HS lesions. MIT of HS lesions is a novel application and merits attention.

Follicular occlusion tetrad in a male patient with pachyonychia congenita: clinical and genetic analysis

The case of a 24-year-old male patient affected by follicular occlusion tetrad (acne conglobata, hidradenitis suppurativa, pilonidal cyst and dissecting cellulitis of the scalp) associated with clinical signs of pachyonychia congenita (PC)-2 (focal palmoplantar keratoderma, plantar pain, onycodystrophy and multiple cysts) is reported. The diagnosis was supported by genetic analysis that showed heterozygous mutation within the exon 1 of KRT17 gene. This case may reflect different expressions of a phenotypic spectrum induced by a common genetic alteration.