Skin tone representation in dermatologic direct-to-consumer advertisements: a cross-sectional analysis and call to action

Background

Direct-to-consumer advertisements (DTCAs) in medical marketing serve as a prominent modality to deliver information to an increasingly diverse audience of consumers and increase prescription sales. In dermatology, advertisements have the potential to shape the public's opinions, aid in the understanding of skin conditions, and raise awareness of available treatments.

Objective

To investigate and characterize the representation of skin tones in DTCAs.

Methods

Nielsen ratings were utilized to identify the networks most watched by Black viewers in 2022. Programming on NBCUniversal, ABC, CBS, and FOX that aired in the District of Columbia, suburban Maryland, and Northern Virginia from June 2022 to July 2022 was reviewed for DTCAs. DTCAs were then analyzed to determine the skin tones of models and skin conditions depicted on models with darkly pigmented skin.

Results

Of the 106 DTCAs related to dermatologic conditions, there were 13 unique advertisements featuring 32 unique models. Four advertisements depicted the skin condition on darkly pigmented skin tones. Using the Monk Skin Tone (MST) scale to assess the 32 unique individuals, only 25% (n = 8) were rated at an MST 7 or above, and 6.25% (n = 2) were rated at an MST 10.

Limitations

This study has the limitation of only sampling DTCAs from Washington, District of Columbia which does not fully represent all dermatology-related DTCAs in the United States.

Conclusion

Results of this content analysis demonstrate that the number of persons of color within dermatologic DTCAs is 23%, whereas there are 13.6% Black individuals in the 2021 US census. This suggests that DTCAs are becoming more diverse since 2018. However, findings also show that the vast majority of DTCAs do not include models with darkly pigmented skin, and there remains a lack of advertisements depicting skin disease among people of color. Given the role of DTCAs in informing and aiding patients' requests for prescription drugs, representation of all skin tones is essential for this communication to be effective, especially in the field of dermatology.

Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic disease characterized by recurrent painful abscesses and chronic sinus tracts in intertriginous areas. In the United States, HS disproportionally affects adults of African-American heritage. Depending on the severity of disease, the consequences of HS can be far-reaching, significantly affecting mental health and quality of life. In recent years, concerted research efforts have been made to better understand the pathophysiology of the disease as well as identify emerging new treatment targets. Herein, we discuss the clinical presentation, diagnostic criteria, and treatment approach of HS with a focus on skin of color.

The Skin of Color Society's Meeting the Challenge Summit, 2022: Diversity in Dermatology Clinical Trials Proceedings

Importance

Clinical trials remain the cornerstone for determining the safety and efficacy of an intervention. A diverse participant pool in dermatology clinical trials is critical to ensure that results are generalizable among the patient population who will ultimately depend on the efficacy of the intervention. The Skin of Color Society hosted the inaugural Meeting the Challenge Summit: Diversity in Dermatology Clinical Trials in Washington, DC, from June 10 to 11, 2022. The summit was an interactive and collaborative effort to advance discussions regarding the need for broader inclusion of racial and ethnic minority patients in dermatology clinical trials.

Observations

The summit focused on 3 principal areas: (1) understanding the current clinical trials landscape; (2) breaking down patient, clinician, industry, and regulatory barriers; and (3) effecting change through a diversity-focused strategy. The program hosted thought-provoking panel talks and discussions with various stakeholder groups, including a keynote presentation from the family of Henrietta Lacks.

Conclusions and Relevance

Panel discussions and insightful presentations from physicians, industry leaders, community trailblazers, and patients fostered new collaborations. The summit provided recommendations and suggested strategies for future initiatives designed to increase the representation of minority individuals in dermatology clinical trials.

Hidradenitis suppurativa in Black and White patients - a clinical study

OBJECTIVE

It is suggested that hidradenitis suppurativa (HS) is more prevalent and causes greater morbidity in Black patients than in White. Clinical data are however lacking.

PATIENTS AND METHODS

We therefore describe HS risk factors, disease severity and clinical phenotypes in the Blacks and Whites. Patients referred for HS between 1984 and 2019 at the Johns Hopkins Hospital were identified using the Pathology Data System (PDS). Clinical and sociodemographic characteristics were extracted and the van der Zee & Jemec HS clinical phenotypes were recovered.

RESULTS

A total of 278 patients were identified. Ethnically, 108 (38.8%) were White, and 170 (61.2%) Black. The following HS phenotypes were found: Regular (n=193, 69.4%), scarring folliculitis (n=40, 1.4%) frictional furuncle (11.2%), conglobata (n=9, 3.2%), syndromic (n=3, 1.1%) and ectopic (n=2, 0.7%). No statistically significant ethnic differences in clinical presentation were found. Blacks however had more severe diseases than Whites (p= 0.024 for trend). With multivariate logistic regression analysis, we found that male sex, disease duration, and smoking were independent predictors of regular HS phenotype. Major limitations are the limited number of cases studied and the lack of data regarding response to therapies.

CONCLUSIONS

Demographics and phenotypical presentation of HS patients do not seem to be associated with Black ethnicity. However, there is a significant trend for Blacks to present with more Hurley stage 2 and 3 disease compared to White patients. It is speculated that ethnic differences are epiphenomena to social factors, highlighting the broader importance of ethnicity.

Premedical Student Interest in and Exposure to Dermatology at Howard University

We conducted a cross-sectional survey study of premedical undergraduate students at Howard University (Washington, DC), to evaluate the level of interest that underrepresented in medicine (UiM) premedical students have in the field of dermatology. The 19-question survey assessed student knowledge, opinions, and exposure to dermatology. Dermatology is an area of great interest for UiM premedical students that has few avenues available for exposure and learning. In dermatologic care, race-concordant mentoring is highly valued by UiM premedical students. Increased shadowing, research, and general events geared to dermatology could help improve the disparity between UiM interest in dermatology and actualizing the goal of becoming a dermatologist.

Neutralizing Anti‒DNase 1 and ‒DNase 1L3 Antibodies Impair Neutrophil Extracellular Traps Degradation in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a debilitating inflammatory skin disorder characterized by abscess-like nodules and boils resulting in fistulas and tissue scarring. We previously reported evidence of an autoimmune signature in HS, characterized by enhanced neutrophil extracellular trap (NET) infiltration in HS skin lesions and dysregulation of the adaptive immune system characterized by the presence of autoantibodies. Timely removal of NETs is critical for tissue homeostasis to prevent a dysregulated generation of modified autoantigens and tissue damage. DNases 1 and 1L3 play important roles in proper NET removal. We tested the hypothesis that NETs in patients with HS are not effectively cleared owing to the presence of antibodies against DNase 1 and DNase 1L3. We report that HS serum poorly degraded NETs. Addition of exogenous DNase 1 restored NET degradation capabilities in a subset of HS samples. DNase 1 activity was significantly decreased in HS sera. Anti‒DNase 1 and ‒DNase 1L3 antibodies were detected in serum samples and skin lesions from patients with HS. Purified IgGs from HS decreased DNase 1 activity and NET degradation. Taken together, this identification of neutralizing antibodies against nucleases in HS expands the understanding of the pathogenesis of this disease to support an autoimmune mechanism in its underlying pathogenesis.

Histopathology of Hidradenitis Suppurativa: A Systematic Review

Hidradenitis suppurativa (HS) is a chronic inflammatory scarring disease felt to be related to occlusion of the hair follicle unit in intertriginous areas. We perform a systematic review on HS histopathology to evaluate current knowledge and discuss future directions. PubMed and Scopus databases were searched for relevant articles published from January 1985 to January 2021 that discussed the pathology of HS. Additional articles were identified by hand-searching, which entailed manually scanning selected journals. A total of 355 citations were identified in the primary search within the main databases. Two hundred and seventy-nine articles were excluded after a review of titles, abstracts, and duplicates. Sixty-one studies did not meet the inclusion criteria or were found to be duplicates, resulting in a total of 15 articles for analysis. Three articles were hand-searched. This comprehensive systematic review of the histopathology of HS confirms a high prevalence of follicular occlusion, follicular hyperkeratosis, and hyperplasia of the follicular epithelium. These findings support the central role of follicular occlusion in the development and progression of HS while providing a potential path to directing therapeutics against follicular occlusion.

Geospatial Heterogeneity of Hidradenitis Suppurativa Searches in the United States: Infodemiology Study of Google Search Data

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Biomarkers of Tretinoin Precursors and Tretinoin Efficacy in Patients With Moderate to Severe Facial Photodamage: A Randomized Clinical Trial

Importance

Topical formulations of tretinoin precursors (retinol and its ester derivatives) are widely available over the counter and may offer similar clinical benefits to those of tretinoin for treatment of photoaging. However, which of the many purported molecular effects of retinoids most strongly drives clinical improvements in tretinoin-treated skin remains unclear.

Objectives

To evaluate the clinical efficacy of topical tretinoin precursors (TTP) vs tretinoin (RA) in treating moderate to severe facial photodamage and to identify potential biomarkers that correlate with clinical efficacy.

Design, Setting, and Participants

This randomized, double-blind, single-center, parallel-arm study of 24 patients with moderate to severe facial photodamage was conducted at an academic referral center from November 2010 to December 2011, with data analysis performed from January 2012 to December 2021.

Interventions

Daily topical application of 0.02% RA or 1.1% TTP formulation containing retinol, retinyl acetate, and retinyl palmitate for 24 weeks.

Main Outcomes and Measures

Photoaging and tolerability were assessed by dermatologist evaluations and patient-reported outcomes. Target gene expression was assessed by real-time quantitative polymerase chain reaction of biopsied tissue from treated areas.

Results

A total of 20 White women were ultimately analyzed (9 randomized to TTP, 11 randomized to RA). At week 24, there was no significant difference in Griffiths photoaging scores among patients receiving TTP vs RA (median, 4 vs 5) (TTP - RA difference: -1; 95% CI, -2 to 1; P = .27). Treatment with TTP was associated with erythema 6 times less frequently than RA (11% vs 64%) (TTP - RA difference: -0.53; 95% CI, -0.88 to -0.17; P = .01). Target gene analysis showed significant CRABP2 messenger RNA (mRNA) induction (confirming retinoic acid receptor signaling) but no significant changes in procollagen I or MMP1/3/9 mRNA in TTP-treated samples. Instead, MMP2 mRNA, which encodes a type IV collagenase, was significantly reduced in TTP-treated samples (week 24 - baseline mRNA difference: -5; 96% CI, -33 to 1.6; P = .02), and changes in MMP2 were strongly correlated with changes in fine wrinkles (r = 0.54; 95% CI, 0.12 to 0.80; P = .01). Interestingly, patients with severe baseline wrinkles exhibited greater improvements (r = -0.74; 95% CI, -0.89 to -0.43; P < .001). This trend was mirrored in MMP2 mRNA, with initial expression strongly predicting subsequent changes (r = -0.78; 95% CI, -0.89 to -0.43; P < .001).

Conclusions and Relevance

In this randomized clinical trial, there was no significant difference in efficacy between this particular formulation of TTP and tretinoin 0.02%. However, the results of these mechanistic studies highlight MMP2 as a possible mediator of retinoid efficacy in photoaging.

Trial Registration

ClinicalTrials.gov Identifier: NCT01283464.

Metastatic Acral lentiginous melanoma: A case report and review

Of the four subtypes of cutaneous melanoma, acral lentiginous melanoma (ALM) is atypical in its presentation. ALM is a rare melanoma subtype that presents on the volar surfaces of the hand and foot. The difficulty of making an early diagnosis of ALM is highlighted by the case seen in our institution. The dire prognosis associated with ALM is postulated to be not only related to its destructive nature, but also due to a lack of patient awareness and vigilance, inadequate physician awareness, and disparity in healthcare access. We present this as a unique account of an ALM lesion in a 76 year old African-American male presenting originally in the left foot that went misdiagnosed for several years. The original lesion was considered to be an ulcerating left great toe lesion with signs typical of osteomyelitis. These clinical findings were corroborated by radiological x-ray evidence. Upon amputation and biopsy for suspected worsening osteomyelitis five years later, the pathological diagnosis of melanoma was finally made.

What's Race Got to Do With It? CRP Levels in Immune Mediated Skin Diseases: Considerations for Hidradenitis Suppurativa

Currently, there is a lack of racial/ethnic heterogeneity in research databases, exposing a systematic issue in studies exploring inflammation-mediated diseases, such as hidradenitis suppurativa (HS). HS is a chronic inflammatory skin condition that disrupts normal structure and functioning of terminal hair follicles, resulting in the formation of recurrent abscesses, nodules, and sinus tracts within intertriginous regions. Studies have described higher serum levels of inflammation-mediated C-reactive protein (CRP) in patients with HS, a disease that predominantly affects skin of color (SOC) populations. Herein, we explore the role of CRP levels in the context of HS disease presentation, management, and psychosocial implications in SOC patients to determine existing disparities in research studies.

Diagnostic accuracy of a rapid diagnostic test for the early detection of COVID-19

OBJECTIVES

This study was undertaken to evaluate the diagnostic performance of the BinaxNOW COVID-19 Ag Card rapid antigen assay (Abbott; Chicago, IL, USA) in the detection of COVID-19 infection compared to the reference standard of PCR testing.

METHODS

We evaluated the BinaxNOW COVID-19 Ag Card rapid antigen assay relative to a standard reference PCR test. We tested 3810 nasal swabs from symptomatic and asymptomatic adults undergoing surveillance COVID-19 testing at Howard University using one swab for each nostril. One swab was tested using the rapid antigen assay and the other using the PCR test.

RESULTS

The sensitivity of the BinaxNOW COVID-19 Ag Card rapid antigen assay was 91.84% (95% confidence interval (CI): 80.40-97.73%) and the specificity was 99.95% (95% CI: 99.81-99.99%). The range of Ct values for the N gene was 10.74-34.90 (M = 26.88, SD=4.86). Fourteen (28.6%) samples had an N gene Ct value > 30. The average N gene Ct value for rapid test negative (i.e. false negative) samples was 31.92.

CONCLUSIONS

The sensitivity of the test in our symptomatic and asymptomatic cohort was lower than the manufacturer's reported sensitivity in a symptomatic cohort (97.1%). Despite their relatively lower sensitivity (especially in asymptomatic individuals), rapid tests have undeniable benefits (i.e., ease of use and rapid results) that make them a helpful tool in the control of the SARS-CoV-2 pandemic. Given the diagnostic accuracy of these tests as evidenced by this study, rapid tests can be thoughtfully employed in situations where swift results are critical.

Bonds and bridges: the role of social capital in building a more diverse dermatology workforce

Several calls to action have been made in response to the lack of racial diversity in dermatology, but we have yet to explore how differences in social capital perpetuate homogeneity in dermatology training programs and the workforce. Herein, the concept of social capital is applied to this problem in dermatology and is used as a scaffold to suggest interventions that may ameliorate the systemic barriers faced by underrepresented-in-medicine (UIM) students.

A Pediatric Case of Transformed Mycosis Fungoides in a BRCA2 Positive Patient

Cutaneous T-cell lymphomas are very rare in children. Although mycosis fungoides is the most common of these rare cutaneous T-cell lymphomas in children, transformation to an aggressive malignancy remains extremely uncommon, and there are no clear guidelines for clinical management in the pediatric population. In addition, the increased usage of next-generation sequencing for pediatric patients with unusual malignancies may result in the discovery of pathogenic germline mutations, though the association between these mutations and the patient's cancer is not always clear. We present here a unique pediatric case of transformed mycosis fungoides in a patient with BRCA2 mutation.

Neutrophil extracellular traps, B cells, and type I interferons contribute to immune dysregulation in hidradenitis suppurativa

Hidradenitis suppurativa (HS), also known as acne inversa, is an incapacitating skin disorder of unknown etiology manifested as abscess-like nodules and boils resulting in fistulas and tissue scarring as it progresses. Given that neutrophils are the predominant leukocyte infiltrate in HS lesions, the role of neutrophil extracellular traps (NETs) in the induction of local and systemic immune dysregulation in this disease was examined. Immunofluorescence microscopy was performed in HS lesions and detected the prominent presence of NETs. NET complexes correlated with disease severity, as measured by Hurley staging. Neutrophils from the peripheral blood of patients with HS peripheral also displayed enhanced spontaneous NET formation when compared to healthy control neutrophils. Sera from patients recognized antigens present in NETs and harbored increased antibodies reactive to citrullinated peptides. B cell dysregulation, as evidenced by elevated plasma cells and IgG, was observed in the circulation and skin from patients with HS. Peptidylarginine deiminases (PADs) 1 to 4, enzymes involved in citrullination, were differentially expressed in HS skin, when compared to controls, in association with enhanced tissue citrullination. NETs in HS skin coexisted with plasmacytoid dendritic cells, in association with a type I interferon (IFN) gene signature. Enhanced NET formation and immune responses to neutrophil and NET-related antigens may promote immune dysregulation and contribute to inflammation. This, along with evidence of up-regulation of the type I IFN pathway in HS skin, suggests that the innate immune system may play important pathogenic roles in this disease.

Specimen Collection for Translational Studies in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder characterized by painful nodules, sinus tracts, and scars occurring predominantly in intertriginous regions. The prevalence of HS is currently 0.053-4%, with a predominance in African-American women and has been linked to low socioeconomic status. The majority of the reported literature is  retrospective, population based, epidemiologic studies. In this regard, there is a need to establish a repository of biospecimens, which represent appropriate gender and racial demographics amongst HS patients. These efforts will diminish knowledge gaps in understanding the disease pathophysiology. Hence, we sought to outline a step-by-step protocol detailing how we established our HS biobank to facilitate the formation of other HS tissue banks. Equipping researchers with carefully detailed processes for collection of HS specimens would accelerate the accumulation of well-organized human biological material. Over time, the scientific community will have access to a broad range of HS tissue biospecimens, ultimately leading to more rigorous basic and translational research. Moreover, an improved understanding of the pathophysiology is necessary for the discovery of novel therapies for this debilitating disease. We aim to provide high impact translational research methodology for cutaneous biology research and foster multidisciplinary collaboration and advancement of our understanding of cutaneous diseases.

Lessons learned from the development of a hidradenitis suppurativa xenograft mouse model

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease originating from the pilosebaceous unit, in which patients develop painful abscesses, sinus tracts, nodules and scarring, typically in intertriginous areas. Major gaps in our understanding of HS exist, and these may be partially due to the lack of an animal model for experimental studies. We developed an HS xenograft mouse model using human HS lesions grafted onto immunocompromised mice. Although the model had its limitations, several informative lessons were learned, which may contribute to future attempts at an HS animal model.

Chronological Aging in African-American Skin: A Reliable Photonumeric Scale Demonstrates Age and Body Mass Index as Contributing Factors

BACKGROUND

Increased photoprotection by natural melanin allows for African-Americans to be less impacted by photoaging than Caucasians. However, less is known about chronological aging in this population.

OBJECTIVE

To create a photonumeric scale for African-Americans to evaluate chronological skin aging and to explore contributing elements to intrinsic aging.

METHODS

Standardized photographs of the upper inner arm were taken from 75 African-American participants. Five participants were chosen as standards to create a 9-point photonumeric scale (0 = none, 8 = most severe). The scale was utilized by three blinded dermatologists to independently rate participants' photographs.

RESULTS

The interrater agreements were 0.768 (95% CI: 0.671-0.834) for trial 1 and 0.725 (0.608-0.794) for trial 2. The intrarater agreements were 0.757 (0.596-0.875), 0.850 (0.771-0.903), and 0.790 (0.686-0.855) for the three raters. Averaged chronological aging scores were correlated with participants' survey responses, which revealed age as a significant predictor (r = 0.72, p < 0.001).

LIMITATION

Our study was limited by the sample size, although the number of study participants was similar on a investigation in Caucasians.

CONCLUSION

This study created the first reliable photonumeric scale for chronologic skin aging in African-Americans and found increased age and greater BMI as contributors to intrinsic skin aging phenotype in this population.

Thalidomide for the treatment of chronic refractory prurigo nodularis

Prurigo nodularis (PN) is a highly pruritic skin condition that is caused by chronic scratching. It occurs in patients with chronic itch and is characterized by multiple hyperkeratotic papules and nodules. The pathogenesis of PN is unclear, but involves a complex interplay of numerous pathways including neurogenic and inflammatory factors. As such, PN is very difficult to treat and patients are often refractory to multiple medications before finding a treatment that is effective. We present a woman with a 20-year history of exuberant prurigo nodularis who failed multiple therapies, including dapsone, azathioprine, mycophenolic acid, prednisone, topical steroids, and phototherapy. She only obtained significant relief of chronic pruritus and lesion flattening with thalidomide 100mg daily. Thalidomide is an antipruritic and anti-inflammatory agent that has shown to be very effective in treating a variety of dermatologic conditions. However, its use today is limited by concerns for its teratogenic and neuropathic side effects. With strict adherence to medication protocols, these adverse effects can be minimized. As such, thalidomide should be considered for patients with refractory dermatologic conditions.

Effect of Age, Gender, and Sun Exposure on Ethnic Skin Photoaging: Evidence Gathered Using a New Photonumeric Scale

BACKGROUND

African-Americans are less affected by photoaging than lighter skin individuals. Although scales for photoaging have been developed for Caucasians and Asians, no scale exists for African-Americans.

AIM

To develop a photonumeric scale for photoaging and to determine factors that contribute to photoaging in African-Americans.

METHODS

Five participants' photographs were selected as standards to create a 9-point photonumeric scale (0 = none, 8 = most severe). Three blinded dermatologists used the scale to grade the remaining participants' photographs.

RESULTS

Interrater reliabilities were 0.775 (95% CI: 0.635, 0.880) for trial 1 and 0.832 (0.747, 0.883) for trial 2. Intrarater reliabilities, assessed over a 1 week interval, were 0.863 (0.727, 0.940), 0.928 (0.890, 0.954), and 0.866 (0.739, 0.935) for the three graders, indicating strong agreement. Photoaging scores were then correlated with participants' survey on lifestyle factors, which yielded age as a significant predictor (r = 0.91, p < 0.001). Furthermore, multiple regression model to predict facial photoaging (adjusted R² = 0.849) selected age (b₁ = 0.111, p < 0.001), sun exposure (b₂ = 0.206, p = 0.014), and gender (b₂ = -0.388, p = 0.063) as the most important variables.

CONCLUSIONS

A reliable photonumeric scale for photoaging in African Americans was developed. Age, sun exposure, and male gender were found to be contributory factors to photoaging.

Patient-provider communication, concordance, and ratings of care in dermatology: Results of a cross-sectional study

ObjectiveTo determine the impact of race concordance on patient perception of quality of dermatologic care.Study designCross-sectional study.SettingAcademic outpatient practices in the Departments of Dermatology of Eastern Virginia Medical School and the Johns Hopkins University School of Medicine.ParticipantsThe study cohort comprised 124 participants including 6 providers and 118 established patients.Main Outcome MeasuresWe hypothesized, a priori, that patients in race-discordant dyads would report lower ratings of participatory decision-making (PDM), satisfaction, trust in the provider, and similarities with providers.ResultsPatients in race-discordant dyads reported less positive ratings on 4 out of 8 participatory decision-making questionnaire items (p values &lt; 0.05), and were significantly more likely to perceive differences with providers in race and culture (p values &lt; 0.05). These differences persisted to varying degrees after controlling for key confounders such as education and income level. Participants in race-concordant and race-discordant dyads did not differ in their perceptions of satisfaction or trust.ConclusionsPatient perception of participation in the decision-making process and of shared similarities with their providers is attributable in varying degrees to race concordance. Continued strengthening of cultural competency skills during medical and dermatology residency training as well as increased diversification of the dermatologic workforce could attenuate the adverse influences of race discordance and other socioeconomic factors on patient-provider communication.

Squamous cell carcinoma complicating a chronic lesion of hidradenitis suppurativa: a case report and review of the literature

Squamous cell carcinoma (SCC) arising from chronic hidradenitis suppurativa (HS) is rare; however, the morbidity associated with this presentation is high and management has not been standardised or optimised. We present a case of HS of the perineum and buttocks complicated by SCC, requiring multiple extensive surgical resections. Adjuvant radiotherapy was withheld initially because of concern for poor healing of the surgical wound but was eventually initiated after a second recurrence was identified. The patient ultimately expired 4 years after the initial diagnosis of SCC. We also review 80 cases of SCC complicating HS found in the English literature. Case reports and mechanistic studies suggest the possibility that human papilloma virus and smoking may be risk factors associated with SCC in HS. Despite the majority of SCC cases being well-differentiated tumours in HS, the highly aggressive nature of SCC in HS and its high likelihood for rapid progression, recurrence, metastasis and high mortality suggests the need to advocate for aggressive treatment. We recommend an aggressive approach to management at the time of SCC diagnosis in HS, which includes appropriate imaging to establish the extent of the tumour, large and deep surgical excision, sentinel lymph node evaluation, consultation with radiation oncology for potential adjuvant radiation therapy and close surveillance.