Clinical characteristics of pediatric hidradenitis suppurativa: a cross-sectional multicenter study of 140 patients

Hidradenitis suppurativa in children and young adults: a retrospective cross-sectional observational study in the United Kingdom

BACKGROUND

Hidradenitis suppurativa (HS) in children and young adults (CYA) (<18 years) is uncommon. No previous observational studies have been carried out in a UK CYA HS population.

METHODS

This study was based on retrospective case note reviews of CYA HS patients attending tertiary-level care in the CYA HS service in a UK hospital. Patients <18 years old with a known diagnosis of HS were screened for inclusion. Exclusion criteria were those with less than one follow-up appointment.

RESULTS

Twenty-eight CYA HS patients were identified, with an M:F ratio of 1:8.3. Mean BMI was 25.2 (SD: 7.6). 17 (61%) of cases had a relevant family history. Long-term antibiotic monotherapy was the most common treatment initiated. Lymecycline was the most commonly prescribed antibiotic, accounting for 23 (56%) of the 41 courses prescribed. Additional treatments initiated included dual therapy with rifampicin and clindamycin, isotretinoin, and adalimumab, which were more commonly prescribed in patients with Hurley Stage II or III.

CONCLUSIONS

This group had a female predominance with an apparent strong genetic predisposition which is seen in other HS CYA cross-sectional research. Treatment was varied in this cohort, however long courses of antibiotics, including combined therapy with rifampicin and clindamycin, were the mainstay of treatment, similar to management in the adult population. This study therefore adds to the limited information on the demographics and management of the HS CYA population.

A Retrospective Review of Laser Therapy for Treatment of Hidradenitis Suppurativa

PURPOSE

Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by painful and foul-smelling cystic nodules and sinus tracts in the apocrine gland-bearing regions. The treatment options include topical, intralesional, systemic, and surgical modalities. Currently, the most novel therapy is laser therapy to provide localized treatment without systemic adverse effects. However, data regarding patient outcomes after laser treatment are limited because of the low prevalence of this disease. This study aimed to evaluate the efficacy of laser therapy as a treatment modality for patients with HS.

METHODS

A retrospective review cohort analysis of patients with HS undergoing laser treatment between 2016 and 2021 was conducted. Patient demographics, lesion location(s), Hurley stage, age of onset and diagnosis, treatment length, type, outcomes, and complications were analyzed.

RESULTS

Ninety-four patients met the inclusion criteria; on average, patients were treated with 5.8 laser sessions for 14.8 months with no complications and minor blood loss. Hidradenitis suppurativa progression commonly starts during puberty, with a median onset of 13.8 years and diagnosis of HS at 16.2 years. All patients (n = 94) showed an improvement in HS disease severity: 59.6% completed treatment, 12.0% are currently undergoing treatment, and 26.0% were lost to follow-up.

CONCLUSIONS

Laser therapy is an effective and safe therapy for HS leading to improved quality of life and should be considered in the treatment and management of HS.

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

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

Expert consensus on priority research gaps in dietary and lifestyle factors in hidradenitis suppurativa: a Delphi consensus study

Hidradenitis suppurativa (HS) is a debilitating systemic inflammatory disease with limited treatment options. Although management through dietary and lifestyle changes is a primary interest of the HS patient community, there is lack of consensus regarding recommendations due to the paucity of evidence. To establish the priority research gaps on this topic, we performed and moderated a Delphi consensus study by integrating expert opinions and the relevant literature. Based on a literature review, research questions on dietary and lifestyle interventions in HS were constructed. HS dietary and lifestyle research questions were sent to an expert panel, consisting of 22 international members, including dermatologists, dietitians, pharmacists, and endocrinologists. Voting on the research questions was conducted using a modified Delphi technique. The primary outcome measure was whether participants could reach consensus on the priority of each research question in the HS dietary and lifestyle factors. After three rounds of surveys investigating the relationships between HS and various diet and lifestyle factors, "BMI", "Obesity", and "Smoking", reached consensus as high priority research questions. Low research priorities per consensus included "effects of iron supplements", "effects of magnesium supplements", "alcohol consumption" and "limiting Brewer's yeast intake. Smoking and obesity were identified as important research questions, concurrent to the literature indicating their association with more significant impact on disease activity. By shedding light on high priority research questions, our study provides a roadmap for further research on dietary and lifestyle modifications in HS and will help determine evidence-based lifestyle and dietary recommendations for patients with HS.

Evaluation of Hidradenitis Suppurativa Diagnostic Criteria in Pediatric Patients

Importance

Hidradenitis suppurativa (HS) is associated with considerable diagnostic delay. Although most patients report adolescent onset, existing HS diagnostic criteria may not adequately capture disease in pediatric populations.

Objectives

To determine the proportion of physician-diagnosed pediatric patients with HS who met diagnostic criteria, and describe demographics, disease characteristics, and diagnostic patterns among pediatric patients with HS.

Design, Setting, and Participants

In this retrospective, cross-sectional study, electronic medical records from 2 sites of a single academic tertiary care center were included. Eligible patients were those born after January 1, 1993, and assigned International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/10) codes for HS (ICD-9 705.83/ICD-10 L73.2) between January 1, 2012, and July 1, 2021. Patients were excluded if they were older than 18 years at diagnosis, had inaccessible diagnostic visit notes, or were unintentionally assigned an HS ICD code.

Exposures

Pediatric patients with HS.

Main Outcomes and Measures

Fulfillment of diagnostic criteria in pediatric patients with HS.

Results

A total of 297 adolescents with HS were included in the study; 123 patients were female (78.1%), 78 self-identified as Black (26.3%), and 116 self-identified as Hispanic (39.1%). The median (IQR) age at diagnosis was 14.0 (13.0-16.0) years. Documentation from the diagnostic visit demonstrated that 127 (42.8%) patients did not meet all 3 major HS diagnostic criteria. Of these patients, 122 (96.1%) did not meet the recurrence interval criterion (≥2 lesions within 6 months). Overall, 96 patients who did not meet the recurrence interval criterion had documentation from additional visits in the health system; 59 (61.5%) had documentation of 1 or more additional lesions consistent with HS. Review of these additional records demonstrated that 26 of these 59 (44.1%) patients met the recurrence interval criterion after diagnosis, and 44 (74.6%) had recurrent lesions within a 1-year interval (median, 6.5 months; interquartile range, 3.5-12.2 months). Medical chart review was conducted from November 22, 2021, to January 12, 2022. Analysis was conducted from January 12, 2022, to January 15, 2022.

Conclusions and Relevance

Overall, 118 (40%) of 297 pediatric patients with HS in this retrospective cross-sectional study did not meet all major diagnostic criteria at the time of diagnosis, largely due to failure to fulfill the 6-month recurrence interval criterion. Future studies are needed to determine the appropriate recurrence interval to facilitate timely diagnosis and promote clinical trial eligibility for pediatric patients with HS.

A cross-sectional study of pediatric hidradenitis suppurativa and the value of the International Hidradenitis Suppurativa Severity Score System (IHS4) as a pediatric clinical trial inclusion criteria

BACKGROUND

Hidradenitis suppurativa (HS) often develops in pediatrics, but few interventional studies include pediatric patients.

OBJECTIVES

This dual analysis of a pediatric HS cohort and typical eligibility criteria in adult trials aims to identify potential patient characteristics and inclusion criteria for future pediatric HS studies.

METHODS

This cross-sectional and descriptive study is based on a prospectively collected data registry from an HS clinic. We also queried 125 HS studies from the Clinicaltrials.gov database and information from 61 interventional systemic HS drug trials was analyzed.

RESULTS

The mean abscess and inflammatory nodule (AN) count in 81 pediatric subjects was 2.3 compared to 5.0 in adults with majority being Hurley stage I (39.5%, 32/81) or II (55.6%, 45/81). Most clinical trials required patients to be Hurley stage II/III with AN count of ≥3.

CONCLUSION

When developing clinical trials for pediatric HS, it is imperative to consider how baseline characteristics impact recruitment and disease assessment. Frequently used eligibility criteria in adult trials may severely limit pediatric recruitment. Although our registry had a large adult sample size, the main limitation of this study was the relatively smaller pediatric sample size.

Diagnosing and Managing Hidradenitis Suppurativa in Pediatrics

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

Features of Common Skin Disorders in Pediatric Patients with Skin of Color

Many dermatologic conditions common in the pediatric population may have unique presentations in skin of color or occur with greater incidence. This may be due to ethnic origin, socioeconomic factors, or other influences. Awareness of the potential variations in skin of color may enhance prompt diagnosis, appropriate treatment, and/or reassurance as indicated.

Pediatric Hidradenitis Suppurativa: A Cross-Sectional Study on Clinical Features and Treatment Approaches

BACKGROUND

Hidradenitis suppurativa is uncommon in patients of pediatric age, and differentiation with adult-onset disease is controversial. Treatment of pediatric hidradenitis suppurativa is scarcely standardized, and specific guidelines are lacking.

OBJECTIVE

We report the clinical features, relevant risk-factors, comorbidity profile, and treatment patterns of a hospital-based cohort of pediatric hidradenitis suppurativa.

METHODS

In a cross-sectional study data on patients' demographics, disease-specific characteristics, early/pre-pubertal onset of disease, comorbidities, and treatment management were retrieved. Reference population data and clinical data from the national hidradenitis suppurativa disease registry were used for comparison.

RESULTS

From a database of 870 patients with hidradenitis, 71 (15 males and 56 females) patients aged <18 years (mean age: 15.3 years; range 8-17 years), with mild (Hurley I, 45.1%) and moderate-severe disease (Hurley II-III, 54.9%), were retrieved. Smoking (23.9%) and overweight/obese frequencies (59.2%) were higher than reference population standards. Patient's older age at baseline (OR 1.43, 95% CI: 1.01 to 2.02) and higher BMI (OR 1.26, 95% CI: 1.07-1.48) were the only factors associated with moderate-severe disease. Family history and early/pre-pubertal onset of disease were not associated with severity or extent of disease. Sebaceous-follicular comorbid conditions were associated with cigarette smoking (P = .002). Among 81 treatment courses, clindamycin-based and zinc-sulphate-based combination regimens were most frequently used (59.3%). Female preponderance, family history of disease and extensive involvement were significantly different from the general hidradenitis suppurativa population.

CONCLUSIONS

Pediatric hidradenitis suppurativa presents a clinical spectrum comparable to adult-onset disease. Increased preventive measures should target obesity and smoking in this population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Physical and psychosocial comorbidities of pediatric hidradenitis suppurativa: A retrospective analysis

BACKGROUND/OBJECTIVES

Hidradenitis suppurativa (HS) is understudied in the pediatric population. Adult HS patients are known to have a high comorbidity burden. We aimed to describe physical and psychosocial comorbidities in a cohort of pediatric HS patients.

METHODS

A retrospective chart review of pediatric HS patients at a single academic institution was conducted. Data on patient demographics, disease characteristics, and physical and psychosocial comorbidities in pediatric patients with HS were collected and analyzed.

RESULTS

Seventy-three pediatric patients were included in this study, 81% female. Mean (SD) age of HS disease onset was 12.6 (2.9) years. Comorbid conditions were reported in 68 of 73 (93%) patients. Significantly increased rates of several comorbidities were seen in our cohort as compared to the general US pediatric population. Metabolic and endocrine abnormalities were prevalent, with 52% (22/42) patients with obesity and 10% (6/59) with polycystic ovary syndrome. The most common cutaneous comorbidity was acne vulgaris, seen in 37% (27/73) of patients. Over one quarter (21/73, 29%) of patients had either an anxiety or depression disorder. Almost one-fifth (14/73, 19%) of our cohort had a diagnosis of asthma and other reactive airway diseases. Only one-third (24/73, 33%) of patients had documentation regarding impact of HS on their daily life. Overall, comorbidities largely did not significantly differ based on race, gender, or disease severity.

CONCLUSIONS

Pediatric patients with HS face a high-comorbidity burden, especially with psychiatric conditions. Early identification, including routine mental health screening, and management of comorbidities is warranted in the pediatric HS population.

Differences Between Children and Adults With Hidradenitis Suppurativa

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Hidradenitis suppurativa in skin of colour

Hidradenitis suppurativa/acne inversa (HS) more prevalent and disproportionally affects African American females. Although there are limited studies in HS skin of colour populations in the USA, there is more scarcity of HS skin of colour studies in other countries, which limits the overall understanding of the disease among these patients. Herein, our overview of the 10th European Hidradenitis Suppurativa Foundation (EHSF) e.V. Conference provided a crude example of the limited number of skin of colour physicians, physician scientists and inclusion of skin of colour patients highlighting the need to increase awareness of this important issue. We summarized the epidemiology, pathogenesis, clinical picture and focused on treatment options from southeast Asia and Africa. Our outlined general recommendations for diagnosis will render better clinical care and outcomes for diverse patient populations.

Endocrinological disorders and inflammatory skin diseases during COVID-19 outbreak: a review of the literature

INTRODUCTION

In the next future, dermatologists, endocrinologist and physicians may cope with the impact of extent SARS-CoV-2 (COVID-19) infection over chronic inflammatory skin diseases and their treatment. COVID-19 pandemic obliged many countries to impose social restrictions, resulting in the need to adapt daily lifestyle habits and working activities. These changes have drastically reduced physical activity and social interactions, with the possible increase of anxiety, eating disorders and weight gain.

EVIDENCE ACQUISITION

We searched for relevant studies (trials, real-life studies and case reports, meta-analysis, pooled data analysis, reviews) on endocrine disorders and inflammatory skin diseases. The database used was PubMed. The studies included were those published in the English language between January 1, 2018 and May 5, 2020.

EVIDENCE SYNTHESIS

Several studies have been previously showed the association of overweight and obesity, with the metabolic syndrome and insulin-resistance. It has been demonstrated how these conditions correlate with the worsening of such chronic inflammatory skin diseases, such as psoriasis, hidradenitis suppurativa and acne. Many evidences suggest an important role of adipose tissue in the production of pro-inflammatory cytokines (Leptin, adiponectin, TNFα, IL-6, MCP-1, PAI-1), involved in the pathogenesis and the exacerbations of these skin diseases. In addition, we should expect an increasing incidence rate of hypovitaminosis D in the next future due to reduced sun exposure caused by isolation at home and missed holidays. Scientific evidences already show the important immunomodulating role of vitamin D in inflammatory skin diseases.

CONCLUSIONS

Our study pays attention on medium-long term effects of COVID-19 outbreak on inflammatory skin disorders, due to the lifestyle changes. In such context this review considers how a multidisciplinary approach, involving dermatologists, nutritionists and endocrinologists, may lead to a better management of dermatologic patients.

The most recent advances in understanding and managing hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent, and debilitating skin disease of the hair follicle unit that typically develops after puberty. HS has a significant negative impact on both the quality of life (QOL) of patients affected by this disease as well as family members and caregivers. However, the pathogenesis of HS is multifactorial and still remains to be fully elucidated, which makes the development of treatments difficult. The last 10 years have seen a surge in HS research, and many new findings have come to light, yet much more remains to be elucidated. Physicians must employ a multidisciplinary approach to maximally address all facets of HS. Clinical characteristics of the disease that differ between females and males as well as across different races and ethnic groups must be considered. Targeted topical, oral, and injectable therapies continue to be developed for HS as a greater understanding of the pathogenesis is reached. However, randomized controlled trials regarding dietary factors that may contribute to HS are needed to meet our patients’ growing concerns and questions about the role of diet in HS pathogenesis. Finally, improved outcome measures are needed to standardize HS severity and grading between physicians and clinical trials, and a more diverse representation of HS populations is needed in clinical trials.

Hidradenitis suppurativa in pediatric patients

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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