Pathogenesis and pharmacotherapy of Hidradenitis suppurativa

A history of asthma is associated with susceptibility to hidradenitis suppurativa: a population-based longitudinal study

The association of hidradenitis suppurativa (HS) and asthma remains to be investigated. To assess the bidirectional association between HS and asthma. A population-based study was conducted to compare HS patients (n = 6779) with age-, sex-, and ethnicity-matched control subjects (n = 33,259) with regard to the incidence of new onset and the prevalence of preexisting asthma. Adjusted hazard ratios (HRs) and adjusted odds ratios (ORs) were calculated. The prevalence of preexisting asthma was higher in patients with HS relative to controls (9.6% vs. 6.9%, respectively; P < 0.001). The odds of HS were 1.4-fold greater in patients with a history of asthma (fully adjusted OR 1.41; 95% CI 1.27-1.55; P < 0.001). The incidence rate of new-onset asthma was estimated at 9.0 (95% CI 6.3-12.7) and 6.2 (95% CI 5.1-7.5) cases per 10,000 person-years among patients with HS and controls, respectively. The risk of asthma was not statistically different in patients with HS and controls (fully adjusted HR 1.53; 95% CI 0.98-2.38; P = 0.062). Relative to other patients with HS, those with HS and comorbid asthma were younger at the onset of HS (30.7 [14.7] vs. 33.3 [15.1], respectively; P < 0.001) and had a comparable risk of all-cause mortality (adjusted HR 0.86; 95% CI 0.44-1.68; P = 0.660). A history of asthma confers susceptibility to subsequent development of HS. This observation is of importance for clinicians managing both patients with HS and asthma. Further research is warranted to elucidate the pathomechanism underlying this finding.

Is Exploration of Alternate Immune Pathways Needed in Hidradenitis Suppurativa? A Case of Atopic Dermatitis and Concurrent Hidradenitis Suppurativa Responding to Dupilumab

Hidradenitis suppurativa (HS) is an inflammatory dermatosis associated with overactive T helper 1/T helper 17 (Th1/Th17) cells. HS has been effectively treated with biologic medications; however, many such biologics lack large randomized controlled trials. Only one such biologic, adalimumab, has been approved by the US Food and Drug Administration (FDA) for the treatment of HS. Other such biologics currently being studied for HS downregulate Th1/Th17 inflammatory pathways. We describe a patient with atopic dermatitis (AD) and comorbid HS, both of which improved several months into treatment with dupilumab. Interestingly enough, dupilumab targets Th2-mediated inflammatory skin conditions through the inhibition of IL-4/IL-13 cytokines. While dupilumab is known for its success in treating Th2-mediated inflammation, this presents a paradox as HS is a Th1/Th17 inflammatory condition. This case highlights how the inflammatory process of HS is not fully understood and how biologic pharmacologic interventions need to be further studied to determine their efficacy in treating HS.

Axillary Hidradenitis Suppurativa: A Comparison between Two Perforator Flap Reconstructive Approaches after Radical Surgical Management

Background

Axillary hidradenitis suppurativa (HS) can result in significant functional impairment in both personal and professional lives. Stage 3 HS requires radical surgical treatment. Flap reconstruction allows for faster healing and better functional and aesthetic outcomes. We compared the results of thoracodorsal artery perforator (TDAP) and propeller inner arm artery perforator (IAAP) flap reconstructions after radical surgical treatment of axillary HS.

Methods

We conducted a retrospective study that included 13 consecutive patients who underwent stage 3 axillary HS treatment between August 2015 and January 2023. Seven patients underwent reconstruction by islanded TDAP flaps, whereas six patients underwent reconstruction by propeller IAAP flaps, with one patient undergoing bilateral reconstruction. The data collected from the patient records included age, gender, smoking status, body mass index, comorbidities, operative time, defect size, flap size, hospital stay, and complications.

Results

Although not statistically significant (P = 0.1923), a higher rate of flap complications is reported here with propeller IAAP flaps (42.86 %), whereas islanded TDAP flaps had no flap complications (0%). We found a statistically significant difference in operative time (P = 0.0006), defect size (P = 0.0064), and flap size (P = 0.0012) between the two groups. All patients exhibited satisfactory functional and aesthetic outcomes. Fourteen flaps were performed in total; only one case exhibited recurrence (7.14%).

Conclusion

After radical surgical management, both islanded TDAP and propeller IAAP flap reconstructions offer excellent outcomes for stage 3 axillary HS. We strongly encourage our peers to consider performing perforator flaps over secondary healing for these patients with a major functional impairment.

Pilonidal Sinus Disease is Associated with Severe Hidradenitis Suppurativa in a Spanish Cohort

Hidradenitis suppurativa is a chronic inflammatory disorder of the hair follicle with a high level of morbidity. Pilonidal sinus disease is a comorbid disorder and may be the reason for first contact with the healthcare system of patients with hidradenitis suppurativa. The aim of this study was to evaluate the frequency of association of pilonidal sinus disease and hidradenitis suppurativa and to explore whether pilonidal sinus disease defines a different clinical profile for patients with hidradenitis suppurativa. A cross-sectional study in which data regarding past history of pilonidal sinus disease, clinical and sociodemographic information were recorded during the first visit to the Hidradenitis Suppurativa Clinic of 2 tertiary hospitals. A total of 839 patients were included in the study. Of these, 51.7% (434/839) were male and mean age was 37.3 ± 13.6 years. Pilonidal sinus disease was present in 32.6% (269/839) of the patients and was associated with an early debut of hidradenitis suppurativa, a higher Hurley stage, inflammatory phenotype and a greater number of fistulas and perianal involvement. Elapsed time between pilonidal sinus disease and diagnosis of hidradenitis suppurativa was associated with higher disease severity. Pilonidal sinus disease is a frequent comorbidity and risk marker for hidradenitis suppurativa disease severity. Pilonidal sinus disease could be a sentinel event to identify patients who would benefit from close treatment and follow-up.

Hidradenitis Suppurativa: The Influence of Gender, the Importance of Trigger Factors and the Implications for Patient Habits

Hidradenitis suppurativa (HS) is a debilitating, chronic, inflammatory skin disease primarily affecting apocrine gland-rich areas of the body. On the one hand, the presence of triggering factors-some identified, others only hypothesized-may initiate or perpetuate the pathogenic process of HS. In addition to cigarette smoking and diet, other trigger factors, including choice of clothing, are frequently observed in clinical practice. On the other hand, the presence of disease may influence habits of HS patients. Indeed, high incidences of sexual and sleep impairment have been reported in these patients. Consequently, alcohol and substance abuse may be a coping strategy for the emotional and psychological disease burden. Furthermore, a greater awareness of gender differences in HS may be important for dermatologists in their own clinical practice (i.e., pregnancy and breastfeeding). Consequently, in this loop interaction, comprehensive knowledge of all factors involved is crucial for the management of HS patients. Thus, the objective of this review is to (i) discuss the influence of gender on HS, (ii) summarize the most frequent triggering factors of HS and (iii) analyze the impact of HS on patient habits.

Top 100 most-cited publications in hidradenitis suppurativa: An updated bibliometric analysis

Background

Over the last several decades, our understanding of hidradenitis suppurativa (HS) has improved considerably, thereby enhancing our ability to clinically diagnose and treat the disease.

Objective

The purpose of this study was to identify and analyze the top 100 most-cited publications related to HS to update bibliometric information on HS.

Materials and methods

We used the Web of Science database to identify reports on hidradenitis suppurativa. Data from the 100 most-cited publications were extracted and analyzed.

Results

The citation number of the top 100 most-cited articles was 89–532 (mean, 153.51), with the most productive periods being from years 2007 to 2016. Most publications originated from the British Journal of Dermatology and the Journal of the American Academy of Dermatology. The 100 articles originated from 18 countries, with Denmark being the most productive country, followed by the United States (17), England (14), and Germany (12). Jemec GB, from the University of Copenhagen, had 32 citations and was the most frequently identified author. The 100 articles encompassed several fields of research as follows: pathogenesis (18%), pathophysiology (7%), epidemiology (14%), clinical diagnosis and features (16%), treatment (25%), comorbidity (10%), and others (10%). In total, 11 reviews, three guidelines, and 86 original articles (nine randomized clinical trials) were included.

Conclusion

Through this bibliometric analysis, we aimed to indicate a series of intellectual landmark publications that offer us critical reviews, guidelines, and original articles, which highlight the immense level of progress achieved in the field of HS.

A systematic review and meta-analysis of sexual dysfunction in patients with hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition associated with significant psychosocial comorbidity. To date, the relationship between HS and sexual dysfunction has not been assessed through meta-analysis. A systematic review was performed by OVID Medline, EMBASE, Cochrane Central, PsycINFO via EBSCO, Web of Science, and LILACS. Original English language studies assessing HS and sexual function published prior to April 2020 were screened. Scores from the Female Sexual Function Index (FSFI), International Index of Erectile Function (IIEF), Arizona Sexual Experiences Scale (ASEX), Frankfurt Self-Concept Scale for Sexuality (FKKS SEX), and Dermatology Life Quality Index (DLQI) were analyzed. Sixteen studies met inclusion criteria, and nine were eligible for meta-analysis. Pooled mean FSFI score for female HS patients met criteria for sexual dysfunction (mean = 20.32, P < 0.001). Females with HS reported worse FSFI scores than controls (pooled mean difference = -5.704, P = 0.003, I² =0). Mean IIEF score among males with HS was 47.96 (P < 0.001). Males with HS also reported worse IIEF scores than controls (pooled mean difference = -18.77, P = 0.00, I²  = 0). Females with HS performed worse on sexual function inventories than males with HS (SMD = -0.72, P = 0.009, I²  = 0). Both male and female HS patients reported significantly more sexual impairment than same-sex controls. Female HS patients also experience more sexual impairment than males and on average meet criteria for sexual dysfunction (FSFI <26.55). Clinicians should be aware that their patients with HS, especially females, may be suffering from sexual dysfunction and treated them appropriately.

Quality of Life of Patients With Hidradenitis Suppurativa in Jeddah, Saudi Arabia

Background 

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that affects the apocrine gland-bearing areas of the body. It initially presents as painful nodules that eventually develop into abscesses, draining sinuses, and scarring. These manifestations have physical and psychological impacts, which lead to poor quality of life. This study examined the association between quality of life and disease severity, as well as identified the areas of the body most affected by HS among patients in Saudi Arabia.

Methods

This cross-sectional study examined patients with HS who were seen at two dermatology outpatient clinics between December 2018 and March 2019. The patients completed a self-administered standardized questionnaire on the Dermatology Life Quality Index (DLQI).

Results

The average DLQI score was 15.39 ± 8.37. The majority of patients were classified as stage 3, which indicated that HS has a very large effect on quality of life. The right and left axillae were the most commonly affected areas of the body, with 80.6% of patients noting involvement. While the mean DLQI score was higher in males compared to females, there was no significant difference between the two groups (16.44 ± 9.01 vs. 13.08 ± 6.65; P = 0.248).

Conclusion

HS caused significant impairment in the quality of life of patients with HS in Saudi Arabia. The mean DLQI score in our study was higher than the score previously reported in the literature. Further studies may identify opportunities to provide additional awareness, care, and support for patients with HS in Saudi Arabia.

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.

Metabolic Disorders/Obesity Is a Primary Risk Factor in Hidradenitis Suppurativa: An Immunohistochemical Real-World Approach

BACKGROUND

Hidradenitis suppurativa (HS) is an inflammatory, potentially scarring disease of the hair follicle, affecting the apocrine gland-bearing skin areas. The major comorbid disorders associated with the occurrence or the aggravation of the disease are obesity and smoking. Numerous efforts to dissociate these factors led to controversial results.

OBJECTIVES

To assess the importance of metabolic disorders/obesity, smoking/environmental toxins, and inflammation in HS by utilizing the differential expression of major relevant protein markers in lesional skin of obese/smoking versus non-obese/non-smoking HS patients.

METHODS

Lesional skin specimens deriving from two groups of HS patients (BMI >30 and smokers, n = 12 vs. BMI <30 and non-smokers, n = 10) were stained with antibodies raised against irisin, PPARγ, and IGF-1R, which correlate with metabolic disorders/obesity, EGFR and AhR, associated with smoking, and IL-17, IL-17R, and S100A8, as markers of inflammation.

RESULTS

Metabolic disorders/obesity-related markers exhibited marked differential expression between the two groups, while smoking-associated markers a limited one. IL-17R expression was stronger in obese/smokers, and S100A8 staining exhibited intense strong immunoreactivity in both groups without significant difference.

CONCLUSIONS

The notion that obesity plays a role in HS development appears to be supported by the prominent regulation of the associated lesional biomarkers. Tobacco smoking might contribute less to HS than previously suspected.

Baseline Characteristics of a National French E-Cohort of Hidradenitis Suppurativa in ComPaRe and Comparison with Other Large Hidradenitis Suppurativa Cohorts

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition substantially impacting patients' quality of life; the pathogenesis remains unclear, and treatment is complex and not yet standardized. Observational data are increasingly being used to evaluate therapeutics in "real-life" interventions, and the development of e-cohorts is offering new tools for epidemiological studies at the population level.

OBJECTIVE

The aim of this study was to describe the clinical characteristics and treatment history of HS participants in the Community of Patients for Research (ComPaRe) cohort and to compare these to other cohorts.

METHODS

We performed a cross-sectional study of the baseline data of HS participants in ComPaRe, an e-cohort of patients with chronic diseases. Data were collected using patient-reported questionnaires about clinical-dem-ographic aspects, quality of life, and treatment history.

RESULTS

A total of 396 participants (339 females, 57 males) were included (mean age 38 years); 83 (21%) had a family history of HS, 227 (57.3%) were current smokers, and 241 (60.9%) were overweight or obese. Most of the participants declared a Hurley stage II (n = 263, 66.4%) or III (n = 76, 20.3%). The breast was more frequently affected in women than men (37.5 vs. 5.3%, p < 0.0001), whereas the dorsal region was more frequently affected in men (39.5 vs. 10.9%, p < 0.0001). Increased disease stage was associated with obesity (25.9 vs. 33.8 vs. 51.3%, p = 0.02) and some HS localizations (genital [p < 0.005], pubis [p < 0.007], gluteal fold [p = 0.02], and groin [p < 0.0001]). The most frequently prescribed treatments were oral antibiotics (n = 362, 91.4%), especially amoxicillin-clavulanic acid and cyclins. Less than 10% of participants received biologics. Most of these results were consistent with previously published cohorts.

CONCLUSION

Recruitment of participants by such a web platform can be a faster way to get relevant scientific data for a wide variety of patients that could be used for epidemiological studies and to evaluate therapeutics in "real-life" interventions.

Hormonal Contraceptives and Dermatology

Hormones play a significant role in normal skin physiology and many dermatologic conditions. As contraceptives and hormonal therapies continue to advance and increase in popularity, it is important for dermatologists to understand their mechanisms and dermatologic effects given the intricate interplay between hormones and the skin. This article reviews the dermatologic effects, both adverse and beneficial, of combined oral contraceptives (COCs), hormonal intrauterine devices (IUDs), implants, injections, and vaginal rings. Overall, the literature suggests that progesterone-only methods, such as implants and hormonal IUDs, tend to trigger or worsen many conditions, including acne, hirsutism, alopecia, and even rosacea. Therefore, it is worthwhile to obtain detailed medication and contraceptive histories on patients with these conditions. There is sufficient evidence that hormonal contraceptives, particularly COCs and vaginal rings, may effectively treat acne and hirsutism. While there are less data to support the role of hormonal contraceptives in other dermatologic disorders, they demonstrate potential in improving androgenetic alopecia and hidradenitis suppurativa.

[CME Dermatology 23: Hidradenitis suppurativa]

CME Dermatology 23: Hidradenitis suppurativa Abstract. Hidradenitis suppurativa (Acne inversa) is a chronic skin disease characterized by recurrent inflammatory nodules, abscesses, and scarring mainly in the intertriginous areas. The prevalence is estimated to be 0.05 to 4.1 % worldwide, with women being more commonly affected. The exact pathogenesis remains unknown, but hair follicle occlusion and inflammation seem to be the initiating events. Several epidemiological correlations with smoking and obesity as well as mutations in gamma secretase genes were described. The therapy depends on the extension of the disorder and should respect the current guidelines. Topical clindamycin is suitable for mild forms of the disease whereas moderate to severe disease requires systemic anti-inflammatory treatment. Surgical intervention is currently the only definitive treatment for hidradenitis suppurativa.

Obesity is Not Associated With Need for Skin Grafting After Hidradenitis Excision

INTRODUCTION

Hidradenitis suppurativa (HS) is a chronic, debilitating disease associated with inflammation, recurrent abscesses, and fistulae of skin containing apocrine sweat glands. We hypothesize that the need for skin grafting after vacuum-assisted closure was decreased with increasing body mass index (BMI).

METHODS

Seventy-one consecutive patients with excisions for HS were retrospectively evaluated for demographic data, number of excisions, the total area of excised skin, need for skin grafting, and BMI. Patients were stratified for BMI and underwent logistic regression to compare all other variables.

RESULTS

Average for BMI was 30.8 ± 7.72, age was 36.89 ±13.52, area excised was 743 cm² ± 774 cm², mean operating room trips were 2.62 ± 1.59, and skin grafting was 0.52 ± 0.55. Patients were 60% male. Forty out of 71 patients were obese. There was no correlation between age, BMI, sex, thenumber of excisions, amount of skin excised, or need for a skin graft. There was a statistically significant relationship between the amount of skin excised and the need for skin grafting (P = .006).

CONCLUSIONS

The amount of skin affected by HS appears to be independent of patient BMI. The need for skin grafting is solely dependent upon the amount of tissue excised.

APPLICABILITY OF RESEARCH TO PRACTICE

This knowledge will help preoperative planning for all patients with HS, regardless of BMI.

A concise clinician's guide to therapy for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, often debilitating, skin condition that historically does not respond well to treatment. Although there is no cure for HS, symptoms can be managed if the appropriate diagnosis is made. HS most commonly develops in postpubertal women and manifests as painful, deep-seated, inflamed lesions, including nodules, sinus tracts, and abscesses. HS flares are marked by increased pain and suppuration at varying intervals and can occur in women before menstruation. HS is commonly misdiagnosed; physicians might mistake a lesion for an infection, abscess, or sexually transmitted infection. Incision and drainage of these lesions often leads to recurrence. Given that management of this chronic disease is often difficult, we sought to outline current diagnosis and management strategies for HS.

Recognition, diagnosis, and treatment of hidradenitis suppurativa

Hidradenitis suppurativa is a chronic skin condition characterized by recurrent painful abscesses usually limited to the intertriginous areas. Global prevalence has been estimated at up to 4% of the population. The exact pathogenesis of hidradenitis suppurativa is yet to be elucidated; however, recent research has shown that the disease occurs under the influence of multiple genetic, environmental, and lifestyle factors. Repeated insults result in sinus tract formation and disfigurement, which can have a significant psychosocial effect on patients. A wide range of treatments are available but none are curative. A combination antibiotic regimen is considered first line, and research into the use of biologics has been promising. Early recognition and treatment is paramount to achieving a better prognosis and improving patient quality of life.

Overall and Subgroup Prevalence of Crohn Disease Among Patients With Hidradenitis Suppurativa: A Population-Based Analysis in the United States

Importance

Limited evidence supports a link between hidradenitis suppurativa (HS) and Crohn disease (CD), and this relationship has not been established in the United States.

Objective

To evaluate the prevalence of CD among patients with HS in the United States and to determine the strength of association between the 2 conditions.

Design, Setting, and Participants

Cross-sectional analysis of data from 51 340 patients with HS identified using electronic health records data in the Explorys multiple health system data analytics and research platform, which includes data from more than 50 million unique patients across all US census regions.

Main Outcomes and Measures

Primary outcome was diagnosis of CD.

Results

Of the 18 455 660 total population considered, 51 340 had HS (35 000 women). Of these patients with HS, 29 010 (56.5%) were aged 18 to 44 years; 17 580 (34,2%), 45 to 64 years; and 4750 (9.3%), 65 years or older. Prevalence of CD among patients with HS was 2.0% (1025/51 340), compared with 0.6% (113 360/18 404 260) among those without HS (P < .001). Prevalence of CD was greatest among patients with HS who were white (2.3%), aged 45 to 64 years (2.4%), nonobese (2.8%), and tobacco smokers (2.3%). In univariable and multivariable analyses, patients with HS had 3.29 (95% CI, 3.09-3.50) and 3.05 (95% CI, 2.87-3.25) times the odds of having CD, respectively, compared with patients without HS. Crohn disease was associated with HS across all patient subgroups. The association was strongest for men (OR, 3.61; 95% CI, 3.24-4.03), patients aged 45 to 64 years (OR, 3.49; 95% CI, 3.16-3.85), nonobese patients (OR, 4.09; 95% CI, 3.69-4.54), and nonsmokers (OR, 3.44; 95% CI, 3.10-3.82).

Conclusions and Relevance

These data suggest that patients with HS are at risk for CD. Gastrointestinal symptoms or signs suggestive of CD warrant additional evaluation by a gastroenterologist.

Miscellaneous Perianal Afflictions

This article provides an overview of hidradenitis suppurativa, lichen planus, lichen sclerosis, calcinosis cuti, pyogenic granuloma, intertrigo, and seborrheic keratosis. This article also focuses on recognition and management of these pleomorphic afflictions of the perianal region.

Association of Hidradenitis Suppurativa With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

Importance

Hidradenitis suppurativa (HS) and inflammatory bowel disease (IBD) are inflammatory diseases that share common genetic susceptibility and immunologic features. However, the link between HS and IBD has been largely unclear.

Objective

To conduct a meta-analysis to investigate the association between HS and IBD.

Data Sources

A search of the MEDLINE, Cochrane Central Register of Controlled Trials, and Embase databases yielded 397 relevant studies from inception to June 10, 2018. Two additional studies were supplied by one of the investigators.

Study Selection

Case-control, cross-sectional, or cohort studies that examined the odds or risk of IBD in patients with HS were included. No geographic or language limitations were imposed.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The Newcastle-Ottawa Scale was used to assess the risk of bias of included studies. Crohn disease and ulcerative colitis were analyzed separately, and a random-effects model meta-analysis was conducted.

Main Outcomes and Measures

The odds ratios (ORs) and hazard ratios (HRs) of IBD, Crohn disease, and ulcerative colitis in association with HS.

Results

Five case-control studies, 2 cross-sectional studies, and 1 cohort study with a total of 93 601 unique participants were included. The meta-analysis of case-control and cross-sectional studies showed significant associations of HS with Crohn disease (pooled OR, 2.12; 95% CI, 1.46-3.08) and ulcerative colitis (pooled OR, 1.51; 95% CI, 1.25-1.82). Two case-control studies found significant association of HS with IBD (ORs, 2.16 [95% CI, 1.40-3.34] and 10.00 [95% CI, 1.94-51.50]). One cohort study found an increased risk of IBD in patients with HS (HR, 5.6; 95% CI not reported; P < .002).

Conclusions and Relevance

The evidence to date supports an association of HS with IBD. These results suggest that consultation with gastroenterologists should be sought when patients with HS present with recurrent abdominal pain, chronic diarrhea, bloody stool, and body weight loss.

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part II: Topical, intralesional, and systemic medical management

Hidradenitis suppurativa is a severe and debilitating dermatologic disease. Clinical management is challenging and consists of both medical and surgical approaches, which must often be combined for best outcomes. Therapeutic approaches have evolved rapidly in the last decade and include the use of topical therapies, systemic antibiotics, hormonal therapies, and a wide range of immunomodulating medications. An evidence-based guideline is presented to support health care practitioners as they select optimal medical management strategies and is reviewed in this second part of the management guidelines. A therapeutic algorithm informed by the evidence available at the time of the review is provided.

Impact of hidradenitis suppurativa on work loss, indirect costs and income

Background

Hidradenitis suppurativa (HS), a chronic cutaneous disease, can negatively affect work life.

Objectives

This retrospective cohort study evaluates the indirect burden among employed patients with HS in the U.S.A.

Methods

Newly diagnosed and general patients with HS, who were employees (age 18–64 years) from a large claims database (Q1 1999 to Q1 2015), were matched 1 : 5 to controls. Income growth and risk of leaving the workforce were assessed among the newly diagnosed HS and control cohorts in the 5‐year study period. Income, work loss days and indirect costs (absenteeism and disability) were assessed among the general HS and control cohorts in the 1‐year study period.

Results

Newly diagnosed (n = 1003, mean age 39·5 years, 66·3% female) and general patients with HS (n = 1204, mean age 39·9 years, 69·1% female) were matched to 5015 and 6020 controls, respectively. Newly diagnosed patients with HS had significantly slower income growth ($324 per year) and higher risk of leaving the workforce (adjusted hazard ratio 1·65, 95% confidence interval 1·45–1·88) compared with controls (all P < 0·05). General patients with HS had more total days of work loss (18·4 vs. 7·7), higher annual total indirect costs ($2925 vs. $1483) and lower annual income ($54 925 vs. $62 357) than controls (all P < 0·001).

Conclusions

Patients with newly diagnosed HS and general patients with HS experienced a greater indirect burden than matched controls.

What's already known about this topic?

Hidradenitis suppurativa (HS), a chronic inflammatory disease, can negatively affect work life.

What does this study add?

This retrospective claims analysis found that HS is associated with high indirect burden, in terms of slower income growth, higher risk of leaving the workforce and higher indirect costs.

These results indicate that patients with HS have unmet disease management needs.

Linked Editorial: Zouboulis. Br J Dermatol 2019; 181:7–8.

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Photodynamic therapy for Hidradenitis Suppurativa/acne inversa: Case report

Hidradenitis suppurativa/acne inversa (HS/AI) is a type of chronic suppurative inflammatory reaction of the hair follicles characterized by recurrent dermal abscesses, sinus tracts and scars. So far, there has not been any prospective study proving the efficacy and safety of photodynamic therapy for the disease. In this report, one case of HS/AI achieved resolution of skin lesions, ulcer healing and disappearance of symptoms after nine treatments with 5-aminolevulinic acid photodynamic therapy (ALA-PDT).

Complement Activation in Inflammatory Skin Diseases

The complement system is a fundamental part of the innate immune system, playing a crucial role in host defense against various pathogens, such as bacteria, viruses, and fungi. Activation of complement results in production of several molecules mediating chemotaxis, opsonization, and mast cell degranulation, which can contribute to the elimination of pathogenic organisms and inflammation. Furthermore, the complement system also has regulating properties in inflammatory and immune responses. Complement activity in diseases is rather complex and may involve both aberrant expression of complement and genetic deficiencies of complement components or regulators. The skin represents an active immune organ with complex interactions between cellular components and various mediators. Complement involvement has been associated with several skin diseases, such as psoriasis, lupus erythematosus, cutaneous vasculitis, urticaria, and bullous dermatoses. Several triggers including auto-antibodies and micro-organisms can activate complement, while on the other hand complement deficiencies can contribute to impaired immune complex clearance, leading to disease. This review provides an overview of the role of complement in inflammatory skin diseases and discusses complement factors as potential new targets for therapeutic intervention.

Identification of HLA-DRB1 association to adalimumab immunogenicity

Anti-drug antibody formation occurs with most biological agents across disease states, but the mechanism by which they are formed is unknown. The formation of anti-drug antibodies to adalimumab (AAA) may decrease its therapeutic effects in some patients. HLA alleles have been reported to be associated with autoantibody formation against interferons and other TNF inhibitors, but not adalimumab. We analyzed samples from 634 subjects with either rheumatoid arthritis (RA) or hidradenitis suppurativa (HS): 37 subjects (17 RA and 20 HS) developed AAA (AAA+) during adalimumab treatment and 597 subjects (348 RA, 249 HS) did not develop AAA (AAA-) during the clinical trials. Using next-generation sequencing-based HLA typing, we identified three protective HLA alleles (HLA-DQB1*05, HLA-DRB1*01,and HLA-DRB1*07) that were less prevalent in AAA+ than AAA-subjects (ORs: 0.4, 0.25 and 0.28, respectively; and P values: 0.012, 0.012 and 0.018, respectively) and two risk HLA alleles (HLA-DRB1*03 and HLA-DRB1*011) that were more abundant in AAA+ than AAA-subjects (ORs: 2.52, and 2.64, respectively; and P values: 0.006 and 0.019). Similar to the finding of Billiet et al. who found that carriage of the HLA-DRB1*03 allele was more prevalent in those with anti-infliximab antibodies (OR = 3.6, p = 0.002, 95% CI: [1.5,8.6]).), we found HLA-DRB1*03 allele was also more prevalent in anti-adalimumab positive (OR = 2.52, p = 0.006, 95% CI: [1.37,4.63]). The results suggest that specific HLA alleles may play a key role in developing AAAs in RA and HS patients treated with adalimumab.

Hidradenitis suppurativa associated with systemic lupus erythematosus: A case report

RATIONALE

Hidradenitis suppurativa (HS) is a chronic inflammatory condition characterized by recurrent swollen, deep, and painful abscesses. Several autoimmune conditions have been shown to be associated with HS including inflammatory bowel disease and spondyloarthropathies.

PATIENT CONCERNS

40-year-old female with systemic lupus erythematous (SLE) presented with recurrent abscesses and nodules on her extremities.

DIAGNOSIS

Early considerations related the described dermatologic findings to the dermatologic manifestations of SLE, however findings from lesion biopsy were suggestive of HS.

INTERVENTIONS

Prednisone and antibiotic therapy with clindamycin were started. Subsequently upon discharge, the patient was also treated with rifampicin and azathioprine.

OUTCOME

In this communication, we demonstrate a case of HS in a patient with SLE that significantly improved under antibiotic and immunosuppressant therapy.

LESSONS

HS can coexist in patients with SLE. Evidence pertinent to the etiology of HS and its association with other autoimmune conditions implies a possible denominator in the disease etiopathogenesis. Increased awareness of the co-occurrence of the two conditions calls for increased efforts to devise better treatment modalities.

Hidradenitis Suppurativa: Modern Concepts of Pathogenesis and Therapy; Successful Experience of Adalimumab Therapy

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that mainly affects the sites of the apocrine glands; HS is characterised by relapsing painful knots and abscesses, leading to the formation of fistulas and scarring. Modern ideas about the pathogenesis of HS allow us to consider it as a kind of inverse acne, since the mechanism of development of HS and inverse acne does not differ. Detailed studies of patients with HS in recent years have provided the basis for several authors to suggest that HS is a systemic, chronic, immune-mediated progressive disease. The key role of the proinflammatory cytokine tumor necrosis factor Į (TNF-Į) in the development of the inflammatory process during HS was determined. Elevated TNF-Į levels are found in the blood and HS lesions, having a positive correlation of the TNF-Į level with the severity of the disease. At the present time, the treatment with a TNF-Į blocker, adalimumab (the only one genetically engineered biological preparation approved for treatment of HS/inverse acne in the world and in Russia), is recommended as a first-line therapy in the absence of an adequate response to standard systemic therapy in the case of active HS of moderate or utmost severity. The presented clinical case confirms the fact that for HS patients it is very important to determine the correct diagnosis as quickly as possible and to prescribe the appropriate treatment according to the developed recommendations. Erroneous diagnoses, inadequate therapy (surgical treatment, short courses of antibiotics, etc.) contribute to the progression of the disease, to the appearance of common symptoms due to the attachment of secondary infection and increase in general intoxication, to limited working capacity, to the emergence of persistent and gross scars, as well as to the deformations of affected skin. Our clinical case of adalimumab (Humira) treatment of a patient with an extremely severe HS form demonstrated that the application of this medication can be effective and well tolerated. 

The critical role of macrophages in the pathogenesis of hidradenitis suppurativa

INTRODUCTION

Hidradenitis suppurativa (HS) is a painful chronic inflammatory disease with a prevalence between 1 and 4% of general population. The pathogenesis of HS long eluded scientists, but growing evidence suggests that it is a consequence of inflammatory dysregulation.

FINDINGS

Recent studies suggest that dysregulated immune response to skin flora and overexpression of inflammatory cytokines leads to chronic skin inflammation seen in HS. Macrophages are the most numerous inflammatory cells found in HS infiltrates and release numerous pro-inflammatory cytokines such as IL-23, and IL-1β and TNF-α, exacerbating the inflammation and contributing to the pathogenesis of HS. Furthermore, in HS, there is dysregulated function of other immune players closely associated with macrophage function including: matrix metalloproteases (MMP) 2 and 9 overexpression, toll-like receptor upregulation, impaired Notch signalling, NLRP3 inflammasome upregulation, and dysregulated keratinocyte function. Lifestyle factors including obesity and smoking also contribute to macrophage dysfunction and correlate with HS incidence.

CONCLUSIONS

The overexpression of pro-inflammatory cytokines and subsequent efficacy of anti-cytokine biologic therapies highlights the importance of managing macrophage dysfunction. Future therapies should target key molecular drivers of macrophage dysfunction such as TLR2 and NLRP3 overexpression.

Prevalence and Risk of Inflammatory Bowel Disease in Patients with Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease. In small studies, inflammatory bowel disease has been associated with the increased prevalence of HS, but the data on the concurrence of inflammatory bowel disease in patients with HS are limited. We therefore investigated the prevalence and risk of inflammatory bowel disease in patients with HS compared with the general population. The study linked all Danish individuals aged ≥18 years in nationwide registers. Adjusted odds ratios and adjusted hazard ratios were estimated by logistic regression and Cox regression, respectively. The study comprised 7,732 patients with HS and 4,354,137 subjects from the general population. The prevalence (HS vs. general population) was 0.8% and 0.3% (odds ratio 2.04; 1.59-2.62) for Crohn's disease and 1.3% and 0.7% (odds ratio 1.75; 1.44-2.13) for ulcerative colitis. The risk of new-onset Crohn's disease (hazard ratio 2.19; 1.44-3.34) and ulcerative colitis (hazard ratio 1.63; 1.18-2.27) was significantly increased among patients with HS. In conclusion, HS was significantly associated with the presence and risk of new-onset inflammatory bowel disease, although the prevalence remained low. Gastrointestinal complaints in patients with HS should warrant further clinical examination.

The effect of smoking and age on the response to first-line therapy of hidradenitis suppurativa: An institutional retrospective cohort study

BACKGROUND

Treatment for hidradenitis suppurativa is often empiric and inadequate, and determining which patients will respond is difficult.

OBJECTIVE

We sought to determine which patient factors are associated with a positive response to first-line medical therapy.

METHODS

A single-center retrospective cohort study of all patients with hidradenitis suppurativa seen between January 1, 1992, and October 1, 2014, was conducted. Response to first-line medical therapy (oral/topical antibiotics, intralesional corticosteroids, and topical washes) was examined at follow-up within 6 months of initiating therapy. A multivariate binary logistic regression model was built examining response to treatment and the interplay of patient factors and treatment initiated.

RESULTS

In all, 198 patients were included in the final model. Nonsmokers (odds ratio 2.634, 95% confidence interval 1.301-5.332, P = .007) and older individuals (odds ratio 1.046 for each additional year, 95% confidence interval 1.020-1.072, P < .001) were more likely to have improvement at follow-up. In addition, current smokers differed significantly from nonsmokers in several regards.

LIMITATIONS

The retrospective nature of this study is a limitation, as is relying on classification of disease severity from physical examination findings in some patients.

CONCLUSIONS

The results of this study suggest that clinicians may be able to more accurately predict which patients with hidradenitis suppurativa will respond to first-line medical therapy, and which patients may require therapy escalation.

Hidradenitis Suppurativa and the Association With Hematological Malignancies

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease affecting skin sites with a high density of apocrine glands. HS commonly presents after puberty, with most patients diagnosed in the second decade of their life. Several studies have investigated smoking, obesity, hypertension, diabetes, and dyslipidemia as possible underlying risk factors for HS. However, we encountered 2 patients with a long-standing history of untreated leukemia who developed late-onset HS.

OBJECTIVE

To investigate the presence of malignancy as an underlying risk factor for development of HS.

METHOD

The PubMed and Scopus databases were searched for keywords such as hidradenitis suppurativa, malignancy, cancer, and epidemiology.

OBSERVATION

Only 1 retrospective Swedish study with 2119 patients investigated the prevalence of cancer, including 6 hematopoietic malignancies, in HS patients. However, the study did not assess the timeline of developing HS in relation to the cancer diagnosis. We report 2 patients with a long-standing history of hematopoietic cancers who received no continuous treatments for their malignancies and developed late-onset HS: a 60-year-old male patient with hairy cell leukemia and a 68-year-old male patient with chronic lymphocytic leukemia who developed HS later in life.

CONCLUSION

Multiple epidemiologic studies found the average age of HS diagnosis to be well prior to the fourth decade of life. The latency of the HS diagnosis as well as the presence of long-standing leukemia in both of our patients raises the necessity for assessing the possibility of malignancy, especially hematopoietic cancer, as a risk factor for HS.

LIMITATION

This is a small retrospective analysis including only 2 patients. Larger studies would better assess the role of malignancy, leukemia in particular, as a possible risk factor for development of HS.

Hydradenitis suppurativa and inflammatory bowel disease: An unusual, but existing association

Inflammatory bowel disease (IBD) could be associated with several extra-intestinal manifestations (EIMs) involving musculoskeletal, hepatopancreatobiliary, ocular, renal, and pulmonary systems, as well as the skin. In the last years, hidradenitis suppurativa (HS) is acquiring an increasing interest. IBD, especially Crohn’s disease (CD), is among the most reported associated diseases in HS patients. The aim of this paper is to give a brief overview of data showing a possible epidemiologic and pathogenetic association between IBD and HS. We performed a pooled-data analysis of four studies and pooled prevalence of HS in IBD patients was 12.8%, with a 95%CI of 11.7%-13.9%. HS was present in 17.3% of subjects with CD (95%CI: 15.5%-19.1%) and in 8.5% of UC patients (95%CI: 7.0%-9.9%). Some items, especially altered immune imbalance, are generally involved in IBD pathogenesis as well as invoked by HS. Smoking is one of the most relevant risk factors for both disorders, representing a predictor of their severity, despite, actually, there being a lack of studies analyzing a possible shared pathway. A role for inheritance in HS and CD pathogenesis has been supposed. Despite a genetic susceptibility having been demonstrated for both diseases, further studies are needed to investigate a genetic mutual route. Although the pathogenesis of IBD and HS is generally linked to alterations of the immune response, recent findings suggest a role for intestinal and skin microbiota, respectively. In detail, the frequent finding of Staphylococcus aureus and coagulase-negative staphylococci on HS cutaneous lesions suggests a bacterial involvement in disease pathogenesis. Moreover, microflora varies in the different cutaneous regions of the body and, consequently, two different profiles of HS patients have been identified on these bases. On the other hand, it is well-known that intestinal microbiota may be considered as “the explosive mixture” at the origin of IBD despite the exact relationship having not been completely clarified yet. A better comprehension of the role that some bacterial species play in the IBD pathogenesis may be essential to develop appropriate management strategies in the near future. A final point is represented by some similarities in the therapeutic management of HS and IBD, since they may be controlled by immunomodulatory drugs. In conclusion, an unregulated inflammation may cause the lesions typical of both HS and IBD, particularly when they coexist. However, this is still a largely unexplored field.