Uncovering burden disparity: A comparative analysis of the impact of moderate-to-severe psoriasis and hidradenitis suppurativa

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

The impact of hidradenitis suppurativa on work productivity and performance: a systematic review and meta-analysis

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder affecting the skinfold regions. There is growing appreciation of the need for socioeconomic factors to be included in multidisciplinary assessments of HS. However, knowledge regarding HS and workplace function is limited.

OBJECTIVES

To assess the relationship between HS and workplace function.

METHODS

CINAHL, Embase, MEDLINE, PsycINFO and PubMed were systematically searched to collect data from studies in which validated surveys of workplace function were administered to patients with HS.

RESULTS

Of 1932 publications, 12 studies were included in this review and 7 reported sufficient data for meta-analysis. The studies included in this review encompassed 5187 patients with HS and no controls. All studies used the Work Productivity and Activity Impairment questionnaire, reporting percentage scores for absenteeism, presenteeism, total work productivity impairment (TWPI) and total activity impairment (TAI). The pooled mean scores for HS were calculated as 10.17% [95% confidence interval (CI) 8.68-11.66] for absenteeism, 31.13% (95% CI 25.02-37.23) for presenteeism, 34.25% (95% CI 29.37-39.14) for TWPI and 42.23% (95% CI 38.56-45.89) for TAI. Significant heterogeneity was identified; most studies were of 'poor' to 'fair' quality.

CONCLUSIONS

Current evidence suggests considerable impairment of workplace functioning in patients with HS. Our findings point to a significant unmet treatment need with respect to improving working capability in HS. The existing literature is inadequate to reliably assess the mechanisms underlying this effect or to comparatively assess the capabilities of HS therapies to improve workplace function.

Guidelines How to Integrate Surgery and Targeted Therapy with Biologics for the Treatment of Hidradenitis Suppurativa: Delphi Consensus Statements from an Italian Expert Panel

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent and painful nodules and abscesses in intertriginous skin areas, which can progress to sinus tract formation, tissue destruction, and scarring. HS is highly debilitating and severely impairs the psychological well-being and quality of life of patients. The therapeutic approach to HS is based on medical therapy and surgery. First-line medical therapy includes topical antibiotics, systemic antibiotics, and biologics. Main surgical procedures include deroofing, local excision, and wide local excision. Despite the availability of multiple therapeutic options, the rates of disease recurrence and progression continue to be high. In recent years, the possibility of combining biologic therapy and surgery has raised considerable interest. In a clinical trial, the perioperative use of adalimumab has been associated with greater response rates and improved inflammatory load and pain, with no increased risk of postoperative infectious complications. However, several practical aspects of combined biologic therapy and surgery are poorly defined. In June 2022, nine Italian HS experts convened to address issues related to the integration of biologic therapy and surgery in clinical practice. To this purpose, the experts identified 10 areas of interest based on published evidence and personal experience: (1) patient profiling (diagnostic criteria, disease severity classification, assessment of response to treatment, patient-reported outcomes, comorbidities); (2) tailoring surgery to HS characteristics; (3) wide local excision; (4) presurgery biologic treatment; (5) concomitant biologic and surgical treatments; (6) pre- and postsurgery management; (7) antibiotic systemic therapy; (8) biologic therapy after radical surgery; (9) management of adverse events to biologics; and (10) management of postoperative infectious complications. Consensus between experts was reached using the Estimate-Talk-Estimate method (Delphi Method). The statements were subsequently presented to a panel of 27 HS experts from across Italy, and their agreement was assessed using the UCLA Appropriateness Method. This article presents and discusses the consensus statements.

S2k‐Leitlinie zur Therapie der Hidradenitis suppurativa/Acne inversa – Kurzfassung

Die S2k‐Leitlinie der Hidradenitis suppurativa/Acne inversa (HS/AI) soll eine akzeptierte Entscheidungshilfe für die Auswahl/Durchführung einer geeigneten/suffizienten Therapie liefern. Hidradenitis suppurativa/Acne inversa ist eine chronisch‐rezidivierende, entzündliche, potenziell mutilierende Hauterkrankung des terminalen Haartalgdrüsenapparats, mit schmerzhaften, entzündlichen Läsionen in den apokrinen drüsenreichen Körperregionen. Ihre Punktprävalenz in Deutschland ist 0,3%, sie wird mit einer Verspätung von 10,0 ± 9,6 Jahren diagnostiziert. Abnormale Differenzierung der Keratinozyten des Haartalgdrüsenapparats und eine begleitende Entzündung bilden die zentrale pathogenetische Grundlage. Primäre HS/AI‐Läsionen sind entzündliche Knoten, Abszesse und drainierende Tunnel. Rezidive in den letzten 6 Monaten mit mindestens zwei Läsionen an den Prädilektionsstellen verweisen auf eine HS/AI mit einer 97‐prozentigen Genauigkeit. HS/AI‐Patienten leiden an einer deutlichen Einschränkung der Lebensqualität. Zur korrekten Therapieentscheidung sollen Klassifikation und Aktivitätsbewertung mit einem validierten Instrument erfolgen, wie dem International Hidradenitis Suppurativa Severity Scoring System (IHS4). Hidradenitis suppurativa/Acne inversa wird nach der Ausprägung der nachweisbaren Entzündung in zwei Formen eingeteilt: aktive, entzündliche (milde, mittelschwere und schwere nach IHS4) und vorwiegend inaktive, nicht entzündliche (Hurley‐Grad‐I, ‐II und ‐III) HS/AI. Orale Tetrazykline oder eine 5‐tägige intravenöse Therapie mit Clindamycin sind mit der Effektivität von Clindamycin/Rifampicin vergleichbar. Subkutan applizierbares Adalimumab, Secukinumab und Bimekizumab sind für die Therapie der HS/AI zugelassen. Für die vorwiegend nicht entzündliche Erkrankungsform stehen verschiedene operative Verfahren zur Verfügung. Medikamentöse/chirurgische Kombinationen gelten als ganzheitliches Therapieverfahren.

S2k guideline for the treatment of hidradenitis suppurativa / acne inversa - Short version

The S2k guideline on hidradenitis suppurativa/acne inversa (HS/AI) aims to provide an accepted decision aid for the selection/implementation of appropriate/sufficient therapy. HS/AI is a chronic recurrent, inflammatory, potentially mutilating skin disease of the terminal hair follicle-glandular apparatus, with painful, inflammatory lesions in the apocrine gland-rich regions of the body. Its point prevalence in Germany is 0.3%, it is diagnosed with a delay of 10.0 ± 9.6 years. Abnormal differentiation of the keratinocytes of the hair follicle-gland apparatus and accompanying inflammation form the central pathogenetic basis. Primary HS/AI lesions are inflammatory nodules, abscesses and draining tunnels. Recurrences in the last 6 months with at least 2 lesions at the predilection sites point to HS/AI with a 97% accuracy. HS/AI patients suffer from a significant reduction in quality of life. For correct treatment decisions, classification and activity assessment should be done with a validated tool, such as the International Hidradenitis Suppurativa Severity Scoring System (IHS4). HS/AI is classified into two forms according to the degree of detectable inflammation: active, inflammatory (mild, moderate, and severe according to IHS4) and predominantly inactive, non-inflammatory (Hurley grade I, II and III) HS/AI. Oral tetracyclines or 5-day intravenous therapy with clindamycin are equal to the effectiveness of clindamycin/rifampicin. Subcutaneously administered adalimumab, secukinumab and bimekizumab are approved for the therapy of HS/AI. Various surgical procedures are available for the predominantly non-inflammatory disease form. Drug/surgical combinations are considered a holistic therapy method.

A systematic review of 454 randomized controlled trials using the Dermatology Life Quality Index: experience in 69 diseases and 43 countries

BACKGROUND

Over 29 years of clinical application, the Dermatology Life Quality Index (DLQI) has remained the most used patient-reported outcome (PRO) in dermatology due to its robustness, simplicity and ease of use.

OBJECTIVES

To generate further evidence of the DLQI's utility in randomized controlled trials (RCTs) and to cover all diseases and interventions.

METHODS

The methodology followed PRISMA guidelines and included seven bibliographical databases, searching articles published from 1 January 1994 until 16 November 2021. Articles were reviewed independently by two assessors, and an adjudicator resolved any opinion differences.

RESULTS

Of 3220 screened publications, 454 articles meeting the eligibility criteria for inclusion, describing research on 198 190 patients, were analysed. DLQI scores were primary endpoints in 24 (5.3%) of studies. Most studies were of psoriasis (54.1%), although 69 different diseases were studied. Most study drugs were systemic (85.1%), with biologics comprising 55.9% of all pharmacological interventions. Topical treatments comprised 17.0% of total pharmacological interventions. Nonpharmacological interventions, mainly laser therapy and ultraviolet radiation treatment, comprised 12.2% of the total number of interventions. The majority of studies (63.7%) were multicentric, with trials conducted in at least 42 different countries; 40.2% were conducted in multiple countries. The minimal clinically importance difference (MCID) was reported in the analysis of 15.0% of studies, but only 1.3% considered full score meaning banding of the DLQI. Forty-seven (10.4%) of the studies investigated statistical correlation of the DLQI with clinical severity assessment or other PRO/quality of life tools; and 61-86% of studies had within-group scores differences greater than the MCID in 'active treatment arms'. The Jadad risk-of-bias scale showed that bias was generally low, as 91.8% of the studies had Jadad scores of ≥ 3; only 0.4% of studies showed a high risk of bias from randomization. Thirteen per cent had a high risk of bias from blinding and 10.1% had a high risk of bias from unknown outcomes of all participants in the studies. In 18.5% of the studies the authors declared that they followed an intention-to-treat protocol; imputation for missing DLQI data was used in 34.4% of studies.

CONCLUSIONS

This systematic review provides a wealth of evidence of the use of the DLQI in clinical trials to inform researchers' and -clinicians' decisions for its further use. Recommendations are also made for improving the reporting of data from future RCTs using the DLQI.

Factors Affecting Treatment Selection Among Patients With Hidradenitis Suppurativa

Importance

Despite the US Food and Drug Administration's approval of adalimumab for the treatment of hidradenitis suppurativa (HS), prescription rates remain low, indicating a critical gap between evidence-based guidelines and clinical practice. Understanding the medical decision-making process that these patients use when considering biologic agents and other HS therapies may uncover opportunities for improved patient-physician communication and HS disease control.

Objective

To elucidate factors that affect the medical decision-making process for patients with HS, with an emphasis on biologic therapies.

Design, Setting, and Participants

Open-ended semistructured interviews were conducted with English-speaking adults with HS (aged ≥18 years) recruited from 2 dermatology clinics that are part of Emory University School of Medicine in Atlanta, Georgia. All participants had an average 7-day pain score of 1 or higher on a 0- to 10-point numeric rating scale. Surveys were conducted between November 2019 and March 2020, and data were analyzed from December 2021 to August 2022. Data collection continued until thematic saturation was reached at 21 interviews.

Results

A total of 21 participants (median [IQR] age, 38.5 [27.9-43.4] years; 16 females [76%]) were included in the analysis. Almost all participants (96%) had Hurley stage II or III disease, and 15 (71%) had a history of adalimumab use. Suffering threshold, perceptions of treatment risk, treatment fatigue, disease understanding, and sources of information (included dermatologists, the internet, advertisements, and friends and loved ones) were identified as factors affecting participants' decisions to initiate new treatments for HS.

Conclusions and Relevance

Results of this qualitative study suggest that mitigating misconceptions about treatment risk, identifying gaps in disease knowledge, and emphasizing early treatment to prevent scarring and disease progression may empower patients with HS to engage in treatment planning and to try new therapies.

Burden of Hidradenitis Suppurativa: A Systematic Literature Review of Patient Reported Outcomes

INTRODUCTION

Hidradenitis suppurativa (HS) has a profound negative impact on patients' health-related quality of life (HRQoL). Here we summarize the evidence on HRQoL and Patient Reported Outcomes (PROs) in patients with HS in real-world settings by conducting a systematic literature review (SLR) of observational studies.

METHODS

Data sources included MEDLINE, Embase & PsycINFO between January 1, 2010 and August 29, 2021, and conference proceedings between 2019 and 2021. Identified abstracts were reviewed and screened independently by two reviewers. Eligibility criteria included patients with HS of any severity, sample size ≥ 100, reporting PROs including HRQoL measures. Included studies were critically appraised.

RESULTS

Fifty-eight observational studies matched inclusion criteria. Dermatology Life Quality Index (DLQI) was the most commonly utilized instrument: 57% of included studies reported mean baseline DLQI scores, ranging between 8.4 and 16.9, indicating a very large impact on the patients' HRQoL. Higher scores were reported with increasing disease severity and among female patients. Pain was assessed mostly by an 11-point (0-10) numeric rating scale (NRS) with a mean baseline score ranging from 3.6 to 7.7 indicating moderate to high pain levels. There was a negative impact of HS on patients' psychological well-being, based on PRO scores related to depression and anxiety. A high proportion of sexual dysfunction was reported, with a larger impact on women than men. Work productivity and leisure activity were consistently found to be impaired in patients with HS.

CONCLUSIONS

All included studies reported a negative impact of HS on patients' lives. A diverse set of disease- and non-disease-specific PRO instruments were utilized highlighting the need for more consistent use of HS-specific validated PRO instruments to assess the impact of HS on the different aspects of patients' HRQoL to allow for data to be more meaningfully interpreted and compared in real-world settings. Patients with HS need better disease management approaches that address the observed low quality of life.

The impact of hidradenitis suppurativa on professional life

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease that affects intertriginous skin.

OBJECTIVES

To determine the extent of work ability and productivity impairment as a result of HS in Germany.

METHODS

A prospective, multicentre, epidemiological, noninterventional study of patients with HS was conducted. Medical history, medical examination performed by dermatologists and patient-reported outcomes [Work Ability Index (WAI) and Work Productivity and Activity Impairment (WPAI)] were collected.

RESULTS

Of the 481 patients with HS included in the study, 99% were below the current statutory retirement age. In total, 53·3% of patients were working full time, 16·8% part time and 7·3% had retired. The unemployment rate was 12·6%, two times higher than in the general German population. Medical leave because of HS, within the last 6 months, was reported in 41·4% [95% confidence interval (CI) 36·9-46·0], with a duration of 39·3 days on average (95% CI 32·4-46·1). The mean HS-related WPAI absenteeism was 13.3% (95% CI 9·7-16·8), and the loss in productivity because of HS during working hours (WPAI presenteeism) was 25.2% (95% CI 21·8-28·6). Presenteeism was associated with HS disease severity. Overall work impairment because of HS was 33·4% (95% CI 29·3-37·6). The WAI score for patients was 32·2, ∼20% lower than for the average German employee. Only 62·8% of patients were relatively certain that they would be able to perform their work in the coming 2 years. Being more depressed and having more severe pain were associated with lower work ability and overall work impairment. The estimated annual loss of gross value added because of HS for Germany was ∼€12.6 billion (€3.3 billion related to a lower employment rate, €3.5 billion related to absenteeism and €5.8 billion related to presenteeism).

CONCLUSIONS

HS leads to a substantial decrease in work ability and productivity and considerable loss of gross value added. Impairment during working hours correlates with disease severity, underlining the socioeconomic importance of early and adequate treatment. Furthermore, decreased work ability and productivity is linked to depressed mood and severe pain, aspects that need more attention in patient care.

Pain experiences among those living with hidradenitis suppurativa: a qualitative study

BACKGROUND

Pain is rated by patients with hidradenitis suppurativa (HS) as the disease's most impactful symptom. HS therapies are often insufficient to control inflammatory disease activity and pain. A better understanding of patient experiences with pain may improve patient-provider relationships and help identify strategies for addressing HS pain.

OBJECTIVES

This qualitative study sought to characterize lived pain experiences of those with HS.

METHODS

English-speaking patients ≥ 18 years old with a dermatologist-confirmed diagnosis of HS and an average numerical rating scale pain score of ≥ 1 over the preceding week were recruited from a single academic medical centre in Atlanta, Georgia, USA. Semistructured interviews were conducted from November 2019 to March 2020 to explore participants' HS pain experiences and the subsequent impact on their lives. Thematic saturation was reached after interviewing 21 participants. Interviews were audio recorded, transcribed, and analysed using thematic analysis.

RESULTS

Among 21 study participants, the median 7-day average pain score was 6 (interquartile range 3-7; scale ranges from 0 to 10, with 10 being most pain). Participants' descriptions of pain were consistent with nociceptive pain, neuropathic pain and itch. Pain impacted multiple life domains, including physical limitations (decreased mobility and impaired sleep), decreased psychological wellbeing (irritability, depression, loss of control, and difficulty communicating pain experiences) and impaired social relationships (social isolation, intimacy problems and difficulty fulfilling social responsibilities). Although participants reported chronic discomfort, acutely painful and unpredictable HS disease flares caused more distress and quality-of-life (QoL) burden. Participants frequently treated their pain without input from the medical team, sometimes with unsafe medication doses or combinations. Factors contributing to self-management of pain included difficulty accessing timely outpatient care during disease flares and fear of stigma from healthcare providers.

CONCLUSIONS

When present, HS-related pain may impact not only physical wellbeing but also mental health and relationships. In addition to therapies that target the inflammatory disease burden, treating the symptom of pain may improve patients' QoL and wellbeing. Because patients with HS have difficulty explaining their pain, proactively asking them about pain may identify unmet needs, facilitate better pain control and improve QoL. Further, the influence of HS-related pain on numerous aspects of QoL suggests the need for multidisciplinary, patient-centred approaches to HS pain management.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

LIMITATIONS

cross-sectional and single center study.

CONCLUSIONS

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

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

LIMITATIONS

cross-sectional and single center study.

CONCLUSIONS

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

Risk of psoriasis in people with hidradenitis suppurativa: A systematic review and meta-analysis

BACKGROUND

Hidradenitis suppurativa were associated with comorbidities in various organ systems. Inflammatory dermatological diseases such as pyoderma gangrenosum were reported to be associated with hidradenitis suppurativa. Nevertheless, as for the association between hidradenitis suppurativa and psoriasis, evidences were insufficient. In many studies, the association between psoriasis and hidradenitis suppurativa has been reported. However, some evidence seems to be controversial. The purpose of the systematic review and meta-analysis was to assess whether there was significant association between HS and psoriasis.

METHODS

On June 01, 2022, we appraised 2,795 articles from databases including PubMed, Web of Science and Embase. Search syntaxes were based on 'hidradenitis suppurativa' or 'acne inversa' with "psoriasis", "comorbidities" or 'epidemiology'. Synonyms were determined based on MeSH terms and Emtree. Observational results that evaluated the odds ratio for people with hidradenitis suppurativa who had psoriasis were extracted for qualitative synthesis.

RESULTS

After the selection process of the initial 2,795 studies, ten observational studies, including 3 cohort studies, 1 case-control study, and 6 cross-sectional studies, were extracted for critical appraisal. Based on the integration of 7 studies (with more than 560,000 participants included), people with hidradenitis suppurativa had a higher risk of having psoriasis, with a 2.67-fold risk (95% CI, 1.84, 3.87). The association remained in the sensitivity analyses utilizing strict adjustment models. In the analysis that only included studies with a similar study design and adjustments in obesity-related factors, the risk of people with hidradenitis suppurativa having psoriasis was 3.24 (95% CI, 2.27, 4.62). In male patients with HS, the risk of having psoriasis was 4.30-fold higher than male patients without HS (95% CI, 2.37, 7.78). Likewise, in an analysis including 3 cross-sectional studies, the risk of female HS patients having psoriasis was 3.94-fold higher than female HS-free patients (95% CI, 2.34, 6.63).

CONCLUSIONS

The co-occurrence of hidradenitis suppurativa and psoriasis can greatly increase the burden of the disease. Psoriasis could be one of the critical comorbidities of hidradenitis suppurativa and should be recommended for future screening and follow up. The association between the two diseases should be kept in mind in managing hidradenitis suppurativa patients. More prospective studies are needed to establish the true magnitude of the association between psoriasis and hidradenitis suppurativa.

Understanding the systemic burden of disease in hidradenitis suppurativa from plasma lipidomic analysis

BACKGROUND

Hidradenitis suppurativa (HS) is an inflammatory skin condition that is often considered a systemic disease due to its association with metabolic comorbidity.

OBJECTIVE

In this study, we aimed to identify differences in plasma lipidomic profiles between HS patients and control subjects.

METHODS

HS patients were recruited from a tertiary dermatological centre and demographic and comorbidity matched controls from the general population. A targeted lipidomic approach was performed to characterize over 700 lipid species representing 35 lipid classes/sub-classes. Linear regression models adjusted for confounding factors were used to compare the plasma lipidomic profiles of HS patients to controls. Ordinal regression models were used to study the association of lipids with disease activity and severity scores.

RESULTS

60 HS patients and 73 control subjects were recruited. Differential levels (p < 0.05) of 32 lipid species in HS patients compared to controls were observed, including a decrease in the long chain base d19:1 containing ceramides, and elevation of hydroxyeicosatetraenoic acid (HETE) and dihydroxyeicosatrienoic acid (DHET) oxylipins. These lipids along with several other molecules showed associations with Hurley, HS-PGA and disease activity scores.

CONCLUSION

This study found mild changes in plasma lipidomic profiles, consistent with previous studies showing attenuated metabolomic changes in plasma as opposed to lesional skin. However, a number of lipid species were associated with increasing activity and severity of the disease. Further, the significant lipid species within the same class showed consistent trends of increase or decrease in HS as compared to controls.

The impact of hidradenitis suppurativa on quality of life is worse than inflammatory bowel disease and myocardial infarction

Quality of life is severely impacted by Hidradenitis Suppurativa. This cross-sectional survey based study highlights that the impact of Hidradenitis Suppurativa on quality of life measured by the World Health Organisation Quality of Life (WHOQOL-BREF) survey is worse than published data for atopic dermatitis and other acute and chronic medical conditions including myocardial infarction and inflammatory bowel disease.

Which hidradenitis suppurativa comorbidities should I take into account?

Hidradenitis suppurativa (HS) is a chronic, recurrent skin inflammatory disease associated with a variety of comorbidities, like metabolic syndrome, reduced quality of life, sexual dysfunction, working disability, inflammatory bowel disease, axial spondyloarthritis, depression and anxiety. Like psoriasis, HS patients have been found to have higher risk of cardiovascular death and suicide risk. Evidence suggests that for such a chronic, multi-comorbid disease, the use of validated outcomes to assess severity and effect of treatment, along with the use of clinically important patient reported outcomes, is essential. Clinicians should be informed about these comorbidities so that appropriate screening is implemented. The potential of available treatments to negatively and positively affect these comorbidities should also be taken into account when designing treatment strategies. This article aims to provide an outline of important HS comorbidities with emphasis on possible implications for daily clinical practice.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Janus kinase 1 inhibitor INCB054707 for patients with moderate-to-severe hidradenitis suppurativa: results from two phase 2 studies

Background

Janus kinase (JAK)‐mediated cytokine signalling contributes to local and systemic inflammation in hidradenitis suppurativa (HS).

Objectives

To describe the safety and efficacy results from two multicentre phase II trials of the JAK1 inhibitor INCB054707 in patients with moderate‐to‐severe HS.

Methods

Patients received open‐label INCB054707 15 mg once daily (QD; Study 1) or were randomized to INCB054707 30, 60 or 90 mg QD or placebo (3 : 1 within each cohort; Study 2) for 8 weeks. Eligible patients were aged 18–75 years and had moderate‐to‐severe HS (Hurley stage II/III disease), lesions present in at least two anatomical locations, and a total abscess and inflammatory nodule count ≥ 3. The primary endpoint for both studies was safety and tolerability. Secondary endpoints included HS Clinical Response (HiSCR) and other efficacy measures.

Results

Ten patients were enrolled in Study 1 (15 mg INCB054707) and 35 in Study 2 (INCB054707: 30 mg, n = 9; 60 mg, n = 9; 90 mg, n = 8; placebo, n = 9). Overall, 70% of patients in Study 1 and 81% of patients receiving INCB054707 in Study 2 experienced at least one treatment‐emergent adverse event; 30% and 42% of patients, respectively, had at least one treatment‐related adverse event. Among the evaluable patients, three (43%) in Study 1 and 17 (65% overall: 30 mg, 56%; 60 mg, 56%; 90 mg, 88%) receiving INCB054707 vs. 4 patients (57%) receiving placebo in Study 2 achieved HiSCR at week 8.

Conclusions

INCB054707 was well tolerated, with responses observed in patients with moderate‐to‐severe HS. The safety and efficacy findings from these studies demonstrate proof of concept for JAK1 inhibition in HS. The studies are registered on ClinicalTrials.gov (NCT03569371 and NCT03607487).

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

Background and Objective

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

Methods

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

Results

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

Conclusions

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

Treatment Outcomes of IL-17 Inhibitors in Hidradenitis Suppurativa: A Systematic Review

The IL-17 pathway is a potential therapeutic target shown to be implicated in hidradenitis suppurativa (HS), however, it remains unclear whether evidence from mechanistic studies may translate into clinical practice. This systematic review summarizes available treatment outcomes of IL-17 inhibitors in patients with HS. Embase, MEDLINE, PubMed, and clinicaltrials.gov were comprehensively searched on February 26, 2021 to include 16 original studies representing 128 patients with HS (mean age: 36.5 years; age range: 21-47 years; male: 50.0%). Treatment outcomes were reported for the following biologics: secukinumab (n = 105), brodalumab (n = 22), and ixekizumab (n = 1). Patients were classified as responders or non-responders according to achievement of a positive response/improvement based on criteria established for each included study. For secukinumab 57.1% (n = 60/105) of patients were responders in a mean response period of 16.2 weeks and 42.9% (n = 45/105) were non-responders; for brodalumab, 100.0% (n = 22/22) of patients were responders within 4.4 weeks; and the one patient treated with ixekizumab was a responder within 10 weeks. In conclusion, IL-17 inhibitors may serve as an effective therapeutic target in approximately two-thirds of patients with HS and can be considered in those who are refractory to other treatment modalities. We also stress the importance of consistent outcome measures to enhance evidence synthesis, decrease reporting bias, provide potential for future meta-analysis, and ultimately improve clinical outcomes for patients with HS.

The measurement performance of the EQ-5D-5L versus EQ-5D-3L in patients with hidradenitis suppurativa

PURPOSE

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that affects up to 1% of the population in Europe. The EQ-5D is the most commonly used generic instrument for measuring health-related quality of life among HS patients. This study aims to compare the measurement properties of the two adult versions of EQ-5D (EQ-5D-3L and EQ-5D-5L) in patients with HS.

METHODS

We recruited 200 consecutive patients with HS (mean age 37 years, 38% severe or very severe HS) to participate in a multicentre cross-sectional survey. Patients completed the EQ-5D-3L, EQ-5D-5L, Dermatology Life Quality Index (DLQI) and Skindex-16 questionnaires.

RESULTS

More than twice as many different health state profiles occurred in the EQ-5D-5L compared to the EQ-5D-3L (101 vs. 43). A significant reduction in ceiling effect was found for the mobility, self-care and usual activities dimensions. A good agreement was established between the EQ-5D-3L and EQ-5D-5L with an intraclass correlation coefficient of 0.872 (95% CI 0.830-0.903; p < 0.001) that was confirmed by a Bland-Altman plot. EQ-5D-5L improved both the absolute and relative informativity in all dimensions except for anxiety/depression. EQ-5D-3L and EQ-5D-5L demonstrated similar convergent validity with DLQI and Skindex-16. EQ-5D-5L was able to better discriminate between known groups of patients based on the number of comorbidities and disease severity (HS-Physician's Global Assessment).

CONCLUSION

In patients with HS, the EQ-5D-5L outperformed the EQ-5D-3L in feasibility, ceiling effects, informativity and known-groups validity for many important clinical characteristics. We recommend using the EQ-5D-5L in HS patients across various settings, including clinical care, research and economic evaluations.

Pain management in hidradenitis suppurativa and a proposed treatment algorithm

Pain contributes substantially to reduced quality of life in individuals living with hidradenitis suppurativa (HS). Although improved understanding of HS pathogenesis and treatment has resulted in improved evidence-based HS management guidelines, comprehensive pain management guidelines have yet to be developed. Few HS-specific data exist to guide pharmacologic analgesia; however, recognizing HS pain as either acute or chronic and predominantly nociceptive (aching and gnawing pain due to tissue damage) versus neuropathic (burning-type pain due to somatosensory nervous system dysfunction) provides a conceptual framework for applying outside pain management practices to HS management. This article incorporates the best available evidence from the HS and pain literature to propose an HS pain algorithm that integrates psychological, pharmacologic, and complementary and alternative treatment modalities.

Validity of EQ-5D-5L, Skindex-16, DLQI and DLQI-R in patients with hidradenitis suppurativa

BACKGROUND

Numerous generic, skin- and disease-specific health-related quality of life (HRQoL) measures are available for patients with hidradenitis suppurativa (HS). Yet, robust psychometric evidence is lacking in many aspects of these outcome measures.

OBJECTIVES

We sought to determine convergent and known-groups validity of multiple generic and skin-specific HRQoL measures and to identify predictors of impaired HRQoL in patients with HS.

METHODS

Between 2017 and 2019, a multicentre cross-sectional study was carried out involving 200 consecutive HS patients. HRQoL outcomes included the EQ-5D-5L, EQ visual analogue scale (EQ VAS), Skindex-16, Dermatology Life Quality Index (DLQI) and DLQI-Relevant (DLQI-R). Disease severity was graded by HS-Physician's Global Assessment (HS-PGA) scale and the Modified Sartorius scale (MSS).

RESULTS

Overall, 77%, 56%, 51%, 46% and 28% reported problems in the pain/discomfort, usual activities, anxiety/depression, mobility and self-care dimensions of EQ-5D-5L. Mean ± SD EQ VAS, DLQI and DLQI-R scores were 64.29 ± 22.68, 11.75 ± 8.11 and 12.19 ± 8.33, respectively. Skindex-16 responses indicated that the emotional burden of HS (64.55 ± 29.28) far exceeded those of functioning (49.40 ± 34.70) and physical symptoms (46.74 ± 29.36). EQ-5D-5L, EQ VAS, DLQI, DLQI-R and Skindex-16 total scores had moderate or strong correlations with each other (range: |0.487| to |0.993|), weak or moderate correlations with HS-PGA (|0.350| to |0.433|) and weak correlations with MSS (|0.324| to |0.389|). DLQI-R slightly outperformed DLQI both in terms of convergent and known-groups validity. Being female, lower education level, more severe disease and genital involvement were associated with worse HRQoL (P < 0.05).

CONCLUSION

This study provides high-quality evidence that among skin-specific outcomes, the DLQI, DLQI-R and Skindex-16, and among generic instruments, the EQ-5D-5L are suitable to be used in HS patients. In future research, we recommend the use of existing well-validated HRQoL tools instead of developing new measures for each study. The development of composite measures that combine physician- and patient-reported outcomes is not supported by evidence in HS. [Correction added on 25 July 2020, after first online publication: in the Abstract section, the ± signs were missing and have been added to this version.].

IL-17 in inflammatory skin diseases psoriasis and hidradenitis suppurativa

The skin is one of the most important organs in the body, providing integrity and acting as a barrier to exclude microbes, allergens and chemicals. However, chronic skin inflammation can result when barrier function is defective and immune responses are dysregulated or misdirected against harmless or self-antigens. During the last 15 years interleukin (IL)-17 cytokines have emerged as key players in multiple inflammatory disorders, and they appear to be especially prominent in skin inflammation. IL-17 cytokines produced by T cells and other cell types potently activate keratinocytes to promote inflammation in a feed-forward loop. Given this key pathogenic role of the IL-17 pathway in autoimmune and inflammatory disease, it has been the focus of intense efforts to target therapeutically. The inflammatory effects of IL-17 can be targeted directly by blocking the cytokine or its receptor, or indirectly by blocking cytokines upstream of IL-17-producing cells. Psoriasis has been the major success story for anti-IL-17 drugs, where they have proven more effective than in other indications. Hidradenitis suppurativa (HS) is another inflammatory skin disease which, despite carrying a higher burden than psoriasis, is poorly recognized and under-diagnosed, and current treatment options are inadequate. Recently, a key role for the IL-17 pathway in the pathogenesis of HS has emerged, prompting clinical trials with a variety of IL-17 inhibitors. In this review, we discuss the roles of IL-17A, IL-17F and IL-17C in psoriasis and HS and the strategies taken to target the IL-17 pathway therapeutically.

Validation of the Three-Item Skindex-Mini Among Hidradenitis Suppurativa Patients With Diverse Racial Backgrounds

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that severely impairs patients' quality of life (QoL). Instruments such as the 10-item Dermatology Life Quality Index and 16-item Skindex-16 have been used to assess QoL in HS; however, it is unknown whether the shorter 3-item Skindex-mini can also provide an accurate assessment of skin-related QoL in patients with HS.

OBJECTIVES

The aim was to assess how well the Skindex-16 correlates with its shorter adaptation, the Skindex-mini, in capturing QoL among patients with HS.

METHODS

This retrospective cross-sectional study included all HS patients seen in the HS Clinic at The Emory Clinic between January 1, 2019, and August 16, 2019. We compared the correlation between the symptom, emotion, and function domains of the Skindex-16 and Skindex-mini using Pearson correlation coefficients (CC). Secondary outcome measures included individual survey item analysis, ItchyQuant scores, and numeric rating scale of pain.

RESULTS

We identified 108 encounters among 75 unique hidradenitis suppurativa patients (43 black/African American, 18 white, 5 Asian/Pacific Islander, 3 Latino, 4 Other, 2 unknown). Pearson CC between the Skindex-16 and Skindex-mini domain scores for all encounters were 0.770 (P < .001), 0.787 (P < .001), and 0.801 (P < .001) for the symptom, emotion, and function domains, respectively. The mean pain and ItchyQuant scores were 4.14 (SD 3.31) and 3.55 (SD 3.34), respectively.

CONCLUSIONS

The Skindex-mini correlated highly with the Skindex-16 in a racially diverse group of patients with HS. The Skindex-mini is a streamlined QoL instrument that could be practically implemented into routine clinical care among diverse patients presenting to dermatology.

Medical and Surgical Management of Hidradenitis Suppurativa: A Review of International Treatment Guidelines and Implementation in General Dermatology Practice

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic painful skin disease that severely impairs patients' quality of life. While high-quality trials of HS therapies remain limited, medical knowledge of best treatment practices is rapidly evolving, leading to the recent publication of multiple international treatment guidelines for HS.

SUMMARY

This review compares international HS treatment guidelines, describes evidence for effectiveness of common and emerging HS therapies, and provides guidance for integrating evidence-based HS care into practice. Although over 50 medical and procedural treatments are mentioned across international HS guidelines, only adalimumab and infliximab have grade B/weak recommendation or higher across all major guidelines. This review describes the appropriate patient selection and effectiveness of the most commonly used medical and procedural treatments for HS. It also includes recommendations for counseling, dosing, and duration of medical therapies as well as procedure videos for the practicing dermatologist.

Baseline patient-reported outcomes from UNITE: an observational, international, multicentre registry to evaluate hidradenitis suppurativa in clinical practice

Background

Hidradenitis suppurativa (HS) is a chronic, inflammatory, skin condition associated with many comorbidities and often has a substantial impact on patients’ lives.

Objectives

To evaluate symptom burden and health‐related quality of life (HRQoL) at baseline in patients with HS in an observational, real‐world, clinical setting using several tools including a validated HS‐specific instrument.

Methods

This study evaluated HRQoL data from the international UNITE HS disease registry. Administration of patient‐reported outcome (PRO) instruments and collection of data were executed per local regulations. All data were assessed using descriptive statistical methods.

Results

PRO data from 529 adults and 65 adolescents were evaluated. Most adults (64.5%) and adolescents (73.8%) were classified as Hurley Stage II with substantial disease burden at baseline. HS had a large effect (mean DLQI = 12.6) and moderate effect (mean CDLQI = 6.9) on the lives of adults and adolescents, respectively. Approximately 58% of adults and 41% of adolescents had anxiety scores beyond the normal range; 30% of adults and 16% of adolescents exhibited symptoms of depression. Based on HSSA and HSIA scores, approximately 30% of adults reported a substantial burden of multiple HS clinical symptoms and more than 45% reported a significant emotional impact of HS that adversely affected their intimate relationships. Only 60% of adults were employed and of those, 64% reported at least some degree of impairment while working because of HS.

Conclusions

Based on PROs collected from patients enrolled in the UNITE registry, a real‐world, clinical setting, HS has a significant negative impact on the everyday lives of patients affected by this disease.

An Update on Health-Related Quality of Life and Patient-Reported Outcomes in Hidradenitis Suppurativa

Hidradenitis suppurativa is a common inflammatory skin condition which causes recurrent abscesses, sinuses and scarring in the axillae, groin and inframammary areas. As well as causing significant physical distress due to pain and discharge, the condition impacts psychological well-being with markedly impaired quality of life. Patients suffer pain, embarrassment and psychological distress with impairment of their work and intimate relationships marking it as one of the most distressing dermatological conditions. Numerous studies have documented markers of psychological distress encompassing the physical effects such as pain and itch, affects on mood and impaired function.

Review of Comorbidities of Hidradenitis Suppurativa: Implications for Daily Clinical Practice

Hidradenitis suppurativa (HS) is a chronic, recurrent skin inflammatory disease associated with a variety of comorbidities, like reduced quality of life, metabolic syndrome, sexual dysfunction, working disability, axial spondyloarthritis, inflammatory bowel disease, depression, and anxiety. Like psoriasis, HS patients have been found to have higher risk of cardiovascular death and suicide risk. Clinicians should be informed about these comorbidities so that appropriate screening is implemented. All this evidence suggests that for such a chronic, multi-comorbid disease, the use of validated outcomes to assess severity and effect of treatment, along with the use of clinically important patient reported outcomes, is essential. The potential of available treatments to negatively and positively affect these comorbidities should also be taken into account when designing treatment strategies. This review provides an outline of important HS comorbidities with emphasis on possible implications for daily clinical practice.

Quality of life measurement in hidradenitis suppurativa: position statement of the European Academy of Dermatology and Venereology task forces on Quality of Life and Patient-Oriented Outcomes and Acne, Rosacea and Hidradenitis Suppurativa

This paper is organized jointly by the European Academy of Dermatology and Venereology (EADV) Task Force (TF) on Quality of Life (QoL) and Patient-Oriented Outcomes and the EADV TF on acne, rosacea and hidradenitis suppurativa (ARHS). The purpose of this paper was to present current knowledge about QoL assessment in HS, including data on HS-specific health-related (HR) QoL instruments and HRQoL changes in clinical trials, and to make practical recommendations concerning the assessment of QoL in people with HS. HS results in significant quimp that is higher than in most other chronic skin diseases. HS impact in published studies was assessed predominantly (84% of studies) by the Dermatology Life Quality Index (DLQI). There is a lack of high-quality clinical trials in HS patients where HRQoL instruments have been used as outcome measures. One double-blind randomized placebo-controlled trial on infliximab with low number of participants reported significantly better HRQoL improvement in the treatment group than in the placebo group. Well-designed clinical studies in HS patients to compare different treatment methods, including surgical methods and assessing long-term effects, are needed. Because of lack of sufficient validation, the Task Forces are not at present able to recommend existing HS-specific HRQoL instruments for use in clinical studies. The EADV TFs recommend the dermatology-specific DLQI questionnaire for use in HS patients. The EADV TFs encourage the further development, validation and use of other HS-specific, dermatology-specific and generic instruments but such use should be based on the principles presented in the previous publications of the EADV TF on QoL and Patient-Oriented Outcomes.