Clinical Epidemiology and Management of Hidradenitis Suppurativa

Comprehensive and Updated Algorithm of Hidradenitis Suppurativa Management from the Experts

Management of hidradenitis suppurativa (HS) can be challenging and often requires a multimodal approach with use of on- and off-label medications. There has been a rapid expansion of available HS treatments in the years since the 2019 North American HS (NAHS) clinical management guidelines. Herein we present an up-to-date practical management algorithm based on the diagnosis and management strategies set forth by the 2019 NAHS guidelines using newly available literature. Evaluation and diagnosis of HS disease involves assessment of severity, extent of disease, and impact on patient quality of life. Initial diagnosis of HS should be shortly followed by comorbidity screening. The multimodal approach to HS treatment typically involves use of treatment stacking of topical therapies, systemic and topical antibiotics, retinoids, hormonal and metabolic therapies, biologics and small molecule inhibitors, systemic immunosuppressants, surgical treatment, pain management, lifestyle modifications, adjunctive treatment, wound care, and flare therapy. Thus, the proposed algorithm aims to guide clinicians in their implementation of treatment stacking in HS.

A diverse hidradenitis suppurativa cohort: A retrospective cross-sectional study of 13,130 patients from a large US health care system database from 1995 to 2022

BACKGROUND

Most epidemiological studies of hidradenitis suppurativa (HS) have described homogeneous patient populations.

OBJECTIVE

To characterize demographics, modifiable health behaviors, and comorbidities of HS patients within a diverse cohort.

METHODS

A retrospective cross-sectional study of 13,130 HS patients within a health care system was conducted.

RESULTS

A female sex bias of ∼3:1 in all racial/ethnic subgroups was observed. Black/African American (AA) patients had a lower age at HS diagnosis than White patients (37.1 years vs 39.4 years, P < .001). A higher proportion of Black/AA females than White females with HS had body mass index in the obese range (69.9% vs 56.5%; P = .03). In contrast, fewer Black/AA males with HS had a body mass index in the obese range compared to White males (51.4% vs 61.0%; P < .001). More Black/AA patients than White patients with HS had congestive heart failure (odds ratio (OR) = 2.10, confidence interval (CI) = 1.19-3.78; P < .05), chronic pulmonary disease (OR = 1.34; CI = 1.02-1.78; P < .05), diabetes with chronic complication (OR = 1.73; CI = 1.16-2.60; P < .05), renal disease (OR = 2.66; CI = 1.67-4.34; P < .05), and Charlson comorbidity index score ≥4 (OR = 1.67; CI = 1.09-2.58; P < .05). Furthermore, male patients were more likely than female patients to have renal disease (OR = 2.62; CI = 1.66-4.14; P < .05).

LIMITATIONS

A single-center study.

CONCLUSION

Subgroups of HS patients had significant differences in demographics, risk factors, and comorbid conditions.

Factors Associated with Severe Hidradenitis Suppurativa, Using Hurley Staging and Metascore

INTRODUCTION

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease for which certain risk factors are well known: obesity and smoking (in particular). However, the factors associated with more severe conditions, and therefore potential aggravators of the disease, remain a matter of debate. Our study aims to determine the clinical factors associated with severe HS using several severity scores.

METHODS

The data were obtained via the ERHS questionnaire from patients exclusively recruited at Erasme Hospital in Brussels. The severity of HS was firstly estimated by the Hurley score, and secondly by a metascore, a system combining the iHS4, HS-PGA, SAHS, and DLQI. Univariable and multivariable analyses were performed.

RESULTS

Six hundred and forty-seven patients were included in the Hurley analysis, and 456 patients in the metascore analysis. In multivariable analysis, men have a more severe metascore than women (odds ratio [OR] = 1.89, p = 0.022), smoking was associated with a more severe disease according to metascore, especially in mild cases (OR = 0.76, p = 0.043), and an elevated body mass index was associated with having Hurley stage III disease compared to Hurley I or II disease (OR = 1.09, p = 0.001). A significant association is also shown between blood pressure and Hurley stage (OR = 0.97, p = 0.025). Self-reports of nonsteroidal anti-inflammatory drugs aggravating the disease is also a factor associated with greater severity according to the metascore (OR = 0.12, p = 0.008). Finally, several locations of HS lesions were associated with greater severity, in particular the armpits according to the metascore (OR = 0.29, p < 0.001), and the perianal area according to the Hurley score (OR = 0.15, p < 0.001).

CONCLUSION

HS seems to be more severe in men; smoking seems to aggravate mild cases of HS, while increased body mass index plays a major role in the transition from Hurley II to Hurley III.

Proof-of-concept study exploring the effect of spesolimab in patients with moderate-to-severe hidradenitis suppurativa: a randomized double-blind placebo-controlled clinical trial

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease with a considerable disease burden. Existing treatment options are limited and often suboptimal; a high unmet need exists for effective targeted therapies.

OBJECTIVES

To explore the effects of spesolimab treatment in patients with HS.

METHODS

This randomized double-blind placebo-controlled proof-of-clinical-concept (PoCC) study was conducted at 25 centres across 12 countries from 3 May 2021 to 21 April 2022. Patients had moderate-to-severe HS for ≥ 1 year before enrolment. Patients were randomized (2 : 1) to receive a loading dose of 3600-mg intravenous spesolimab (1200 mg at weeks 0, 1 and 2) or matching placebo, followed by maintenance with either 1200-mg subcutaneous spesolimab every 2 weeks from weeks 4 to 10 or matching placebo. The primary endpoint was the percentage change from baseline in total abscess and inflammatory nodule (AN) count at week 12. Secondary endpoints were the absolute change from baseline in the International Hidradenitis Suppurativa Severity Score System (IHS4), percentage change from baseline in draining tunnel (dT) count, the proportion of patients achieving a dT count of 0, absolute change from baseline in the revised Hidradenitis Suppurativa Area and Severity Index (HASI-R), the proportion of patients achieving Hidradenitis Suppurativa Clinical Response (HiSCR50), the proportion of patients with ≥ 1 flare (all at week 12) and patient-reported outcomes.

RESULTS

In this completed trial, randomized patients (n = 52) received spesolimab (n = 35) or placebo (n = 17). The difference vs. placebo in least squares mean is reported. At week 12, the percentage change in total AN count was similar between treatment arms: -4.1% [95% confidence interval (CI) -31.7 to 23.4]. There was greater numerical improvement in the spesolimab arm, as measured by IHS4 (13.9, 95% CI -25.6 to -2.3); percentage change from baseline in dT count (-96.6%, 95% CI -154.5 to -38.8); and the proportion of patients achieving a dT count of 0 (18.3%, 95% CI -7.9 to 37.5). Spesolimab treatment also improved HASI-R and HiSCR50 vs. placebo. Spesolimab demonstrated a favourable safety profile, similar to that observed in trials in other diseases.

CONCLUSIONS

This exploratory PoCC study supports the development of spesolimab as a new therapeutic option in HS.

Metabolomic and lipidomic fingerprints in inflammatory skin diseases - Systemic illumination of atopic dermatitis, hidradenitis suppurativa and plaque psoriasis

Auto-inflammatory skin diseases place considerable symptomatic and emotional burden on the affected and put pressure on healthcare expenditures. Although most apparent symptoms manifest on the skin, the systemic inflammation merits a deeper analysis beyond the surface. We set out to identify systemic commonalities, as well as differences in the metabolome and lipidome when comparing between diseases and healthy controls. Lipidomic and metabolomic LC-MS profiling was applied, using plasma samples collected from patients suffering from atopic dermatitis, plaque-type psoriasis or hidradenitis suppurativa or healthy controls. Plasma profiles revealed a notable shift in the non-enzymatic anti-oxidant defense in all three inflammatory disorders, placing cysteine metabolism at the center of potential dysregulation. Lipid network enrichment additionally indicated the disease-specific provision of lipid mediators associated with key roles in inflammation signaling. These findings will help to disentangle the systemic components of autoimmune dermatological diseases, paving the way to individualized therapy and improved prognosis.

Comorbidities, Clinical Presentation, Subtypes, and Treatment of HS Patients in Lithuania

Background: Hidradenitis suppurativa (HS) is a persistent, recurring skin inflammatory condition linked to various comorbidities. Management involves antibiotics, hormone therapy, immune-modulating drugs, surgery, and treatment of comorbidities. The objectives of the study were to assess the comorbidities, clinical presentation subtypes, and applied treatment of patients with HS. Methods: Patients with HS who visited the Centre of Dermatovenereology at Vilnius University Hospital Santaros Klinikos in Lithuania underwent evaluation based on the guidelines of the European Hidradenitis Suppurativa Foundation Registry questionnaire. Results: The study included 49 patients, and 61.22% (n = 30) had comorbidities. A strong positive correlation was found between a family history of inflammatory diseases (69.38% (n = 34)) and the severity of HS according to Hurley stage (r = 0.71 p < 0.05). A statistically significant correlation (r = 0.944, p = 0.02) was found between metabolic comorbidities and Hurley stage. Patients on biologic treatment had a mean IHS4 of 7.38 at the beginning of treatment and 3.22 at follow-up (p < 0.05). For patients not on biologics, the initial IHS4 score was 6.21 and 5.42 at follow-up (p > 0.05). Conclusions: A family history of inflammatory diseases and metabolic comorbidities showed a strong correlation with HS severity. Treatment with biologics showed significant improvement in HS scores compared to systemic antibiotics.

A Rare Case of Pregnancy After Surgical Treatment for Stage III Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic inflammatory skin condition primarily affecting areas with apocrine glands. It commonly manifests as painful nodules, abscesses, and sinus tracts, significantly impacting the patient's well-being. In this report, we discuss a case of a 32-year-old pregnant woman with Hurley stage III hidradenitis suppurativa who had undergone surgical reconstruction of the vulva before conception. The patient underwent a cesarian section and received topical treatment for her lesions near the genitalia. The importance of early identification, a collaborative approach involving multiple specialists, and individualized treatment strategies for managing this debilitating condition during pregnancy are emphasized in this case study.

Epidemiology of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent skin disease affecting hair follicles in predominantly intertriginous areas, characterized by deep, painful nodules and abscesses, fistulas, sinus tracts, and scarring. The estimated global prevalence of HS is highly variable, as revealed in a growing body of published literature, and ranges from 0.053% to 4.1%. In North American and European patients, HS is three times more common in women than men, whereas in South Korea and Japan, male predominance is found. The disease most frequently manifests itself between the ages of 18 and 29. Numerous published studies have reported the association between smoking, obesity, and HS, although there are limitations in confirming the causal relationship due to the retrospective design of the available studies. Case-control studies have frequently evaluated the association between HS, metabolic syndrome, and other systemic comorbidities. Due to increased mental health problems, a higher risk of suicide in patients with HS has been reported. We provide up-to-date evidence about the epidemiology, genetic and environmental risk factors, comorbidities, and quality of life of patients with HS. The divergence in HS frequency, possibly due to differences in populations and methodologies, remains to be explained in future worldwide studies.

Incidence, Risk Factors, and Prognosis of Hidradenitis Suppurativa Across the Globe: Insights from the Literature

Hidradenitis suppurativa, a chronic inflammatory disease of the skin, affects a patient's quality of life to a greater extent. While the disease burden, including its incidence and prevalence, has been extensively studied in the western population, there is a paucity of data from developing countries on the epidemiology of Hidradenitis suppurativa. Therefore, a general literature review was conducted to shed light on the epidemiology of Hidradenitis suppurativa across the globe. We reviewed the most recently available information on epidemiology, including incidence, prevalence, risk factors, prognosis and quality of life, complications, and associated comorbid among patients with Hidradenitis suppurativa. The estimated global prevalence of Hidradenitis suppurativa is found to be 0.00033-4.1%, with a relatively higher prevalence of 0.7-1.2% in European and US populations. Both genetic and environmental factors are associated with Hidradenitis suppurativa. Patients with Hidradenitis suppurativa have associated comorbid such as cardiovascular disease, type II diabetes mellitus, mental health issues, and sleep and sexual dysfunctions. These patients spend poor quality of life and tend to be less productive. Future studies are needed to assess the burden of Hidradenitis suppurativa in developing countries. Since the disease tends to be underdiagnosed, future studies should rely on clinical diagnosis rather than self-reporting to avoid the potential of recall bias. Attention needs to be diverted to developing countries with less amount of data on Hidradenitis suppurativa.

Special Issue "Reproductive Health Concerns for Women"

There are specific health issues concerning the reproductive age of women, including inflammatory disease, fertility, and childbearing [...].

Shoulder dystocia and composite adverse outcomes for the maternal-neonatal dyad

BACKGROUND

Although the neonatal morbidity associated with shoulder dystocia are well known, the maternal morbidity caused by this obstetrical emergency is infrequently reported.

OBJECTIVE

This study aimed to assess the composite adverse maternal and neonatal outcomes among vaginal deliveries (at 34 weeks or later) with and without shoulder dystocia.

STUDY DESIGN

This is a secondary analysis of the Consortium of Safe Labor, an observational obstetrical cohort of all vaginal deliveries occurring at 19 hospitals (from 2002-2008) and for which data on the occurrence of shoulder dystocia were available. The composite adverse maternal outcome included third- or fourth-degree perineal laceration, postpartum hemorrhage (>500 cc blood loss for a vaginal delivery and >1000 cc blood loss for cesarean delivery), blood transfusion, chorioamnionitis, endometritis, thromboembolism, admission to intensive care unit, or maternal death. The composite adverse neonatal outcome included an Apgar score of <7 at 5 minutes, a birth injury, neonatal seizure, hypoxic ischemic encephalopathy, or neonatal death. A multivariable Poisson regression was used to estimate the adjusted relative risks with 95% confidence intervals. The area under the receiver operating characteristic curve was constructed to determine if clinical factors would identify shoulder dystocia.

RESULTS

Of the 228,438 women in the overall cohort, 130,008 (59.6%) met the inclusion criteria, and among them, shoulder dystocia was documented in 2159 (1.7%) cases. The rate of composite maternal morbidity was significantly higher among deliveries with shoulder dystocia (14.7%) than without (8.6%; adjusted relative risk, 1.71; 95% confidence interval, 1.64-2.01). The most common maternal morbidity with shoulder dystocia was a third- or fourth-degree laceration (adjusted relative risk, 2.82; 95% confidence interval, 2.39-3.31). The risk of composite neonatal morbidity with shoulder dystocia (12.2%) was also significantly higher than without shoulder dystocia (2.4%) (adjusted relative risk, 5.18; 95% confidence interval, 4.60-5.84). The most common neonatal morbidity was birth injury (adjusted relative risk, 5.39; 95% confidence interval, 4.71-6.17). The area under the curve for maternal characteristics to identify shoulder dystocia was 0.66 and it was 0.67 for intrapartum factors.

CONCLUSION

Although shoulder dystocia is unpredictable, the associated morbidity affects both mothers and newborns. The focus should be on concurrently averting the composite morbidity for the maternal-neonatal dyad with shoulder dystocia.