Association of hidradenitis suppurativa disease severity with increased risk for systemic comorbidities

Autoimmune, Autoinflammatory Disease and Cutaneous Malignancy Associations with Hidradenitis Suppurativa: A Cross-Sectional Study

BACKGROUND

Hidradenitis suppurativa (HS) is a debilitating cutaneous disease characterized by severe painful inflammatory nodules/abscesses. At present, data regarding the epidemiology and pathophysiology of this disease are limited.

OBJECTIVE

To define the prevalence and comorbidity associations of HS.

METHODS

This was a cross-sectional study of EPICTM Cosmos© examining over 180 million US patients. Prevalences were calculated by demographic and odds ratios (OR) and identified comorbidity correlations.

RESULTS

All examined metabolism-related, psychological, and autoimmune/autoinflammatory (AI) diseases correlated with HS. The strongest associations were with pyoderma gangrenosum [OR 26.56; confidence interval (CI): 24.98-28.23], Down syndrome (OR 11.31; CI 10.93-11.70), and polycystic ovarian syndrome (OR 11.24; CI 11.09-11.38). Novel AI associations were found between HS and lupus (OR 6.60; CI 6.26-6.94) and multiple sclerosis (MS; OR 2.38; CI 2.29-2.48). Cutaneous malignancies were largely not associated in the unsegmented cohort; however, among Black patients, novel associations with melanoma (OR 2.39; CI 1.86-3.08) and basal cell carcinoma (OR 2.69; CI 2.15-3.36) were identified.

LIMITATIONS

International Classification of Diseases (ICD)-based disease identification relies on coding fidelity and diagnostic accuracy.

CONCLUSION

This is the first study to identify correlations between HS with melanoma and basal cell carcinoma (BCC) among Black patients as well as MS and lupus in all patients with HS.

What should a surgeon know about hidradenitis suppurativa?

Otherwise known as Verneuil's disease, hidradenitis suppurative (HS) is a severe dermatosis of heterogeneous appearance affecting 1% of the population. Its pathophysiology is multifactorial, involving genetic predisposition, inflammatory disorder and environmental elements. Its diagnosis is based on the association of three clinical characteristics: characteristic lesions, typical localizations, and the chronic and recurrent nature of the lesions. Given its diversified aspects, diagnosis can be difficult to achieve. As its manifestations often include abscesses, it is important for the surgeon to know how to detect this pathology. The development of biologics has improved treatment of this disease, treatment that necessitates a multidisciplinary medical and surgical approach involving dermatologists and proctologists as well as surgeons. The objective of this report is to synthesize what a surgeon will need to know so as effectively treat HS patients.

Hidradenitis Suppurativa: Molecular Etiology, Pathophysiology, and Management-A Systematic Review

Hidradenitis suppurativa is a chronic inflammatory skin condition that affects the hair follicles in areas of the body with apocrine glands. The condition is characterized by recurrent, painful nodules, abscesses, and draining sinuses that can lead to scarring and disfigurement. In this present study, we provide a focused evaluation of recent developments in hidradenitis suppurativa research, including novel therapeutics and promising biomarkers that may facilitate clinical diagnosis and treatment. We conducted a systematic review of controlled trials, randomized controlled trials, meta-analyses, case reports, and Cochrane Review articles in accordance with the PRISMA guidelines. The Cochrane Library, PubMed, EMBASE, and Epistemonikos databases were queried via Title/Abstract screen. Eligibility criteria included the following: (1) has a primary focus on hidradenitis suppurativa, (2) includes measurable outcomes data with robust comparators, (3) details the sample population, (4) English language, and (5) archived as full-text journal articles. A total of 42 eligible articles were selected for review. Qualitative evaluation identified numerous developments in our understanding of the disease's multiple potential etiologies, pathophysiology, and treatment options. It is important for individuals with hidradenitis suppurativa to work closely with a healthcare provider to develop a comprehensive treatment plan that addresses their individual needs and goals. To meet this objective, providers must keep current with developments in the genetic, immunological, microbiological, and environmental factors contributing to the disease's development and progression.

Metformin Treatment of Hidradenitis Suppurativa: Effect on Metabolic Parameters, Inflammation, Cardiovascular Risk Biomarkers, and Immune Mediators

Hidradenitis suppurativa (HS) is a common cutaneous and systemic inflammatory disease with a significant impact on mental health and quality of life. It is associated with obesity, insulin resistance, metabolic syndrome, cardiovascular (CV) disease, and increased all-cause mortality. Metformin is used frequently in HS treatment and is effective for some patients. The mechanism of action of metformin in HS is unknown. A case-control study of 40 patients with HS (20 on metformin and 20 controls) was conducted to assess differences in metabolic markers, inflammation (C-reactive protein [CRP], serum adipokines, and CV risk biomarkers), and serum immune mediators. Body mass index (BMI), insulin resistance (77%), and metabolic syndrome (44%) were high overall, but not significantly different between the groups. This highlights the need for co-morbidity screening and management. A significant reduction in fasting insulin and a trend towards a reduction in insulin resistance were identified in the metformin group compared with pre-treatment levels. CV risk biomarkers were significantly favourable in the metformin group (lymphocytes, monocyte-lymphocyte ratio, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio). CRP was lower in the metformin group but was not statistically significant. Adipokines were dysregulated overall but were not different between the two groups. Serum IFN-γ, IL-8, TNF-α, and CXCL1 trended lower in the metformin group but did not reach significance. These results suggest that metformin improves CV risk biomarkers and insulin resistance in patients with HS. When the results of this study are considered alongside other studies in HS and related conditions, it is likely that metformin also has beneficial effects on metabolic markers and systemic inflammation in HS (CRP, serum adipokines, and immune mediators), warranting further research.

African American race is a risk factor for severe hidradenitis suppurativa

BACKGROUND

African Americans face a disproportionate incidence and prevalence of hidradenitis suppurativa (HS) in the United States, but HS severity and outcomes across racial and ethnic groups have not been well-established while controlling for potentially confounding factors. In this retrospective cohort study, we investigated the associations of race and ethnicity with HS severity, emergency department (ED) visits, hospitalizations, and surgeries for HS while controlling for age, sex, body mass index (BMI), tobacco use, and insurance type.

METHODS

We reviewed 1190 patients seen at the Medical College of Wisconsin with ≥3 encounters for HS between 1/1/2002 and 3/19/2019, excluding those without race data or an encounter in which HS was treated.

RESULTS

A total of 953 patients were included; 470 patients were Black or African American non-Hispanic (49%), 39 Hispanic (4%), 418 White non-Hispanic (44%), and 26 other race or ethnicity (3%). Controlling for age, sex, BMI, tobacco use, and insurance type, Black patients had 2.8 times the odds of having Hurley stage III disease (95% CI 1.76-4.45, P < 0.001), 2.86 times the risk for experiencing an ED visit for HS (95% CI 2.12-3.88, P < 0.001), 2.25 times the risk for experiencing a hospitalization for HS (95% CI 1.42-3.56, P < 0.001), and 1.61 times the risk for experiencing a surgical encounter for HS (95% CI 1.34-1.95, P < 0.001) when compared to White patients.

CONCLUSIONS

African Americans face significant disparities in HS severity, ED visits, hospitalizations, and surgeries. The causes of these disparities must be further investigated and addressed.

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.

Real-world safety and effectiveness of adalimumab in patients with hidradenitis suppurativa: 12-week interim analysis of post-marketing surveillance in Japan

Hidradenitis suppurativa (HS) is a painful chronic skin disease characterized by abscesses, nodules, and tunnels in the skin. Adalimumab, a monoclonal antibody against tumor necrosis factor‐α, is approved for the treatment of HS in Europe, the USA, and Japan. This multicenter, open‐label, post‐marketing, observational study (ClinicalTrials.gov: NCT03894956) evaluated the safety and effectiveness of adalimumab in routine clinical practice in Japan (March 2019–May 2021). Patients with HS were treated with s.c. doses of adalimumab according to the dosage described in the package insert. The primary end‐point was safety (data cut‐off, December 2020). Secondary end‐points assessed effectiveness, including HS Clinical Response (HiSCR), skin pain, Dermatology Life Quality Index (DLQI), and C‐reactive protein (CRP). Here, we report 12‐week interim effectiveness results. A total of 84 eligible patients from 65 sites were enrolled; 83 patients were included in this analysis. Mean age was 42.0 years, mean body mass index was 26.9 kg/m², 78.3% of patients were male, 61.4% had Hurley stage III disease, 39.8% had a disease duration ≥10 years, and 7.2% had a family history of HS. The most common affected sites were the axilla (60.2%), buttocks (59.0%), and the inguinal and femoral regions (47.0%). Mean abscess and inflammatory nodule count was 13.0 (standard deviation, 12.0). Among patients with a comorbidity (57.8%), the most common were diabetes mellitus, hypertension, and chronic kidney disease. No patient reported a serious infection or any safety event of special interest. One patient died from a serious adverse event of cardiac failure unrelated to adalimumab. At week 12, 57.4% of patients achieved HiSCR, and significant reductions from baseline in skin pain, DLQI (both p < 0.0001), and CRP (p = 0.0029) were observed. These results support the administration of adalimumab as a well‐tolerated and effective treatment for Japanese patients with HS in real‐world clinical practice.

Insights into the Pathogenesis of HS and Therapeutical Approaches

Hidradenitis suppurativa (HS) is a debilitating, chronic, (auto)inflammatory disease primarily affecting apocrine gland-rich areas of the body. Although pathogenic mechanisms responsible for HS have not yet been fully elucidated, it is a multifactorial process whose main target is the terminal follicle. The role of the inflammatory process (and consequently of cytokine milieu) and of several other factors (genetics, lifestyle, hormonal status, microbiome, innate and adaptive immune systems) involved in HS pathogenesis has been investigated (and often defined) over the years with a view to transferring research results from bench to bedside and describing a unique and universally accepted pathogenetic model. This review will update readers on recent advances in our understanding of HS pathogenesis and novel (potential) medical therapies for patients with moderate-to-severe HS.

Hidradenitis Suppurativa: Where We Are and Where We Are Going

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease primarily affecting apocrine gland-rich areas of the body. It is a multifactorial disease in which genetic and environmental factors play a key role. The primary defect in HS pathophysiology involves follicular occlusion of the folliculopilosebaceous unit, followed by follicular rupture and immune responses. Innate pro-inflammatory cytokines (e.g., IL-1β, and TNF-α); mediators of activated T helper (Th)1 and Th17 cells (e.g., IFN-γ, and IL-17); and effector mechanisms of neutrophilic granulocytes, macrophages, and plasma cells are involved. On the other hand, HS lesions contain anti-inflammatory mediators (e.g., IL-10) and show limited activity of Th22 cells. The inflammatory vicious circle finally results in pain, purulence, tissue destruction, and scarring. HS pathogenesis is still enigmatic, and a valid animal model for HS is currently not available. All these aspects represent a challenge for the development of therapeutic approaches, which are urgently needed for this debilitating disease. Available treatments are limited, mostly off-label, and surgical interventions are often required to achieve remission. In this paper, we provide an overview of the current knowledge surrounding HS, including the diagnosis, pathogenesis, treatments, and existing translational studies.

The Impact of Body Mass Index Upon the Efficacy of Adalimumab in Hidradenitis Suppurativa

Elevated BMI in Hidradenitis Suppurativa is associated with decreased response to Adalimumab therapy. BMI is proposed to segregate distinct disease subtypes. It remains unresolved whether a threshold BMI exists above which increased dosages may provide clinical benefit. Individual patient data from 578 PIONEER Phase 3 participants were analyzed. Descriptive, multivariable regression analysis and receiver operating characteristic (ROC) curves were calculated to assess the relationship between BMI and clinical outcome measures using R v3.5.3. Participants in the overweight and obese BMI category had reduced odds (58 and 67%, respectively) of achieving HiSCR [OR = 0.42 (95%CI −0.19, 0.91) p = 0.03], [OR = 0.33 (95%CI 0.16, 0.67) p = 0.002] compared to participants with BMI < 25. Reduction in AN count and IHS4 score was not significantly associated. ROC analysis did not reveal any cut off value predictive of treatment outcome. No correlation between BMI and baseline disease activity or covariate interactions were identified. These findings suggest BMI is a significant covariate in the setting of lower baseline disease activity, supporting the concept of disease heterogeneity and differential therapeutic response to Adalimumab.

Prevalence of depression among children, adolescents, and adults with hidradenitis suppurativa

BACKGROUND

Information on prevalence of depression among children, adolescents, and adults with hidradenitis suppurativa (HS) is limited.

OBJECTIVE

To compare prevalence of depression in HS patients with that of controls.

METHODS

Cross-sectional analysis of 38,140 adult and 1162 pediatric HS patients and controls identified using data from electronic health records. Primary outcome was prevalent depression.

RESULTS

Prevalence of depression among adults with HS was 30.0% (95% Confidence interval [CI], 29.6-30.5), compared with 16.9% (95% CI, 16.7-17.1) among controls. Among children and adolescents with HS, prevalence of depression was 11.7% (95% CI, 10.0-13.7), compared with 4.1% (95% CI, 3.6-4.7) among controls. In adjusted analyses, adults and children/adolescents with HS had 1.26 (95% CI, 1.25-1.28; P < .001) and 1.42 (95% CI, 0.999-2.01; P = .051) times the odds of having depression relative to controls, respectively.

LIMITATIONS

We could not evaluate the influence of disease severity on the outcome.

CONCLUSION

Depression is prevalent among children, adolescents, and adults with HS. Periodic screening for depression may be warranted.

Lifestyle modifications associated with symptom improvement in hidradenitis suppurativa patients

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition that substantially reduces patient quality of life. Many HS patients ask their dermatologist about potential lifestyle modifications, such as following particular diets or avoiding specific products, in an attempt to alleviate their symptoms. However, insufficient research has been conducted to support well-informed lifestyle modification counseling, and patients frequently defer to anecdotal endorsements of various interventions found on social media support groups. Therefore, we sought to clarify what lifestyle modifications were capable of improving HS symptoms.

METHODS

We conducted a survey-based study to examine modifiable risk factors and their association with the severity of HS. Five hundred and ninety-one patients with HS participated in an online survey detailing the severity of their HS symptoms before and after various lifestyle interventions. Average improvements in both subjective and objective ratings of symptom severity were calculated and statistical differences between the levels of improvement seen among various categories of lifestyle interventions were determined.

RESULTS

Numerous lifestyle interventions including substantial weight loss, smoking cessation, use of gentle skin and depilatory products, and menstrual regulation were associated with both subjective and objective improvements in symptom severity.

CONCLUSIONS

Our results suggest that patients affected by HS may experience clinically significant improvement from a variety of lifestyle modifications.

A Unified Concept of Acne in the PAPA Spectrum Disorders

BACKGROUND

Acne is a common condition. Sometimes acne or acne-like features are a part of autoinflammatory diseases such as PAPA spectrum disorders. Our objective wasto determine whether acne in PAPA spectrum disorders has specific phenotypic traits.

SUMMARY

This is aliterature review on reported cases of patients with PAPA, PAMI, PASH, PAPASH, PsAPASH, PAC or PASS syndrome. Acne was classified into four categories: moderate, severe, nodulocystic, acne fulminans.One hundred patients were included. Age of onset of acne and topography were the same as in acne vulgaris. Acne's phenotype was at least severe (including acne fulminans, nodulocystic and severe) in 83% of cases. Genetic mutations or variants with potential pathological significance were reported in 49 patients. The addition of isotretinoin to biotherapies was required to control acne in several patients.

The findings of 18F-fluorodeoxyglucose positron emission tomography-computed tomography scan in patients with hidradenitis suppurativa in Malaysia: A multicenter study

Hidradenitis suppurativa (HS) is known to have association with systemic diseases with chronic inflammation such as psoriasis. We aim to describe the concomitant systemic inflammation in patients with HS using 18F-fluorodeoxyglucose positron emission tomography–computed tomography (¹⁸F-FDG PET/CT) scan. This was a case–control study conducted in three tertiary hospitals in Northern Malaysia from January to December 2017, involving HS patients aged 18 years and above. Thirty-two HS patients with age- and sex-matched controls were recruited with a mean age of 31.4 years (range: 18–56). Numerous cutaneous inflammatory foci were detected on FDG-PET/CT scan in clinically unapparent sites (27/32, 84.4%). Approximately 90.6%, 93.8%, and 50.0% of the patients had significantly higher cutaneous uptake over nasal, mandibular, and scalp regions, respectively (P < 0.0001). PET/CT scan did not detect any systemic inflammation unlike those found in psoriasis. Three (9.4%) patients had thyroid nodules with high uptake (maximum standard uptake values ranging from 2.9 to 11.3). Two of them were confirmed to have papillary thyroid carcinoma, while the third patient has inconclusive finding. ¹⁸F-FDG PET/CT scan may be useful to map disease burden of HS. Nonlesional inflammatory foci on the skin of the nose, mandibular, and scalp are probably significant. The association of thyroid carcinoma in HS warrants further evaluation.

Integrated multidisciplinary approach to hidradenitis suppurativa in clinical practice,

Background

The European hidradenitis suppurativa (HS) guidelines recommend a multidisciplinary approach for patients with HS and management of comorbidities.

Objective

We aimed to describe the organization of a multidisciplinary HS program and characterize the patient population.

Methods

We conducted a retrospective study of patients with HS undergoing prospectively defined multidisciplinary work-up including examinations by a dermatologist, plastic surgeon, smoking specialist, and nutritionist in our outpatient unit between October 2015 and January 2017.

Results

The study included 49 patients with a sex ratio of 1:1. A total of 73.4% of patients were smokers, 20.4% were overweight, 48.9% were obese, and 30.6% had symptoms of depression. The mean Sartorius score was 30.4 (±17.6). The outcome of plastic surgery consultation was as follows: 16 patients had operations, 5 were excluded based on medical history, 9 refused surgery, and 16 remained undecided. The refusal rates for consulting with the smoking cessation and nutrition specialists were 55.8% and 69.5%, respectively. Twelve patients received antibiotics, 9 received biologics, 9 underwent medico-surgical treatment, 9 underwent surgery, and 10 were lost to follow-up. The mean visual analogue scale score for satisfaction was 8.3 (±1.6; n = 28).

Conclusion

An integrated multidisciplinary care model for HS is associated with high patient satisfaction. Adherence to the proposed comorbidity management was higher in female patients and related to empathetic interactions with physicians.

Questionnaire-based epidemiological study of hidradenitis suppurativa in Japan revealing characteristics different from those in Western countries

Hidradenitis suppurativa (HS) is a chronic relapsing skin disease localized mainly on the apocrine gland‐bearing areas. In Japan, HS is yet to be fully understood, and no criteria have been established for its diagnosis or severity assessment. The purpose of this study was to investigate and characterize HS in Japan. We conducted a nationwide questionnaire‐based study, in which Japanese diagnostic criteria were proposed. Question items included age, sex, disease duration, past history, family history, smoking status, disease severity scores (Hurley stage, modified Sartorius score and Physician Global Assessment [PGA] score), treatments, comorbidities and prognosis. We analyzed 300 patients (219 males and 81 females) diagnosed with HS based on our criteria. Average disease duration was 92.3 ± 6.82 months. Only 12 (4%) patients had a family history of HS. Disease severity was classified by PGA score (mild, 100 [33.3%]; moderate, 133 [44.3%]; severe, 34 [11.3%]; most severe, 29 [9.7%]) and Hurley stage (I, 69 [23%]; II, 109 [36.3%]; III, 121 [40.3%]). Disease severities based on PGA score and Hurley stage were positively correlated to modified Sartorius score using the Kruskal–Wallis test (P < 0.001, respectively). Patients with diabetes mellitus showed higher PGA scores (χ² = 10.977, P = 0.01185). Presence of axillary lesions related to higher PGA scores (χ² = 8.6378, P = 0.03452). The results in this study and previous studies indicate that Japanese HS patients have different backgrounds from those in Western countries, and are characterized by male predominance, higher incidence of Hurley stages II and III, higher PGA scores in patients with axillary lesions and much fewer familial cases.

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.

Alexithymia, Psychological Distress, and Social Impairment in Patients with Hidradenitis Suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a rare, chronic, inflammatory skin disease characterized by deep-seated nodules, abscesses, and draining fistulas. HS has a substantial adverse impact on patients' lives. Only a few studies investigated the relationship between health-related quality of life, psychological distress, and emotional dysregulation in patients with HS. Alexithymia, namely the difficulty in describing or recognizing emotions, has been associated with various psychological disorders, such as anxiety, depression, and psychological distress.

OBJECTIVE

The aim of this study was to examine the prevalence of alexithymia in patients with HS and its association with demographic and clinical variables, quality of life indices, and psychological distress.

METHODS

Ninety outpatients with HS completed the 20-item Toronto Alexithymia Scale, the 12-item General Health Questionnaire (GHQ-12), the Dermatology Life Quality Index, the Skindex-17, and the 36-Item Short-Form Health Survey. Information on sociodemographic and clinical variables was retrieved from clinical records.

RESULTS

Alexithymia or borderline alexithymia was observed in 44.4% of patients with HS, with a higher prevalence of the alexithymic trait in women than in men (51.7 vs. 31.2%). We did not find any association between alexithymia and clinical variables. Of the entire sample analyzed, 46.1% reported high psychological distress; among them, 78% reported alexithymia or borderline alexithymia compared to 16.7% among GHQ noncases. Furthermore, HS patients with alexithymia or borderline alexithymia showed significantly higher scores on the Skindex-17 psychosocial scale and the Dermatology Life Quality Index, and a lower score on the mental component of the 36-item Short-Form Health Survey, than nonalexithymic patients.

CONCLUSIONS

Dermatologists should consider alexithymia in the diagnosis and treatment of HS patients, given its important role in psychological and psychosocial distress.

Dietary and metabolic factors in the pathogenesis of hidradenitis suppurativa: a systematic review

Hidradenitis suppurativa (HS) is a systemic recalcitrant inflammatory condition characterized by debilitating lesions with high morbidity. Its known association with obesity and smoking indicate correlation with other environmental factors, such as diet, suggesting a larger role for lifestyle modifications in disease treatment. This study seeks to assess the contribution of weight loss and dietary intake in HS management. A primary literature search was conducted using PubMed, Web of Science, and CINAHL in November 2018 to include association and intervention studies on the influence of diet and weight on HS. Twenty-five articles were included. Meta-analysis of nine case-control studies across Asia, Europe, and the United States showed that HS patients are four times more likely to be obese compared to the general population; random effects pooled odds ratio 4.022 (2.667-6.065), P < 0.001. Five articles assessed weight-loss interventions and revealed mixed findings. The remaining articles included three association studies on micronutrient levels, eight dietary intervention studies, and one article analyzing both micronutrient association and dietary intervention. Included articles in this systematic review reveal that low serum zinc and vitamin D levels are associated with increased lesion count in HS. Supplementation of zinc, vitamin D, vitamin B12, or exclusion of dairy or brewer's yeast can be effective in partial or complete lesion resolution. Reviewed data show that weight loss from bariatric surgery may lead to HS improvement but often results in more severe malnutrition that worsens or even leads to new onset HS post bariatric surgery. Future reporting is needed to conclusively determine the role of diet in HS.

Weight Loss and Dietary Interventions for Hidradenitis Suppurativa: A Systematic Review

Hidradenitis suppurativa (HS) is a common inflammatory disorder characterized by recurrent, painful, and malodorous abscesses and nodules predominantly in skin folds. HS is associated with substantial morbidity and poor quality of life. There are no curative therapies, and the only approved biologic drug has variable efficacy and requires high doses, making adjunct treatments crucial. An important risk factor for disease severity is obesity. Our primary objective was to conduct a systematic review examining weight loss and dietary interventions, in HS. Our secondary objective was to examine nutritional supplements in HS.A systematic literature search was conducted using Medline, EMBASE, and the Cochrane Database. We included all study types in adults (>18 years), with a minimum sample size of 5, examining the effects of any dietary or weight loss intervention on HS severity. Two authors screened n = 1279 articles of which 9 met inclusion criteria. All included studies were observational and all interventions were associated with various measures of decreased HS severity. Patient-controlled weight loss and bariatric surgery were associated with HS regression, though a subset of patients with significant increase in panniculi experienced exacerbations and required excision of excess skin. Diets demonstrating benefit eliminated dairy and brewer's yeast. Nutritional supplements including zinc gluconate, vitamin D, and riboflavin had a suppressive, rather than curative, effect on HS lesions in single studies. Overall, the reviewed interventions show promise as potential adjunct treatments in a HS management plan. Prospective randomized controlled trials should validate these findings.

Long-Wave Medical Infrared Thermography: A Clinical Biomarker of Inflammation in Hidradenitis Suppurativa/Acne Inversa

BACKGROUND

A more reliable classification of skin inflammation and severity of active disease results from ultrasound sonography and the new hidradenitis suppurativa/acne inversa (HS) classification system IHS4. However, an objective assessment of skin inflammation in a continuous mode is still the ultimate goal. Long-wave medical infrared thermography (MIT) may offer a blood flow and temperature differential assessment in inflammatory conditions.

OBJECTIVE

To evaluate the application of MIT in HS.

METHODS

Standardized photography of the areas involved or been candidates for HS involvement was performed and MIT pictures were taken simultaneously and superimposed on the photographs of 18 patients (11 female, 7 male, median age 38.75 years [95% confidence interval 28.5 and 51 years], Hurley score I 5.6%, Hurley score II 38.9%, and Hurley score III 55.5%). A modification of the Otsu's method facilitated the automatic lesion segmentation from the background, depicting the inflammation area. Moreover, MIT was administered in real-time mode during radical HS surgery.

RESULTS

A 1°C temperature difference from a corresponding symmetric body region was indicative of inflammation. MIT figures detected a gradual increase of skin temperature from 33.0°C in healthy skin on average to 35.0-36.6°C at the center of inflamma tory lesions in the axilla and to 35.4-36.9°C at the center of inflammation in the groin area. Real-time MIT assessment enabled the definition of the margins and depth of the surgical intervention during the procedure.

CONCLUSION

MIT is a promising tool for the detection of inflammation severity in HS lesions and can be used as a clinical biomarker in evaluation studies of medical and surgical HS treatment.

Association of Resilience With Depression and Health-Related Quality of Life for Patients With Hidradenitis Suppurativa

Importance

Hidradenitis suppurativa (HS) places a significant burden on the health-related quality of life (HRQOL) of patients, many of whom have depression. Resilience can play a role in mitigating the negative stressors, such as the symptoms of HS, on patients' mental health.

Objective

To investigate the correlation among resilience, depression, and HRQOL for patients with HS.

Design, Setting, and Participants

This cross-sectional survey study of 154 patients from 2 referral centers in the United States and in Denmark was conducted from June 1, 2016, to March 31, 2017. Patients were considered eligible if they were 18 years or older and had a visit for HS at 1 of the 2 referral centers in the past 2 years (from January 1, 2014, through December 31, 2016). Patients were excluded if they declined to participate, could not read or write in English or Danish, or had a cognitive disability that would preclude their understanding of the survey questions.

Main Outcomes and Measures

The survey instrument included 4 questionnaires: (1) a sociodemographic and clinical characteristics questionnaire, (2) the Brief Resilient Coping Scale, (3) the Hospital Anxiety and Depression Scale, and (4) the Dermatology Life Quality Index. The main outcome of interest was the HRQOL as measured by the Dermatology Life Quality Index.

Results

All 154 patients submitted a completed survey. The mean (SD) age of the participants was 40.93 (13.5) years; most participants were women (130 [84.4%]), and most participants self-identified as white (139 [90.2%]). The rate of depression among the patients in this study was comparable to those reported in previous studies; 55 patients (35.7%) were classified as having depression, and 32 patients (20.8%) had borderline depressive symptoms. Patient-rated HS severity and the depression score each independently estimated 27% and 10% of variation in HRQOL, respectively. The interaction term for resilience and depression was significant, indicating that resilience moderates depression. Analysis of the mediation effects of resilience was not significant, indicating that resilience did not mediate the association between depressive symptoms and HRQOL. The resilience score was significantly associated with depressive symptoms (regression coefficient a = -0.21; P < .001), and the depressive symptoms score (c = 0.637; P < .001) was significantly associated with lower HRQOL (c' = 0.644; P < .001). However, both the direct association (b = 0.033; P = .86) and the indirect association (a × b = 0.007; P = .87) of resilience with HRQOL were not significant.

Conclusions and Relevance

Patients with higher resilience levels experienced a smaller decrease in HRQOL as depressive symptoms increased. Because the findings suggest that resilience can be taught, there is an opportunity to develop a resiliency training program and investigate its role in stress levels and depressive symptoms, as well as in HRQOL and disease activity.

Gene expression of sphingolipid metabolism pathways is altered in hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a debilitating skin disease characterized by painful recurrent nodules and abscesses caused by chronic inflammation. Early events in the development of HS are believed to occur in the folliculopilosebaceous unit; however, the signaling pathways behind this mechanism are unknown. Sphingolipids, such as ceramide, are essential components of the skin and appendages and have important structural and signaling roles.

OBJECTIVE

We sought to explore whether the gene expression of enzymes involved in sphingolipid metabolic pathways is altered in HS.

METHODS

A microarray data set including 30 samples was used to compare the expression of sphingolipid-related enzymes in inflammatory skin lesions from HS patients (n = 17) with the expression in clinically healthy skin tissue (n = 13). Differential expression of sphingolipid metabolism-related genes was analyzed using Gene Expression Omnibus 2R.

RESULTS

HS lesional skin samples have significantly decreased expression of enzymes generating ceramide and sphingomyelin, increased expression of enzymes catabolizing ceramide to sphingosine, and increased expression of enzymes converting ceramide to galactosylceramide and gangliosides.

LIMITATIONS

Limitations of this study include assessing the expression of sphingolipid-related enzymes without assessing the levels of the related sphingolipids.

CONCLUSION

Our study suggests that sphingolipid metabolism is altered in HS lesional skin compared with normal skin.

Hidradenitis suppurativa, neutrophilic dermatoses and diverticular disease in a young African-American patient

Hidradenitis suppurativa (HS) is a chronic skin disorder of the terminal follicular epithelium of apocrine sweat glands, manifesting as painful and exudative papules, pustules, cysts or nodules. This inflammatory condition often presents with other systemic and cutaneous disorders. We present the case of an African-American man with HS who was also diagnosed with neutrophilic dermatoses and diverticular disease. Neutrophilic dermatosis was identified based on histopathology findings. Our patient underwent multiple surgeries for flaring of his skin condition. Colchicine and doxycycline were started, but the patient was not able to tolerate them. Humira was planned for treatment of HS and neutrophilic dermatosis but could not be pursued because of the pericolic abscess. Colonoscopy and radiological investigation revealed multiple colonic diverticuli, for which he initially underwent percutaneous drainage followed by surgical removal of sigmoid mass and colocutaneous fistula. Culture from the specimen revealed abnormal growth of Actinomyces.

Increased interleukin (IL)-17 serum levels in patients with hidradenitis suppurativa: Implications for treatment with anti-IL-17 agents

BACKGROUND

Biologics seem to offer a promising nonsurgical approach in hidradenitis suppurativa (HS), especially in disease with highly pronounced inflammation. Recent studies revealed increased expression of a broad range of cytokines in lesional HS skin, including interleukin (IL)-17.

OBJECTIVE

This study was undertaken to determine IL-17 serum levels in this group of patients.

METHODS

Our study was conducted on a group of 86 patients between 16 and 72 years of age with HS. A total of 86 matched healthy volunteers constituted the control group. Enzyme-linked immunosorbent assay kits were used to quantify IL-17 serum concentration.

RESULTS

The mean IL-17 serum level of patients with HS was 3.68 ± 2.08 pg/mL, which was significantly elevated (P < .0001) compared with that found in healthy volunteers (2.5 ± 1.11 pg/mL). Moreover, there was a tendency toward higher serum concentrations of IL-17 in patients with more advanced disease (P = .005). Disease duration; patient sex, age, and body mass index; and smoking habits were not determining factors for IL-17 serum concentration.

LIMITATIONS

Hospital-based study population was a limitation, as was a lack of posttreatment assessment.

CONCLUSION

In light of our findings and literature on increased expression of IL-17 in HS lesions, evaluating the clinical effectiveness of using anti-IL-17 agents in the treatment of patients with HS is justified.

Prevalence, Risk Factors, and Comorbidities of Hidradenitis Suppurativa

It is challenging to estimate a true prevalence of hidradenitis suppurativa (HS) because it is underdiagnosed and misdiagnosed. Prevalences have been reported from 0.00033% to 4.1%. The incidence seems to be rising. In addition to dermatologic symptoms, HS is associated with metabolic syndrome, and increased cardiovascular risk. The majority of HS patients are smokers. Additional somatic comorbidities complicating HS include autoimmune conditions, follicular syndromes, rheumatologic conditions, and malignancies. HS patients are troubled by psychological comorbidities. When treating HS patients it is imperative not only to treat the skin symptoms, but also address the screening and treatment of possible comorbidities.

Systemic associations of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a progressive, inflammatory disease that affects mostly young women and appears to be caused by inflammation of hair follicles in areas of friction in the body (eg, the axillae, groin, perineum, and medial aspects of the thighs). Given this pathophysiology, one might expect comorbidities that contribute to inflammation and friction. Observed comorbidities fall into several categories: obesity and the metabolic syndrome, hormone-related disorders, deleterious health habits and mood, autoimmune disease, inflammatory disease and finally, the risk of skin cancer and sequelae of nonhealing wounds. The available literature on comorbid diseases of HS is limited but rapidly increasing. In this review, we summarize recent and major studies of HS disease association.

Correlation of inflammatory serum markers with disease severity in patients with hidradenitis suppurativa (HS)

BACKGROUND

Data regarding the association of routinely obtained serum markers of inflammation, namely C-reactive protein (CRP), white blood cell count, and neutrophil count, with disease severity of hidradenitis suppurativa (HS) according to a scoring system have not been reported to our knowledge.

OBJECTIVE

We sought to evaluate these inflammatory serum markers for assessing disease severity of HS.

METHODS

Medical files of 275 patients who were referred to the outpatient HS center of the Department of Dermatology, Venereology, and Allergology, Ruhr-University Bochum, in 2013 were evaluated retrospectively.

RESULTS

CRP levels and neutrophil count significantly differed among Hurley stages I, II and III (P < .0001, P = .0002, respectively). There were significant positive correlations among CRP levels (r = 0.496, P < .0001) and neutrophil count (r = 0.330, P = .0009) with modified Hidradenitis Suppurativa Score. CRP was a significant independent predictor for Hurley stage III (odds ratio 1.077, 95% confidence interval 1.013-1.145, P = .016). CRP and body mass index were significant independent predictors for severe disease according to modified Hidradenitis Suppurativa Score (odds ratio 1.065, 95% confidence interval 1.015-1.117, P = .009; and odds ratio 1.12, 95% confidence interval 1.009-1.243, P = .032, respectively).

LIMITATIONS

Files were analyzed retrospectively.

CONCLUSION

These inflammatory markers, especially CRP, are effective for assessing the extent of disease severity and the grade of inflammation in patients with HS.

[What's new in clinical dermatology?]

Dermatoses have been better characterized as hypochromic vitiligo in subjects with dark skin or the acquired racquet nails associated with hyperparathyroidism. The innate immunity has a central role in the new classification of auto inflammatory diseases, neutrophilic dermatoses, neutrophilic urticaria or pseudo-neutrophilic urticaria. Comorbidities have been studied e.g. cardiovascular co morbidities for psoriasis, IBD associated with hidradenitis suppurativa or neurological disorders associated with pemphigoid. Bullous pemphigoid could be renamed as cutaneous pemphigoid, it can be induced by drugs especially gliptins. Genetic predispositions are analyzed in auto inflammatory diseases, psoriasis (HLA), drug eruptions (HLA or cytokines). Telaprevir often induces rashes, which can be severe but other treatments against hepatitis C as interferon can also induce debilitating rashes, some eligible for drug tolerance induction. European guidelines for the definition, classification, diagnosis of chronic spontaneous urticaria have been published. Severe cutaneous adverse drug reactions may be associated with severe systemic symptoms such as organ involvement in AGEP or the occurrence of a shock in DRESS. Allover Europe, there is now an epidemic of contact allergies to methylisothiazolinone (MIT), contained in cosmetics, wet wipes but also in paints. MIT should be tested at 2.000 ppm in water, included in the standard series for patch tests. Its role has to be evoked in any case localized on the face or hand, airborne or generalized eczema. Among infectious diseases, skin manifestations due to Parvovirus have been specified, a febrile rash can be related to dengue infection or to Zika virus.