Interventions for hidradenitis suppurativa: a Cochrane systematic review incorporating GRADE assessment of evidence quality

Procedural dermatology and its unmet need

Procedural dermatology includes invasive conventional dermatologic surgeries which involve significant use of knife and suture, minimally invasive procedures and device-based procedures. Device-based procedures are the easiest to learn and are less prone to human errors due to automation but can lead to monotony, while conventional surgeries require significant skill, craftsmanship and interest. There has been a recent shift in the approach to procedural dermatology as a therapeutic option with complementary and combination models replacing the conventional hierarchical model in which procedures were last in the step-ladder approach. The demand for both conventional dermatologic surgeries and minimally invasive cosmetic procedures is increasing. Unfortunately, this demand has not been met with adequate supply. Consequently, the number of trained professionals with expertise in these procedures is very limited; they are far outnumbered by unqualified practitioners. A limited number of dermatologic surgeons practicing conventional surgeries has resulted in huge waiting lists for vitiligo surgeries, inappropriate excisions for skin cancers and poor cosmetic outcomes of excisions without proper knowledge of flaps and grafts. Increasingly procedures are being performed by inadequately trained personnel, resulting in complications. There is also an absence of good quality research on the subject of procedural dermatology, which has resulted in a lack of standardisation of various procedures and knowledge about the efficacy of various drug-procedure and procedure-procedure combinations. An increasing variety of gimmicky but costly procedures are being offered to the public without much evidence of efficacy. Individual institutional and broad policy directives are needed to address these issues. Special emphasis is required on formal hands-on procedural dermatology training during residency and beyond it.

Research priorities in the management of hidradenitis suppurativa

There is a need for high-quality research to support the management of hidradenitis suppurativa. This letter offers suggestions for priority research topics derived from a stakeholder consensus meeting. Investigation of laser hair removal treatment, potentially in combination with medical treatment, was recognized as an important focus for future hidradenitis suppurativa research.

Inborn Errors of Immunity in Hidradenitis Suppurativa Pathogenesis and Disease Burden

Hidradenitis suppurativa (HS), also known as Verneuil's disease and acne inversa, is a prevalent, debilitating, and understudied inflammatory skin disease. It is marked by repeated bouts of pathological inflammation causing pain, hyperplasia, aberrant healing, and fibrosis. HS is difficult to manage and has many unmet medical needs. There is clinical and pharmacological evidence for extensive etiological heterogeneity with HS, suggesting that this clinical diagnosis is capturing a spectrum of disease entities. Human genetic studies provide robust insight into disease pathogenesis. They also can be used to resolve etiological heterogeneity and to identify drug targets. However, HS has not been extensively investigated with well-powered genetic studies. Here, we review what is known about its genetic architecture. We identify overlap in molecular, cellular, and clinical features between HS and inborn errors of immunity (IEI). This evidence indicates that HS may be an underrecognized component of IEI and suggests that undiagnosed IEI are present in HS cohorts. Inborn errors of immunity represent a salient opportunity for rapidly resolving the immunological landscape of HS pathogenesis, for prioritizing drug repurposing studies, and for improving the clinical management of HS.

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.

Establishing an Association between Polycystic Ovarian Syndrome and Pilonidal Disease in Adolescent Females

STUDY OBJECTIVE

We sought to determine whether pilonidal disease (PD) is associated with polycystic ovarian syndrome (PCOS) in adolescent females.

DESIGN

Retrospective cohort study SETTING: Urban tertiary children's hospital PARTICIPANTS: All girls aged 12 to 21 who received a diagnosis of PD and/or PCOS from 2012 to 2019 INTERVENTIONS: Treatment for PCOS and PD MAIN OUTCOME MEASURES: The variables analyzed included age, race/ethnicity, body mass index, age at menarche, tobacco use, payer status, treatment of PCOS and PD, and serum markers of hyperandrogenism and metabolic syndrome.

RESULTS

During the study period, 100,043 patients presented to an urban tertiary medical center. Of these patients, 966 were diagnosed with PD, and 219 were diagnosed with both PD and PCOS. Compared with patients with only PD, patients with both diagnoses had a higher body mass index (31.4 vs 27.4 kg/m²; P < .01) and were older (18.76 vs 18.30 years; P = .003). The prevalence ratio for patients with PD having PCOS per the original Rotterdam criteria was 26.1 (CI, 22.0-31.0) and 28.7 (CI, 24.3-33.9) for having PCOS per the modified Rotterdam criteria. Patients with both diagnoses were less likely to receive intervention for PD (OR = 0.22; CI, 0.13-0.37; P < .001).

CONCLUSIONS

Adolescent females diagnosed with PD are likely to demonstrate features of PCOS. PCOS treatment could positively alter the disease course of PD. As such, surgical providers should consider referring adolescent females with PD to endocrinologists, gynecologists, and adolescent medicine specialists for evaluation of PCOS.

Overview and comparison of the clinical scores in hidradenitis suppurativa: A real-life clinical data

Introduction

Partly due to its clinical heterogeneity, hidradenitis suppurativa (HS) is difficult to score accurately; illustrated by the large number of disease scores. In 2016, a systematic review by Ingram et al. reported the use of about thirty scores, and since then, this number has increased further. Our aim is twofold: to provide a succinct but detailed narrative review of the scores used to date, and to compare these scores with each other for individual patients.

Materials and methods

The review of the literature was done among articles in English and French, on Google, Google scholar, Pubmed, ScienceDirect and Cochrane. To illustrate the differences between scores, data from some Belgian patients included in the European Registry for HS were selected. A first series of patients compares the severity of the following scores: Hurley, Hurley Staging refined, three versions of Sartorius score (2003, 2007, 2009), Hidradenitis Suppurativa Physician Global Assessment (HS-PGA), International Hidradenitis Suppurativa Severity Scoring System (IHS4), Severity Assessment of Hidradenitis Suppurativa (SAHS), Hidradenitis Suppurativa Severity Index (HSSI), Acne Inversa Severity Index (AISI), the Static Metascore, and one score that is not specific to HS: Dermatology Life Quality Index (DLQI). A second set of patients illustrates how some scores change over time and with treatment: Hurley, Hurley Staging refined, Sartorius 2003, Sartorius 2007, HS-PGA, IHS4, SAHS, AISI, Hidradenitis Suppurativa Clinical Response (HiSCR), the very new iHS4-55, the Dynamic Metascore, and DLQI.

Results

Nineteen scores are detailed in this overview. We illustrate that for some patients, the scores do not predictably and consistently correlate with each other, either in an evaluation of the severity at a time-point t, or in the evaluation of the response to a treatment. Some patients in this cohort may be considered responders according to some scores, but non-responders according to others. The clinical heterogeneity of the disease, represented by its many phenotypes, seems partly to explain this difference.

Conclusion

These examples illustrate how the choice of a score can lead to different interpretations of the response to a treatment, or even potentially change the results of a randomized clinical trial.

Pain measurement in painful skin conditions and rheumatoid arthritis randomized controlled trials: a scoping review to inform pain measurement in hidradenitis suppurativa

BACKGROUND

Pain is the most common and bothersome symptom experienced by people with hidradenitis suppurativa (HS) and has been prioritized as an outcome domain by the HIdradenitis SuppuraTiva cORe outcomes set International Collaboration (HISTORIC).

OBJECTIVES

To perform a scoping review of pain measurement in randomized control trials (RCTs) of painful skin conditions (PSCs) and use of the pain numerical rating scale (NRS) and visual analogue scale (VAS) in rheumatoid arthritis RCTs, to inform the efforts of HISTORIC to reach consensus on how to measure pain intensity in HS trials.

METHODS

A search was conducted on several publication databases. Inclusion criteria were RCTs with a minimum of 10 participants that measured pain intensity.

RESULTS

Pain NRS and VAS were used in 68% of PSC trials. Respectively, 77% and 87% of PSC and rheumatoid arthritis RCTs did not specify the recall window. The commonest recall window in PSCs when specified was 24 h. In total, 33% of PSC trials assessed maximum pain intensity and 3% average pain intensity, while 87% of rheumatoid arthritis trials did not provide details. Pain data were reported as mean difference by 76% of PSC trials and 75% of rheumatoid arthritis trials. Respectively, 10% and 11% of PSC and rheumatoid arthritis studies reported pain as the percentage of patients reaching a desirable state and only 1% and 2% reported number needed to treat.

CONCLUSIONS

While pain NRS and VAS are standard methods to measure pain intensity in PSCs, key details such as the recall window are often omitted and there is no consensus on how to report pain NRS data. What is already known about this topic? Pain is the most burdensome symptom experienced by patients with hidradenitis suppurativa and has been prioritized as an outcome domain by the HIdradenitis SuppuraTiva cORe outcomes set International Collaboration (HISTORIC). What does this study add? Our review shows substantial variation in how pain numerical rating scale (NRS) and visual analogue scale are utilized in clinical trials. This variation restricts meta-analysis of pain intensity results. There is a need for consensus regarding the recall window for pain NRS and maximum vs. average pain, and whether current pain should be measured.

The Use of Botulinum Toxin in the Management of Hidradenitis Suppurativa: A Systematic Review

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by suppurative infection, sinus tract, and abscess formation. International management guidelines are largely consensus-based. Botulinum toxin (BTX) has been widely used in the treatment of apocrine and eccrine gland disorders, such as hyperhidrosis, although the effectiveness of BTX in the treatment of HS remains unknown. The aim of this systematic review was to understand the published evidence of BTX safety and effectiveness in the management of HS.

METHODS

We conducted a PRISMA-compliant, prospectively registered (PROSPERO, CRD42021228732), systematic review. We devised bespoke search strategy and applied it to the Cochrane Central Register of Controlled Trials, Medline, Embase, and OpenGrey up until March 2022. We included all clinical studies that reported outcomes following BTX treatment in patients diagnosed with HS (both adult and pediatric).

RESULTS

A total of 4658 studies were identified, of which six met full inclusion criteria reporting data on 26 patients. The six identified studies included one randomized control trial, one case series, and four case studies. The one included randomized control trial demonstrated a significant reduction in the Dermatology Life Quality Index score at 3 months following treatment with BTX.

CONCLUSIONS

The effectiveness and safety of BTX in the treatment of HS remain unknown. This systematic review identified a paucity of high-quality clinical data. Evidence of treatment effectiveness is likely to come from registry-based cohort studies using established core outcome sets in the first instance.

Potential use of microwave technology in dermatology

BACKGROUND

Microwaves are used in medicine for diagnostics, and treatment of cancer. Recently, novel microwave devices (Swift^®, Emblation Ltd, UK and miraDry^®, Miramar Labs Inc., CA) have been cleared by the FDA and Health Canada for various dermatological conditions.

OBJECTIVE AND METHODS

To review the dermatological use of microwave-based treatments (plantar warts, corns, actinic keratosis, dermatophytosis, axillary hyperhidrosis, osmidrosis, and hidradenitis suppurativa). Clinical trials, case reports, or in vitro studies for each condition are summarized.

RESULTS AND CONCLUSION

Microwaves are a promising alternative therapy for cutaneous warts, actinic keratosis, axillary hyperhidrosis, and osmidrosis, with favorable safety profiles. However, patients with hidradenitis suppurativa have had negative clinical outcomes. Limited treatment of corns showed good pain reduction but did not resolve hyperkeratosis. A preliminary in vitro study indicated that microwave treatment inhibits the growth of T. rubrum. We present the first case of toenail onychomycosis successfully treated with microwaves. Despite the advancements in the use of microwaves, the mechanism of action in non-ablative treatment is not well understood; further research is needed. More high-quality randomized clinical trials with larger groups and long follow-up periods are also required to evaluate the clinical benefits and possible adverse effects of microwaves in treating dermatological conditions.

Surgical Management of Hidradenitis Suppurativa: A Narrative Review

OBJECTIVE

Hidradenitis suppurativa (HS) is a debilitating, chronic, dermatological inflammatory skin disease that affects apocrine gland bearing skin in the axillae, groin, and inframammary regions. It is underdiagnosed and its pathogenesis incompletely understood. This paper provides a comprehensive review of the existing literature on the surgical management of HS, focusing upon outcomes of definitive surgery.

METHODS

A literature search was conducted according to PRISMA guidelines. PubMed and EMBASE databases were searched for original studies pertaining to the surgical management of HS published from January 1970 to July 2020. A total of 33 papers were included for analysis.

RESULTS

Management options include risk factor modification, pharmacological agents, and surgical intervention. Many surgical management techniques exist, including incision and drainage, CO₂ laser therapy, deroofing, wide local excision, and reconstructive surgery. Incision and drainage is commonly utilized for symptom relief of sepsis. While data on curative surgical management are lacking, studies on surgical approaches have shown favorable outcomes in highly selected cases.Wide excision with flap reconstruction results in high patient satisfaction rates, good cosmesis, and reduced disease recurrence.

LIMITATIONS

A small number of suitable papers met our specific focus and inclusion and exclusion criteria. Novel techniques described in case studies were missed. Additionally, this study examined HS management as a whole, but region-specific management was not reviewed closely.

CONCLUSION

The success of surgical management is dependent on multiple factors. Thus far, the precise role of surgery in elective treatment of refractory HS requires further analysis and reporting of outcomes.

Assessing the compliance of systematic review articles published in leading dermatology journals with the PRISMA statement guidelines: A systematic review

Background

Reporting quality of systematic reviews and meta-analyses is of critical importance in dermatology because of their key role in informing health care decisions.

Objective

To assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines.

Methods

This review was carried out in accordance with PRISMA guidelines. Included studies were reviews published across 6 years in the top 4 highest-impact-factor dermatology journals of 2017. Records and full texts were screened independently. Data analysis was conducted with univariate multivariable linear regression. The primary outcome was to assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the PRISMA statement.

Results

A total of 166 studies were included and mean PRISMA compliance across all articles was 73%. Compliance significantly improved over time (β = .016; P = <.001). The worst reported checklist item was item 5 (reporting on protocol existence), with a compliance of 15% of articles.

Conclusion

PRISMA compliance within leading dermatology journals could be improved; however, it is steadily improving.

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.

[Impact of LAight therapy on hidradenitis suppurativa care]

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease with high burden for patients and limited treatment options. We recently analyzed the efficacy of local treatment with LAight therapy, a combination of intense pulsed light (IPL) and radiofrequency (RF).

OBJECTIVES

The aim of the present survey was to compare care of HS patients under LAight with standard care prior to therapy.

MATERIALS AND METHODS

The retrospective study included 111 patients who were treated with LAight at least 5 times between 01/2014 and 03/2017. Primary endpoint was the change in surgical interventions. Secondary endpoints included additional patient-reported outcomes, e.g., effects on their quality of life.

RESULTS

In all, 50 completed surveys were available for evaluation. Under LAight therapy, the number of surgical interventions decreased from 3.2 to 0.3 per year (p < 0.001). Secondary endpoints were also significantly improved: The days of sick leave/year due to HS decreased from 30.4 to 7.2 (p = 0.002), and the number of doctor appointments due to HS flare ups was altered from 7.3 to 1.5 (p < 0.001). In line, patient-reported pain levels, general wellbeing and quality of life were also improved.

CONCLUSION

This retrospective assessment of patient-reported treatment outcomes of 50 HS cases after treatment with LAight revealed a significant reduction of required surgical interventions and sick-days along with improved quality of life. Thus, it appears that IPL + RF treatment not only improves disease activity, but also secondary care aspects. Future studies will need to confirm these findings in a controlled setting.

Efficacy and safety of adalimumab in hidradenitis suppurativa: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Adalimumab is used as a first-line biologic agent in the management of moderate-to-severe hidradenitis suppurativa (HS). The objective of the present study was to evaluate the efficacy and safety of adalimumab in patients with moderate-to-severe HS.

METHODS

We performed a systematic review and meta-analysis according to Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. Pooled estimates, namely standardized mean difference (SMD) and relative risk (RR), were calculated using random-effect model with trial sequential analysis. Small study effects were examined using the Doi plot. Certainty of evidence (CoE) was assessed using "The Grading of Recommendations Assessment, Development, and Evaluation" approach, and number-needed-to-treat (NNT) was calculated.

RESULTS

Five randomized controlled trials, involving 1014 patients, were included. We performed subgroup analysis of adalimumab administered subcutaneously both weekly and every other week. Adalimumab administered weekly was associated with better clinical response achievement (RR 1.76, 95% confidence interval [95% CI] 1.35-2.29; trial sequential analysis TSA-adjusted CI 1.01-3.08; CoE: low; NNT = 5) and a significant improvement in modified Sartorius score (SMD = -0.45, 95% CI = -0.76 to -0.13; CoE: very low; NNT = 10) and dermatology life quality index (DLQI) (SMD -0.47, 95% CI -0.61 to -0.32; CoE: low; NNT = 10). Nevertheless, adalimumab administered every other week showed an improvement only in modified Sartorius score. The pooled RRs of adverse events in both groups revealed no statistical significance when compared with the placebo.

CONCLUSIONS

Adalimumab administered weekly resulted in not only better clinical responses than placebo but also significantly improved disease severity and quality of life of patients with moderate-to-severe HS. Our study provides supporting evidence to the current guidelines and aids decision-making in the application of adalimumab in HS management.

Seven Years-Experience of adalimumab therapy for hidradenitis suppurativa in a real-life dermatologic setting

INTRODUCTION

Hidradenitis Suppurativa (HS) often causes severe impairment of the quality of life of patients affected, as it is characterized by recurrent relapses of inflammation and predisposes to retractive scars, with severe alteration of anatomy of the affected regions. Adalimumab is currently the only approved long-term biological therapy for this disease.

MATERIAL AND METHOD

we retrospectively review the data of HS patients treated with Adalimumab at the "Hidradenitis Suppurativa Clinic", University of Ferrara, Italy since the drug was first available to October 2020. The aim is to describe our real-life experience in a clinical outpatient service. We assessed the main demographic features, therapy duration, reasons of suspension and efficacy (evaluated by HiSCR - Hidradenitis Score) in relation to surgical procedures, hospitalization, number of areas involved by the disease and BMI >30. We also assessed the aspects related to the use of adalimumab's biosimilar.

RESULTS

data on 76 patients, with a mean age of 38.26 ± 14.74 years and mean BMI 28.10 ± 5.92 were collected. Most of the treated patients had Hurley stage III (58/76); mean Sartorius score was 115.5 ± 55.86, mean IHS4 was 76.1 ± 44.3. A statistically significant correlation between hospitalization and cessation of adalimumab, the loss of the achievement of the HiSCR, and surgery was found. No need to do surgery was a protective factor against the failure of adalimumab treatment, meaning that the most severe cases are more likely to fail the biological therapy.

CONCLUSION

new scenarios are opening up in clinical practice: the arrival of biosimilars allow greater sustainability of expenditure, while the anti-IL17 allow the patient who has failed therapy with adalimumab a valid and safe therapeutic option to be undertaken. A comprehensive care including hospitalization, a specific antibiotic therapy and surgical treatment is often mandatory to achieve a satisfactory control of the disease.

Multidisciplinary Update on Genital Hidradenitis Suppurativa: A Review

Importance

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease with a predilection for the genital region. Genital HS requires medical and surgical management as well as close collaboration among a multidisciplinary team.

Observations

Hidradenitis suppurativa is a disease of the hair follicles that results in recurrent nodules, abscesses, and tunneling sinus tracts. Medical treatment mainstays include antibiotics and retinoids, but the evolving class of biologic medications has gained traction in the treatment of moderate and severe disease. Many of the medical therapies come with adverse effects requiring clinical and laboratory monitoring over the course of treatment. When lesions are refractory to therapy or are too large for medical therapy alone, surgical intervention is required. Surgical procedures can include treatment of affected areas with deroofing or excision of affected skin. When large portions of genital skin are removed, reconstruction is necessary to restore function and aesthetics of the genitals. We describe a variety of reconstructive techniques based on the size and location of the skin deficiency.

Conclusions and Relevance

Effective management of genital hidradenitis suppurativa requires a thorough understanding of medical and surgical techniques for prevention, treatment, and reconstruction of genital defects.

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.].

Hidradenitis suppurativa: Current and emerging treatments

The treatment of hidradenitis suppurativa (HS) has remained challenging because of the many knowledge gaps regarding etiology. However, recent studies into the pathogenesis of HS have enabled the investigation of newer therapies. The second article in this continuing medical education series reviews the evidence for established therapies for HS, including anti-inflammatories, antibiotics, and surgery. New and emerging therapies that specifically target cytokines involved in HS pathogenesis will be covered. The potential therapeutic roles of anticytokine therapies, including both the expanded application of existing molecules as well as the specific development of novel therapies for HS are discussed. With increased attention on HS and with numerous clinical trials currently underway, we hope that the variety of treatment options for HS will be expanded.

Biologic Treatment for Hidradenitis Suppurativa

Patients with hidradenitis suppurativa (HS) are often undertreated and there are limited efficacious therapies available for treating this population. Biologics are an emerging therapeutic modality used in the management of many inflammatory conditions including HS. Implementation of biologics is typically reserved for moderate-to-severe cases or in those cases that are refractory to treatment. Though many biologics have been trialed for use in HS, only one biologic, adalimumab, is currently US FDA (Food and Drug Administration) approved for the treatment of moderate-to-severe HS. Limitations in the use of biologics for HS include the many scoring systems utilized in research studies and the relatively few well-designed, adequately powered clinical trials.

Is There a Role for Antiandrogen Therapy for Hidradenitis Suppurativa? A Systematic Review of Published Data

BACKGROUND

Hidradenitis suppurativa/acne inversa is a disease with deep-seated chronic painful nodules, abscesses, and draining sinus tracts, which manifests on the apocrine gland-rich skin areas of the body. Observational findings demonstrate that the disease usually appears after puberty, exhibits pre-menstrual flares in women, improves in pregnancy, and worsens post-partum, which indicates a role of hormones and particularly of androgens in its pathophysiology. Because increased androgen levels in serum have not been widely reported, an end-organ androgen hypersensitivity has been postulated.

OBJECTIVE

The aim of this systematic review was to identify and present evidence for antiandrogen therapeutic options for the treatment of hidradenitis suppurativa/acne inversa.

METHODS

A literature search was conducted in different medical electronic databases using the keywords "hidradenitis", "suppurativa", "acne inversa", and "antiandrogen" on 1 December, 2018. The main therapeutic options were subsequently used as separate keywords with the disease terms in a separate search.

RESULTS

The main therapeutic options yielded were cyproterone acetate, spironolactone, finasteride, and metformin. One randomized controlled crossover trial and seven case series were identified following use of a standard extraction form for eligibility.

CONCLUSION

The existing studies do not allow a robust evidence-based recommendation for the use of antiandrogens in the treatment of hidradenitis suppurativa/acne inversa. Further randomized controlled trials are needed to define the role of hormonal treatment as an alternative or concomitant therapy together with antibiotics or biologics.

Pain perception in patients with hidradenitis suppurativa

BACKGROUND

Pain is a prominent symptom of hidradenitis suppurativa (HS) and has been defined as a domain in the Core Outcome Set for the disease. Quality and intensity of pain is influenced by depression and anxiety, both of which are associated with HS.

OBJECTIVES

To describe HS-related pain quantitatively and qualitatively; and to investigate how disease severity, depression and anxiety correlate with self-reported pain quality.

METHODS

Pain perception was investigated using the McGill Pain Questionnaire. Symptoms of depression and anxiety were examined using the Hospital Anxiety and Depression Scale. Statistical analyses investigated differences in number of words chosen (NWC) and pain-rating index rank [PRI(R)] in patients with severe disease and in patients with depression/anxiety.

RESULTS

A total of 138 patients with HS were recruited in an outpatient clinic (October 2017-March 2018). Patients presented a median NWC of 11·5 and a PRI(R) of 59·0%. Most common descriptors were 'shooting' (83%), 'itchy' (79%) and 'blinding' (75%). Patients with depression or anxiety presented significantly higher PRI(R)s [depressed 65% vs. non-depressed 57% (P = 0·015); anxious 65% vs. nonanxious 57% (P = 0·004)]. Patients with involvement of three or more HS regions vs. those with fewer than three involved regions exhibited a significantly higher NWC (13 vs. 8; P = 0·048).

CONCLUSIONS

HS-related pain includes nociceptive and neuropathic pain, and perception appears to be influenced by disease severity, anxiety and depression. A multimodal pain management strategy may be the most appropriate; however, more detailed studies are necessary to define recommendations on pain management. What's already known about this topic? Pain is a core outcome domain hidradenitis suppurativa. Few studies have addressed this significant clinical problem. What does this study add? This study suggests that HS pain comprises both nociceptive and neuropathic pain. Pain appears associated to depression, anxiety and severity of the disease.

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management

Hidradenitis suppurativa is a chronic inflammatory disorder affecting hair follicles, with profoundly negative impact on patient quality of life. Evidence informing ideal evaluation and management of patients with hidradenitis suppurativa is still sparse in many areas, but it has grown substantially in the last decade. Part I of this evidence-based guideline is presented to support health care practitioners as they select optimal management strategies, including diagnostic testing, comorbidity screening, and both complementary and procedural treatment options. Recommendations and evidence grading based on the evidence available at the time of the review are provided.

Consensus on the treatment of hidradenitis suppurativa - Brazilian Society of Dermatology

Hidradenitis suppurativa is a chronic immune mediated disease of universal distribution that causes great damage to the quality of life of the affected individual, whose prevalence is estimated at 0.41% in the Brazilian population. The objective of this work was update on physiopathogenesis, diagnosis and classification of hidradenitis suppurativa and to establish therapeutic recommendations in the Brazilian reality. It was organized as a work group composed of eight dermatologists from several institutions of the country with experience in the treatment of hidradenitis suppurativa and carried out review on the topic. Recommendations were elaborated and voted by modified Delphi system and statistical analysis of the results was performed. The Brazilian consensus on the clinical approach of hidradenitis suppurativa had the support of the Brazilian Society of Dermatology.

Exploring changes in placebo treatment arms in hidradenitis suppurativa randomized clinical trials: A systematic review

BACKGROUND

Hidradenitis suppurativa (HS) is characterized by recurrent, painful nodules in flexural areas.

OBJECTIVE

The objective of this study was to explore the placebo response in HS randomized clinical trials and to compare it briefly with the placebo response in psoriasis and atopic dermatitis.

METHODS

A Cochrane Review on interventions in HS was used as a starting point, and a systematic review was then undertaken by using the PubMed database, yielding 7 HS randomized clinical trials for inclusion in this study.

RESULTS

This review demonstrates that there is a robust placebo response in HS that is most marked in physical signs but also marked in pain responses.

LIMITATIONS

Multiple outcome measures utilized in these studies and reporting bias limited this review.

CONCLUSION

This large placebo response has implications for clinical trial design. This knowledge can also help deliver improved clinical care by forming the basis of nonpharmacologic treatments and help optimize current medication use to maximize the placebo effect.

TNF-α inhibitors in the treatment of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a complex disease with a dramatic impact on the quality of life of patients that it afflicts. Despite this, there are few treatment options offering long-term relief. The exact pathophysiology of HS is unclear, although the current theory involves follicular obstruction, rupture, and subsequent inflammation leading to fistula and abscess development in intertriginous skin. Several inflammatory modulators have been implicated in the development of HS, including tumor necrosis factor (TNF)-α as well as interleukin (IL)-1β, IL-10, and IL-17. Initial evidence for the use of TNF-α inhibitors in HS stemmed from recognition that inflammatory bowel disease patients treated with these medications saw a concurrent improvement in their HS symptoms. Early case reports and case series illustrated TNF-α inhibitors’ value in the treatment of HS. Later, two phase III clinical trials, PIONEER I and PIONEER II, demonstrated that adalimumab is an efficacious treatment for HS. Infliximab represents another effective HS treatment option with its main advantage being dosing flexibility. In contrast, clinical trials have failed to show evidence for application of etanercept in HS. There is limited data on other TNF-α inhibitors such as certolizumab-pegol and golimumab. This review outlines the history, dosing, response, and adverse effects of TNF-α inhibitors in the treatment of HS.

Inter- and intrarater reliability of Hurley staging for hidradenitis suppurativa

Background

Hidradenitis suppurativa (HS) is a chronic, inflammatory and recurrent skin disease. Different staging instruments have been suggested, but none has achieved universal acceptance. Despite the fact that Hurley staging is one of the most widely applied HS disease severity staging instruments, it has not been validated.

Objectives

To determine the inter‐ and intrarater reliability of the Hurley staging system.

Methods

Fifteen raters (five plastic surgeons, five general surgeons and five dermatologists) independently staged 30 photos of patients with HS according to Hurley staging at two time points. Reliability was assessed using kappa (&kgr;) statistics, and multivariable logistic regressions were used to determine independent risk factors for photos with discordant staging.

Results

Inter‐rater reliability was moderate for the three stages of HS [κ = 0·59, 95% confidence interval (CI) 0·48–0·70]. It was moderate for Hurley stage I (κ = 0·45, 95% CI 0·32–0·55) and stage II (κ = 0·51, 95% CI 0·31–0·71) and it was almost perfect for stage III (κ = 0·81, 95% CI 0·62–1·00). The intrarater reliability was substantial for all stages and all raters (κ = 0·65, 95% CI 0·58–0·72). For stage I it was moderate (κ = 0·50, 95% CI 0·38–0·62), for stage II it was substantial (κ = 0·62, 95% CI 0·51–0·73) and for stage III it was almost perfect (κ = 0·82, 95% CI 0·77–0·87). Hurley stages II and III were less likely to result in discordant staging than Hurley stage I (odds ratios 0·47, 95% CI 0·29–0·77 and 0·21, 95% CI 0·12–0·38, respectively). The mean time spent on staging a photo was 14 s.

Conclusions

Hurley staging is reliable for rapid severity assessment of HS, with moderate inter‐rater and substantial intrarater reliability for all stages. It is best for assessing Hurley stage III HS, which is an indication for surgery.

What's already known about this topic?

Hidradenitis suppurativa is a relatively common disease without a universally accepted disease severity staging instrument.

Hurley staging is one of the most widely applied disease severity staging instruments.

What does this study add?

This study is the first to determine the inter‐ and intrarater reliability of Hurley staging.

Hurley staging is reliable for rapid severity assessment of hidradenitis suppurativa. It is best for assessing Hurley stage III disease, which is an indication for surgery.

Linked Comment: https://doi.org/10.1111/bjd.18158.

https://doi.org/10.1111/bjd.18188 available online

https://www.bjdonline.com/article/inter-and-intrarater-reliability-of-the-hurley-staging-for-hidradenitis-suppurativa/

The Treatment of Genitoperineal Hidradenitis Suppurativa: A Review of the Literature

Hidradenitis suppurativa is a chronic inflammatory condition affecting the axilla, genitals, perineum, and perianal regions. The pathophysiology of hidradenitis suppurativa is complex and requires a multidisciplinary approach to treatment involving medical and surgical management when indicated. We describe our multidisciplinary protocol for treatment, which includes rheumatology-monitored immunotherapy, medical management, wide surgical resection, wound care, and reconstruction. The multidisciplinary care team includes rheumatology, wound care, and reconstructive urologic surgery. Surgical management includes wide local surgical resection, negative pressure dressing, delayed reconstruction, and perioperative immunotherapy. Multimodal treatment with surgical, medical, wound, and immunotherapy care is vital to successful treatment.

Patient-reported outcomes in hidradenitis suppurativa

Hidradenitis suppurativa, also known as acne inversa, is a chronic recurrent inflammatory disease of the skin making management challenging and continuously evolving. A large number of modalities exist aimed at quantifying the efficacy of treatment in studies on hidradenitis suppurativa. Both physician-reported and patient-reported outcomes are used as endpoints in these studies; however, the vast majority of the modalities used to survey these reported outcomes lack validation and congruence between studies. Heterogeneity of outcome measures and lack of standardization from study to study make it difficult to design future hidradenitis suppurativa trials and to compare results. This high variability between studies further contributes to the lack of high-quality evidence available to guide clinical management decisions of this inflammatory skin disease. Therefore this review aims to assess the modalities frequently used to assess patient-reported treatment outcomes in hidradenitis suppurativa. Patient-reported outcomes in hidradenitis suppurativa include outcomes regarding symptoms and disease progression, measures of treatment satisfaction, quality of life surveys, impairment of function, pain, and patient-reported outcomes combined with physician-reported outcomes. Nearly all surveys demonstrate significant heterogeneity, lack standardization, and many are not validated or constructed specifically for the assessment of hidradenitis suppurativa. Yet patient-reported outcomes on symptoms and disease severity, treatment satisfaction, and quality of life are instrumental in evaluating hidradenitis suppurativa treatment efficacy in clinical trials. As such, standardization and validation of patient-reported outcome instruments are essential for comparability among studies and improved quality of evidence.

Efficacy of adalimumab in moderate to severe hidradenitis suppurativa: Real life data

Hidradenitis suppurativa (HS) is a relapsing, inflammatory disease characterized by painful nodules, abscesses, sinuses track formation and scarring. HS has a great impact on patients’ quality of life and its treatment may be really challenging. Adalimumab provides a new therapeutic option for HS. Our aim was to assess the therapeutic potential of adalimumab on patients with HS based on the data from the daily clinical practice of an HS Outpatient Clinic. 19 patients with clinically evident moderate to severe HS, under adalimumab treatment for at least 24 week, participated in this observational, retrospective study. The Hidradenitis Suppurativa Physician’s Global Assessment scale, Modified Santorius scale and Dermatology Life Quality Index (DLQI) at baseline, week 4, week 12 and week 24 were retrieved from the records. Both Modified Santorius score and DLQI were significantly decreased during the weeks of evaluation (Friedman’s test; P < 0.001). The proportion of patients who achieved clinical response was 10.5% (n = 2) at week 4, 42.1% (n = 8) at week 12 and 63.2% (n = 12) at week 24. Treatment with adalimumab was linked with both clinical remission of HS and improvement of patients’ quality of life.

Hidradenitis Suppurativa: Causes, Features, and Current Treatments

Hidradenitis suppurativa (HS), a relatively common and chronic inflammatory skin disorder. HS can have debilitating consequences if not diagnosed and treated appropriately. Clinically defined by recurrent, inflamed nodules in intertriginous regions (i.e., axillary, inguinal, and perianal areas), HS can cause intense pain and, in severe disease stages, lead to the formation of fistulas, sinus tracts, and extensive scarring. Postpubertal onset and female preponderance further characterize HS. Numerous pathogenic mechanisms have been proposed in HS, including immune dysregulation, genetics, smoking, and obesity; however, the exact etiology remains to be elucidated. The association of HS with inflammatory bowel disease, cardiovascular disease risk factors, and psychiatric disorders suggests HS is a systemic disease. HS significantly impairs quality of life in patients in excess versus other skin diseases. Unfortunately, experiences indicate long diagnostic delays, which in many cases might be due to disease unawareness among physicians. Increased knowledge of HS is therefore important in order to optimize disease management and ultimately improve the quality of life of patients.

Radical resection and local coverage of hidradenitis suppurativa - acne inversa: analysis of results

ABSTRACT Objective: to evaluate the primary outcome of local complications and late recurrence in patients with hidradenitis suppurativa undergoing radical resection and specific reconstruction. Methods: we conducted a retrospective analysis of the medical records of patients attended by the Plastic Surgery Service of the Clinics Hospital, Medical School, USP, between 2010 and 2016. We included patients who underwent radical resection of hidradenitis suppurativa in advanced stage and reconstruction through primary closure, grafts or flaps. Results: we analyzed 34 lesions in 19 patients, of which 64.5% had local complications, though with 73.5% efficient healing after 12 weeks postoperatively. We observed late recurrence in 47%, but in isolation, 22.2% of the reconstructions with locoregional flaps had recurrence after one year. Conclusion: extensive and radical resection of the disease associated with locoregional flap coverage (pedicled or perforating) has been shown to be the best management in terms of late results.

T helper 17 cell/regulatory T-cell imbalance in hidradenitis suppurativa/acne inversa: the link to hair follicle dissection, obesity, smoking and autoimmune comorbidities

BACKGROUND

Disintegration of the infundibula of terminal hair follicles (HFs) in intertriginous skin areas exhibits the histological hallmark of hidradenitis suppurativa (HS)/acne inversa, featuring a dissecting terminal hair folliculitis. Elevated serum levels of interleukin (IL)-17 and local increase in the ratio of proinflammatory T helper (Th)17 cells and anti-inflammatory regulatory T cells (Tregs) have been reported. Perifollicular Tregs play a key role in HF stem cell homeostasis and infundibular integrity.

OBJECTIVES

In this review, we evaluate the Th17/Treg ratio in HS, its aggravating conditions and associated comorbidities. Furthermore, we intended to clarify whether drugs with reported beneficial effects in the treatment of HS readjust the deviated Th17/Treg axis.

METHODS

PubMed-listed, peer-reviewed original research articles characterizing Th17/Treg regulation in HS/acne inversa and associated comorbidities were selected for this review.

RESULTS

This review presents HS as a disease that exhibits an increased Th17/Treg ratio. Perifollicular deficiencies in Treg numbers or function may disturb HF stem cell homeostasis, initiating infundibular dissection of terminal HFs and perifollicular inflammation. The Th17/Treg imbalance is aggravated by obesity, smoking and decreased Notch signalling. In addition, HS-associated autoimmune diseases exhibit a disturbed Th17/Treg axis resulting in a Th17-dominant state. All drugs that have beneficial effects in the treatment of HS normalize the Th17/Treg ratio.

CONCLUSIONS

HS immunopathogenesis is closely related to deviations of the Th17/Treg balance, which may negatively affect Treg-controlled HF stem cell homeostasis and infundibular integrity. Pharmacological intervention should not only attenuate Th17/IL-17 signalling, but should also improve Treg function in order to stabilize HF stem cell homeostasis and infundibular integrity.

Investigational drugs in clinical trials for Hidradenitis Suppurativa

INTRODUCTION

Hidradenitis suppurativa is a chronic skin disease with a significant unmet need for treatment options. Randomized controlled trials are few and only a single drug (adalimumab) has Hidradenitis as a registered indication.

AREAS COVERED

The clinicaltrials.gov and the EudraCT clinical trials register for reported trials on Hidradenitis Suppurativa was searched on the 22-06-2017. Trials for upcoming new drugs for HS are reported focusing on drugs in phase I and II trials.The clinicaltrials.gov and the EudraCT clinical trials register for reported trials on Hidradenitis Suppurativa was searched on the 22-06-2017. Trials for upcoming new drugs for HS are reported focusing on drugs in phase I and II trials.

EXPERT OPINION

Currently, MABp1, Secukinumab, CJM112, Apremilast and IFX-1 are being investigated in Phase I and II trials and offer theoretical and promising new treatment options. A trial with the drug MEDI8968 has been terminated with disappointing results. Metformin, Botulinum Toxin B, Provodine, Benzoyl Peroxide and intralesional triamcinolone are being tested as well. Treatment of Hidradenitis remains a challenge and quality RTCs are needed. Studies indicates a range of potential targets for therapy such as interleukin-1 and interleukin-17, but 'broad-spectrum' immunosuppressants like phosphodiesterase-4 inhibitors are being examined as well. A range of outcomes, including Physician Global Assessment, Sartorius scores and hidradenitis suppurativa clinical response are used in these trials, making future meta-analysis of the data difficult.

Approach to the Management of Patients With Hidradenitis Suppurativa: A Consensus Document

BACKGROUND

Hidradenitis suppurativa (HS) is a painful, debilitating, and poorly understood condition, which is suboptimally diagnosed, managed, and treated. Evidence supporting various treatment modalities is sparse.

OBJECTIVES

To incorporate scientific evidence and expert opinions to develop useful guidance for the evaluation and management of patients with HS.

METHODS

An expert panel of Canadian dermatologists and surgeons developed statements and recommendations based on available evidence and clinical experience. The statements and recommendations were subjected to analysis and refinement by the panel, and voting was conducted using a modified Delphi technique with a prespecified cutoff agreement of 75%.

RESULTS

Ten specific statements and recommendations were accepted by the expert panel. These were grouped into 4 domains: diagnosis and assessment, treatment and management, comorbidities and a multidisciplinary approach, and education.

CONCLUSIONS

These statements and recommendations will serve to increase awareness of HS and provide a framework for decisions involving diagnosis and management. Evidence suggests that antibacterial and anti-tumour necrosis factor therapies are effective in the treatment of HS. This is supported by the clinical experience of the authors. Further clinical research and the establishment of multidisciplinary management teams will continue to advance management of HS in Canada.

Treatments for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is not easily treated. Although not uncommon, HS is often misdiagnosed outside specialized clinics and inappropriately treated as a simple boil or abscess. In recent years, guidelines have been developed on the basis of expert opinion and the available literature. A multifaceted approach is necessary as HS lesions include both inflammation (amenable to medical treatment) as well as fibrosis (amenable to surgery only). The recommended antiinflammatory therapies encompass both antimicrobials and regular anti-inflammatory drugs. We have, therefore, reviewed treatments with the following agents: clindamycin, tetracycline, rifampicin, ertapenem, dapsone, triamcinolone, infliximab, adalimumab, and anakinra. The development of new medical treatments, however, is an ongoing effort, and important new data have been presented since the publication of the guideline. The current approach to the management of fibrotic lesions is surgery. It is important, as manifest fibrosis is generally not susceptible to medical treatment. Here minor excision, carbon dioxide-laser, and major surgery are discussed, and current evidence supporting their use is provided. A comprehensive three-pronged approach with adjuvant therapy, medical therapy, and surgery is recommended. The importance of adjuvant therapy, that is, pain management, wound care, and attention, is stressed. Adjuvant therapy not only plays a major role in patients' perception of a successful treatment but also is of practical importance to their coping and self-management. HS presents a significant unmet need, and this review provides a mechanistic update on the current real-world therapeutic option for the management of this distressing disease.