Hidradenitis suppurativa: pathogenesis, clinical presentation, epidemiology, and comorbid associations

The Comorbidities of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory disease that drammatically decreases the quality of life for afflicted patients. A number of factors may co-exist with HS: stigmatization, social isolation, tobacco use, alcohol abuse, suicidal ideation, depression, other psychiatric disorders, plus medical comorbidities that include obesity, diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome, coronary artery disease, and polycystic ovarian syndrome may coexist with hidradenitis suppurativa. These comorbidities should be kept in mind while planning the treatment. A rare but important long-term complication of hidradenitis suppurativa is squamous cell cancer; men with perianal, gluteal, or perineal lesions are at increased risk, and multiple biopsies should be taken in case of any suspicious lesions.

Essential Considerations for Radiologists in Diagnosing Hidradenitis Suppurativa

Hidradenitis suppurativa, also referred to as inverse acne, manifests as a persistent inflammatory skin disorder characterized by lesions such as deep nodules, abscesses, sinus tracts, and fibrotic scars. These manifestations predominantly occur in skin folds and intertriginous areas, notably in the axillary, inguinal, perianal, perineal, and inframammary regions. Due to similarities with other conditions in its initial stages, accurate diagnosis of hidradenitis suppurativa is often delayed, sometimes spanning several years. Diagnosis relies on identifying specific morphologic features (such as deep, inflamed, and painful nodules; sinus tracts; and scars), considering the affected sites (skin folds and areas with apocrine glands), and recognizing the chronic nature of the condition (persistent course with periods of exacerbation and remission). There are no definitive biologic or pathologic diagnostic tests, and biopsy of the affected area is not necessary. Treatment varies based on severity and may include topical and systemic antibiotics, hormonal therapy, immunomodulators, and surgery. Due to associated pain, increased site sensitivity, secretion drainage, odor, and scarring, this condition can have a negative psychosocial impact. Imaging studies, including high-frequency US and MRI with subsequent three-dimensional reconstruction, serve as valuable tools for precise staging, monitoring disease activity, and preoperative assessment. Currently, high-frequency US stands as the preferred method, incorporating sonographic classifications, while MRI and thee-dimensional imaging represent an emerging and promising approach. Imaging helps identify the extent of sinus tracts, assess involvement dimensions in advanced disease stages, and monitor proposed treatments. ©RSNA, 2024 Supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.

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.

Biosensing circulating MicroRNAs in autoinflammatory skin diseases: Focus on Hidradenitis suppurativa

MicroRNAs (miRNAs) play a crucial role in the early diagnosis of autoinflammatory diseases, with Hidradenitis Suppurativa (HS) being a notable example. HS, an autoinflammatory skin disease affecting the pilosebaceous unit, profoundly impacts patients' quality of life. Its hidden nature, with insidious initial symptoms and patient reluctance to seek medical consultation, often leads to a diagnostic delay of up to 7 years. Recognizing the urgency for early diagnostic tools, recent research identified significant differences in circulating miRNA expression, including miR-24-1-5p, miR-146a-5p, miR26a-5p, miR-206, miR338-3p, and miR-338-5p, between HS patients and healthy controls. These miRNAs serve as potential biomarkers for earlier disease detection. Traditional molecular biology techniques, like reverse transcription quantitative-polymerase chain reaction (RT-qPCR), are employed for their detection using specific primers and probes. Alternatively, short peptides offer a versatile and effective means for capturing miRNAs, providing specificity, ease of synthesis, stability, and multiplexing potential. In this context, we present a computational simulation pipeline designed for crafting peptide sequences that can capture circulating miRNAs in the blood of patients with autoinflammatory skin diseases, including HS. This innovative approach aims to expedite early diagnosis and enhance therapeutic follow-up, addressing the critical need for timely intervention in HS and similar conditions.

Global consensus process to establish a core dataset for hidradenitis suppurativa registries

BACKGROUND

Several registries for hidradenitis suppurativa (HS) already exist in Europe and the USA. There is currently no global consensus on a core dataset (CDS) for these registries. Creating a global HS registry is challenging, owing to logistical and regulatory constraints, which could limit opportunities for global collaboration as a result of differences in the dataset collected. The solution is to encourage all HS registries to collect the same CDS of information, allowing registries to collaborate.

OBJECTIVES

To establish a core set of items to be collected by all HS registries globally. The core set will cover demographic details, comorbidities, clinical examination findings, patient-reported outcome measures and treatments.

METHODS

Beginning in September 2022, 20 participants - including both clinicians with expertise in HS and patient advocates - from eight countries across three continents participated in a Delphi process consisting of four rounds of voting, with all participants completing each round. A list of potential items for inclusion in the core set was generated from the relevant published literature, including systematic reviews of comorbidities in HS, clinical and examination findings, and epidemiology. For disease severity and progression items, the Hidradenitis SuppuraTiva Core outcome set International Collaboration (HiSTORIC) core set and other relevant instruments were considered for inclusion. This resulted in 47 initial items. Participants were invited to suggest additional items to include during the first round. Anonymous feedback was provided to inform each subsequent round of voting to encourage consensus.

RESULTS

The eDelphi process established a CDS of 48 items recommended for inclusion in all HS registries globally.

CONCLUSIONS

The routine adoption of this CDS in current and future HS registries should allow registries in different parts of the world to collaborate, enabling research requiring large numbers of participants.

The Pathogenesis and Treatment of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a multifactorial disease involving the skin and subcutaneous tissues characterized by deep-seated, painful nodules and abscesses with draining sinus tracts. It affects mostly younger individuals between the ages of 18 and 34. The discomfort and embarrassment that patients affected by HS experience negatively impact their daily lives. It is associated with decreased quality of life and high rates of comorbid depression and anxiety. The rate of depression in HS was reported to be as high as 26%. Its pathogenesis is multifactorial and as such requires a multimodal approach to treatment, which subsequently is reviewed here. Moreover, the pathogenesis of HS is complex and only partially understood. Autoinflammation is the key driver of disease development and is linked with dysregulated inflammasome activation with the subsequent production of inflammatory cytokines. Genetics and cutaneous microbiome play a role in the development of chronic inflammation and lesion formation. Risk factors such as obesity, metabolic syndrome, diabetes, and smoking also add to the systemic inflammation. Targeting these risk factors is a key aspect of the treatment of HS. Lifestyle modifications are used in conjunction with pharmacotherapy and procedures to effectively manage the disease.

Epidemiology of hidradenitis suppurativa

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

Prevalence of Hidradenitis Suppurativa in an African Population: Validation of a Screening Questionnaire in Lagos, Nigeria

BACKGROUND

Epidemiologic hidradenitis suppurativa (HS) studies from Africa are lacking. This study aimed at uncovering the prevalence of HS in Lagos, Nigeria, to validate an HS screening questionnaire, and to contribute to the Global Hidradenitis Suppurativa Atlas (GHiSA).

METHODS

This was a cross-sectional study of 802 healthy adults accompanying their relations to the outpatient clinic of Family Medicine and Ophthalmology at the Lagos State University Teaching Hospital in Lagos, Nigeria, following ethical approval. Verbal and written consents were obtained prior to inclusion of study participants. The study was conducted using a validated screening questionnaire. Screen-positive and randomly selected screen-negative participants were clinically examined. Severity was categorized using the Hurley score.

RESULTS

The prevalence of HS in the sample was 2.2% (18/802; 95% CI: 1.4-3.5%) with no gender predominance. The mean age in the HS group was 34 years (IQR 28-42) and the median body mass index (BMI) of the HS patients was 27.0 (IQR 21.4-28.6). There was no significant difference in BMI between the HS and control group. The screening questionnaire had a sensitivity of 1 (18/18), specificity of 0.8 (20/25), positive predictive value of 0.8 (18/23), and a negative predictive value of 1 (20/20). The axilla was the predominant site of affection (66.7%), and all HS patients were classified as mild disease (Hurley score 1).

CONCLUSION

The prevalence of HS in Lagos, Nigeria, was 2.2% and, in this population, BMI did not appear to be a risk factor. The axilla was the most affected site, and all patients had a mild disease severity (Hurley score 1). Finally, the HS screening questionnaire is a suitable tool in population surveys.

Submental liposuction with VASER complicated with hidradenitis suppurativa in neck area: a case report

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder that is characterized by deep-seated painful nodules, classically in the intertriginous skin and apocrine gland-rich areas of the body such as the anogenital, axillary, inframammary and inguinal regions. This is a case of a 35-year-old female, who is known to have gluteal HS, she underwent neck liposuction procedure that was then complicated by anterior neck HS, which is considered as an atypical location. The patient received medical treatment with antibiotics and showed huge improvement. In addition, in patients who do not show response to medical therapy, surgical treatment is usually carried out by incising the area affected and leaving the wound open to be healed by secondary intention or covering it with a skin graft if the area is extensive.

Surgical treatment of postauricular hidradenitis suppurativa with delayed diagnosis: a case report and literature review

Hidradenitis suppurativa (HS) is a chronic inflammatory condition that is difficult to diagnose, with a period of 10.0± 9.6 years from symptom onset to diagnosis. A 32-year-old Asian man presented with bilateral postauricular abscesses that first appeared 5 years previously. Despite several incisions and drainage, the symptoms only temporarily improved and continued to recur. On physical examination, chronic scars and sinus tracts were observed around the lesion. Postauricular HS was diagnosed, and surgical treatment was performed. We performed a wide excision and reconstructed the defect using a posterior auricular artery perforator-based keystone flap. Histological examination confirmed the diagnosis of HS. The reconstruction was successful, and there was no recurrence for 2 years after surgery. HS is difficult to diagnose without specific attention. Although the postauricular region is not a typical site of HS, it can occur in this area. Therefore, if a patient presents with recurrent abscesses in the postauricular region, HS should be considered. Additionally, if HS is diagnosed in the postauricular region, wide excision with reconstruction using a posterior auricular artery perforator-based keystone flap can lead to a favorable outcome.

Hidradenitis suppurativa: Evaluating activity patterns and predictors of recalcitrant course-A population-based study

BACKGROUND

Epidemiological evidence regarding the course and activity patterns of hidradenitis suppurativa (HS) is yet to be delineated.

OBJECTIVE

To identify activity patterns of HS throughout the time axis and to outline predictors of recalcitrant disease course.

METHODS

A population-based retrospective cohort study was performed to follow patients with HS (n = 4417) throughout the initial 10 years following their diagnosis. The disease was considered active in a certain month if one of the following criteria was fulfilled: (i) purchase of an HS-related drug, (ii) admission to a dermatological ward and (iii) referral to a dermatological consultation in an emergency room. Patients with a recalcitrant disease were defined as those with ≥5 years of follow-up with ≥6 'active months' each. Patients with an indolent course were defined as those experiencing ≥9 years of follow-up with ≤1 'active months' each.

RESULTS

The average (SD) number of months in which patients had an active disease was 1.37 (1.28) months per year. While 98 (2.2%) patients pursued a recalcitrant course, 1390 (31.5%) went through an indolent disease course. Older age (≥38 years; adjusted OR, 6.17; 95% CI, 3.33-11.43), Arab ethnicity (adjusted OR, 2.04; 95% CI, 1.20-3.48), low socioeconomic status (adjusted OR, 1.64; 95% CI, 1.03-2.60), obesity (adjusted OR, 3.47; 95% CI, 2.25-5.34) and smoking (adjusted OR, 2.65; 95% CI, 1.57-4.47) were found to independently predict recalcitrant course of HS.

CONCLUSIONS

Mild course is more frequently encountered than severe course among Israeli patients with HS. Modifiable risk factors of recalcitrant course should be carefully addressed.

Impact of Psoriasis and Hidradenitis Suppurativa in Pregnancy, a Systematic Review

Psoriasis and hidradenitis suppurativa (HS) are chronic inflammatory skin diseases that frequently develop in young women. The aim of this study is to evaluate how hidradenitis suppurativa and psoriasis impact women desiring to conceive, and their influence on fertility and gestation. A systematic review of articles dating from January 2015 to April 2021 was performed using the Scopus (Elsevier) database. The search terms were (psoriasis and (birth or pregnancy or fertility)) and ((hidradenitis suppurativa or acne inversa) and (birth or pregnancy or fertility)). The search was limited to human data. Systematic reviews, case reports, clinical practice guidelines, expert consensus and conference papers were excluded. The impact of HS on pregnancy includes an impaired desire for pregnancy, a decrease in fertility, the worsening of the disease during pregnancy and potential adverse events during pregnancy. Moreover, the pregnancy might imply a change on the treatment of HS. The impact of psoriasis on pregnancy includes a decrease in fertility, potential adverse events during pregnancy and an unpredictable evolution of the disease. Moreover, the pregnancy might imply a change on the treatment of psoriasis, although biologic therapies do not appear to increase the risk of adverse events. In conclusion, both HS and psoriasis have an impact on pregnancy. A decrease of fertility has been reported. Moreover, both diseases have an unpredictable evolution during pregnancy. Pregnant women who are under biologic therapy do not seem to have a higher rate of adverse events. Treatment of both conditions is usually halted during pregnancy since scientific evidence about their safety is not conclusive, or teratogenic risk has been proven.

Plant Antimicrobial Peptides as Potential Tool for Topic Treatment of Hidradenitis Suppurativa

Among chronic skin autoinflammatory diseases, Hidradenitis Suppurativa (HS) stands out for its chronicity, highly variable condition, and profound impact on the patients' quality of life. HS is characterized by suppurative skin lesions in diverse body areas, including deep-seated painful nodules, abscesses, draining sinus, and bridged scars, among others, with typical topography. To date, HS is considered a refractory disease and medical treatments aim to reduce the incidence, the infection, and the pain of the lesions. For this purpose, different classes of drugs, including anti-inflammatory molecules, antibiotics and biological drugs are being used. Antimicrobial peptides (AMPs), also called defense peptides, emerge as a new class of therapeutic compounds, with broad-spectrum antimicrobial action, in addition to reports on their anti-inflammatory, healing, and immunomodulating activity. Such peptides are present in prokaryotes and eukaryotes, as part of the innate eukaryotic immune system. It has been proposed that a deregulation in the expression of AMPs in human epithelial tissues of HS patients may be associated with the etiology of this skin disease. In this scenario, plant AMPs stand out for their richness, diversity of types, and broad antimicrobial effects, with potential application for topical systemic use in patients affected by HS.