Quality of life in Hidradenitis Suppurativa (Acne Inversa): A scoping review

Background

Hidradenitis Suppurativa (HS) is a chronic, relapsing, inflammatory skin condition which is physically, psychologically and socially disabling and often affects a patient's quality of life (QOL). There are numerous QOL tools used in dermatology. However, assessment of QOL in patients with HS is difficult due to the inability of generic QOL tools to specifically capture QOL in patients with HS. Numerous HS-specific QOL tools have been developed in recent years. It is important to identify evidence on full psychometric evaluation of these tools.

Objectives

There has been a gradual increase in the use of generic and disease-specific QOL tools in the last few decades. The aim of this scoping review (SR) is to evaluate the most widely used generic QOL tools and HS-specific QOL tools to identify the psychometric evaluation of such tools.

Methods

Design: An SR guided by Joanna Briggs Institute manual and Arskey O'Malley framework guidelines. Data extraction included the studies available on full psychometric evaluation of the most widely used dermatology generic QOL tools in HS and HS-specific QOL tools.

Results

Ten papers were included in the review, eight papers demonstrated HS-specific QOL assessment tools. The psychometric properties of these tools were underpinned by reliability, validity and sensitivity measurement. Six disease-specific tools were identified in this SR. However, they all lack full psychometric evaluation.

Conclusion

This review indicates that an extensive research in the field of QOL tools for HS is much needed. It is crucial to develop user-friendly and validate disease-specific tools to measure the real impact of disease on patients QOL. QOL instruments can evaluate the impact on life of an HS patient, thus helping improve intervention and management of disease. There is a necessity for more research into existing HS-specific QOL tools and they should be widely tested and fully validated.

Measuring Quality of Life in Hidradenitis Suppurativa: Development and Validation of a Disease-specific Patient-reported Outcome Measure for Practice and Research

Hidradenitis suppurativa is a chronic disease that disrupts patients' physical and psychological well-being. A disease-specific measure was developed and validated for assessing health-related quality of life in hidradenitis suppurativa. After qualitative item development, the quality of life in hidradenitis suppurativa instrument was tested in 101 patients, applying convergent measures and a usability questionnaire. Descriptive and validation-specific analyses were conducted. There was no ceiling, but moderate floor effects (scores between 0 and 3.13 on a scale of 0-4). Few missing values were observed (21 of 23 items < 5%). Internal consistency was satisfying: 2 subscales with 6 and 16 items were identified (Cronbach's alpha=0.95 and 0.88). The quality of life in hidradenitis suppurativa instrument correlated significantly with all convergent criteria (including change in convergent patient-reported outcomes; p < 0.05) except for Hurley stage (p = 0.490). In conclusion, the quality of life in hidradenitis suppurativa questionnaire is an internally consistent, valid, responsive, and usable instrument to assess quality of life in patients with hidradenitis suppurativa.

Use of Patient-Reported Outcome Measures in the Surgical Treatment of Hidradenitis Suppurativa: A Systematic Review

BACKGROUND

Surgery is considered to be the best treatment for recurrent hidradenitis suppurativa (HS). Although it is necessary to assess the effect on health-related quality of life (HR-QoL), patient-reported outcome measures (PROMs) are scarce and heterogeneously used in the literature about the surgical treatment of HS.

OBJECTIVE

The aim of this study was to provide a review of the complete literature for different PROMs used in the surgical treatment of HS and to assess their methodological qualities.

METHODS

A systematic literature search of PubMed, Medline, Cochrane, CINAHL, and Embase with an assessment following the COnsensus-based standards for the Selection of health status Measurement INstrument criteria.

RESULTS

The search identified 218 articles, with the inclusion of 6 studies for analysis. Identified PROMs were as follows: the Dermatology Life Quality Index (DLQI), the Derriford Appearance Scale-24 (DAS-24), and the Work Productivity and Activity Impairment (WPAI). These non-disease-specific PROMs seem to have poor results concerning development and content validation.

CONCLUSION

The DLQI, WPAI, and DAS-24 are generic PROMs with poor methodological qualities for PROM development and content validation. Hidradenitis suppurativa-specific instruments are not used in available studies because they have been developed recently and, therefore, partially validated. More research is needed to further investigate methodological qualities of HS-specific instruments.

Trends in Hidradenitis Suppurativa Disease Severity and Quality of Life Outcome Measures: Scoping Review

BACKGROUND

Although there has been an increase in the number of randomized controlled trials evaluating treatment efficacy for hidradenitis suppurativa (HS), instrument measurements of disease severity and quality of life (QoL) are varied, making the compilation of data and comparisons between studies a challenge for clinicians.

OBJECTIVE

We aimed to perform a systematic literature search to examine the recent trends in the use of disease severity and QoL outcome instruments in randomized controlled trials that have been conducted on patients with HS.

METHODS

A scoping review was conducted in February 2021. The PubMed, Embase, Web of Science, and Cochrane databases were used to identify all articles published from January 1964 to February 2021. In total, 41 articles were included in this systematic review.

RESULTS

The HS Clinical Response (HiSCR) score (18/41, 44%) was the most commonly used instrument for disease severity, followed by the Sartorius and Modified Sartorius scales (combined: 16/41, 39%). The Dermatology Life Quality Index (18/41, 44%) and visual analogue pain scales (12/41, 29%) were the most commonly used QoL outcome instruments in HS research.

CONCLUSIONS

Randomized controlled trials conducted from 2013 onward commonly used the validated HiSCR score, while older studies were more heterogeneous and less likely to use a validated scale. A few (6/18, 33%) QoL measures were validated instruments but were not specific to HS; therefore, they may not be representative of all factors that impact patients with HS.

TRIAL REGISTRATION

National Institute of Health Research PROSPERO CRD42020209582; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020209582.

[Epidemiology, patient quality of life, and treatment costs of hidradenitis suppurativa/acne inversa]

Hidradenitis suppurativa/acne inversa (HS) is associated with numerous and relevant restrictions on the quality of life for those affected and their relatives. The exact prevalence of HS varies significantly across studies, but it is likely to be higher than suggested in previous publications. HS care is associated with high costs for the healthcare system and for those affected. The introduction of biologic therapy has led to additional costs, but also to considerable additional benefits in terms of care. In view of the complexity of diagnostics and therapy, there is a particular need for optimized care concepts in order to reduce the burden on those affected, their relatives and the healthcare system.

Wide Local Excisions and Pedicled Perforator Flaps in Hidradenitis Suppurativa: A Study of Quality of Life

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic skin pathology characterized by the occurrence of inflamed and swollen lesions, with a devastating impact of the disease on patient's quality of life. Wide local excision (WLE) of the affected tissue is the criterion-standard treatment, but there is no general consensus on the best reconstructive technique. The aim of this article is to evaluate the quality of life before and after WLE combined with pedicled perforator flap reconstruction, in patients suffering from HS.

METHODS

We analyzed 26 consecutive patients suffering from Hurley stage III HS. Every patient underwent WLE, followed by reconstruction with pedicled perforator flap. Dermatology Quality of Life Index (DLQI) tests were administered to every patient preoperatively and 6 months after surgery, when the clinical condition was considered stable. Dermatology Quality of Life Index scores were compared in terms of means with Student t test. Linear regression studies were used to compare the changes in DLQI score with the surgical and clinical variables.

RESULTS

Axillary area involvement was found in 21 of 27 patients; 6 patients had more than 1 body region involved. Thirty-two pedicled perforator flaps were performed, and 22 were thoracodorsal artery perforator flaps. Mean DLQI test score before the first operation was 21.31 ± 4.79; the average DLQI score after the last follow-up was 5 ± 2.95 (P < 0.0001). Dermatology Quality of Life Index scores were not influenced by complications including reoperation. There were also no correlations found between DLQI score delta and number of reoperation (-0.18) or days of hospital stay (-0.13).

CONCLUSIONS

Wide local excision followed by pedicled perforator flap reconstruction allows a radical excision of HS areas with short postoperative healing periods. Dermatology Quality of Life Index scores confirmed high levels of patients' satisfaction. Disadvantages of this technique include difficult learning curve, long operating time, and a nonnegligible complications rate.

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

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

The Hidradenitis Suppurativa Quality of Life (HiSQOL) score: development and validation of a measure for clinical trials

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory condition that can have a large negative impact on health-related quality of life (HRQOL). A reliable and validated measure of HS-specific HRQOL in clinical studies is needed.

OBJECTIVES

To develop and validate the Hidradenitis Suppurativa Quality Of Life (HiSQOL©) scale, for clinical trial measurement of HS-specific HRQOL.

METHODS

In stage 1, qualitative concept elicitation interviews were conducted with patients with HS in Denmark (n = 21) and the U.S.A. (n = 21). In stage 2, cognitive debriefing interviews were performed with U.S. (n = 30) and Danish patients with HS (n = 30). In stage 3 an observational study of 222 patients with HS in the U.S.A. was conducted for item reduction, measure validation and assessment of psychometric properties. In stage 4, an observational study of 215 patients with HS in Denmark was conducted to confirm the psychometric structure derived in stage 3. In both studies the Dermatology Life Quality Index, Hospital Anxiety and Depression Scale and numerical rating scale for pain were also included.

RESULTS

In concept elicitation, 99 items were generated, which were reduced to 41 after removing duplicates. In cognitive debriefing, two items were added and one item removed. A 42-item instrument was psychometrically assessed. Based on psychometric analyses and patient input, the instrument was reduced to 17 items that had strong psychometric properties in both the U.S. and Danish samples.

CONCLUSIONS

The HiSQOL is a reliable and valid instrument to measure HS-specific HRQOL in clinical trials.

Development and Preliminary Validation of the HSQoL-24 Tool to Assess Quality of Life in Patients With Hidradenitis Suppurativa

INTRODUCTION AND OBJECTIVES

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin with a negative impact on quality of life. Up to now, there are no disease specific instruments in Spanish to assess quality of life in HS. The objective of this study was to develop and validate a questionnaire to evaluate the quality of life in patients with HS.

MATERIAL AND METHODS

A multicentre study was carried out in Spain between 2016 and 2017 to develop the questionnaire. Both the conceptual framework and understanding of the patient's situation were considered through a review of the literature, consensus of professionals from different related health areas, and in-depth interviews with patients. The resulting questionnaire was passed to a group of 30 patients with 30±10 days of interval between both assessments.

RESULTS

The reliability analysis shows a good internal consistency and reproducibility with Cronbach's alpha score of 0.920 (test) and 0.917 (retest) and intraclass correlation coefficient with DLQI and Skindex-29 of 0.698 IC 95% (0.456-0.844) and 0.900 IC 95% (0.801-0.951) respectively. Cut-off points were established for its use and the instrument was found to be sensitive to change.

CONCLUSIONS

The HSQoL-24 is the first disease-specific self-administered instrument to assess quality of life in patients with HS in Spanish. It is user friendly, and easy to score. This study shows that the instrument is reliable, valid and sensitive to change, pending confirmatory study with a larger sample of 100 patients with HS.

Subjective well-being in patients with pemphigus: a path analysis

BACKGROUND

Pemphigus is a chronic autoimmune blistering disease of the skin and mucosa severely impairing patients' health-related quality of life (HRQoL). To date, no studies have measured subjective well-being in terms of life satisfaction in pemphigus. Our main objective was to evaluate satisfaction with life in patients with pemphigus, and to analyse its relationship with clinical severity and HRQoL.

METHODS

A cross-sectional survey was carried out enrolling 77 patients with pemphigus. Subjective well-being was measured using the Satisfaction with Life Scale (SWLS). HRQoL was assessed by the Dermatology Life Quality Index (DLQI) and EQ-5D-5L. Disease severity was measured by Autoimmune Bullous Skin Disorder Intensity Score (ABSIS).

RESULTS

Mean ABSIS, DLQI, EQ-5D-5L and SWLS scores of patients were 11.7 (SD 17.3), 5.4 (6.8), 0.84 (0.22) and 4.76 (SD 1.52), respectively. The proportion of patients indicating extreme dissatisfaction, dissatisfaction, slightly below average in life satisfaction, average satisfaction, high satisfaction and very high satisfaction with life was 6 (7.8%), 5 (6.5%), 14 (18.2%), 16 (20.8%), 21 (27.3%) and 15 (19.5%), respectively. Life satisfaction was independent from age, gender, level of education and type of disease. A path analysis revealed that there was no direct relationship between ABSIS and SWLS (beta = - 0.09; p = 0.428); however, the following indirect path was confirmed: ABSIS → DLQI → EQ-5D-5L → SWLS.

CONCLUSIONS

Disease severity and HRQoL measures regularly used to assess patients' health status may be complemented with a measure of subjective well-being, such as SWLS, to achieve a more holistic assessment of patients' lives and optimise pemphigus care.

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

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

Proceeding report of the Second Symposium on Hidradenitis Suppurativa Advances (SHSA) 2017

The 2nd Annual Symposium on Hidradenitis Suppurativa Advances (SHSA) took place on 03-05 November 2017 in Detroit, Michigan, USA. This symposium was a joint meeting of the Hidradenitis Suppurativa Foundation (HSF Inc.) founded in the USA, and the Canadian Hidradenitis Suppurativa Foundation (CHSF). This was the second annual meeting of the SHSA with experts from different disciplines arriving from North America, Europe and Australia, in a joint aim to discuss most recent innovations, practical challenges and potential solutions to issues related in the management and care of Hidradenitis Suppurativa patients. The last session involved clinicians, patients and their families in an effort to educate them more about the disease.

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.