What happens after a single surgical intervention for hidradenitis suppurativa? A retrospective claims-based analysis

Phenotype Algorithms to Identify Hidradenitis Suppurativa Using Real-World Data: Development and Validation Study

BACKGROUND

Hidradenitis suppurativa (HS) is a potentially debilitating, chronic, recurring inflammatory disease. Observational databases provide opportunities to study the epidemiology of HS.

OBJECTIVE

This study's objective was to develop phenotype algorithms for HS suitable for epidemiological studies based on a network of observational databases.

METHODS

A data-driven approach was used to develop 4 HS algorithms. A literature search identified prior HS algorithms. Standardized databases from the Observational Medical Outcomes Partnership (n=9) were used to develop 2 incident and 2 prevalent HS phenotype algorithms. Two open-source diagnostic tools, CohortDiagnostics and PheValuator, were used to evaluate and generate phenotype performance metric estimates, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value.

RESULTS

We developed 2 prevalent and 2 incident HS algorithms. Validation showed that PPV estimates were highest (mean 86%) for the prevalent HS algorithm requiring at least two HS diagnosis codes. Sensitivity estimates were highest (mean 58%) for the prevalent HS algorithm requiring at least one HS code.

CONCLUSIONS

This study illustrates the evaluation process and provides performance metrics for 2 incident and 2 prevalent HS algorithms across 9 observational databases. The use of a rigorous data-driven approach applied to a large number of databases provides confidence that the HS algorithms can correctly identify HS subjects.

Hidradenitis-suppurativa-bedingte Kosten, ein Plädoyer für Aufmerksamkeit: eine systematische Literaturübersicht

Die Daten zu Hidradenitis suppurativa (HS)-bedingten Kosten sind begrenzt und inhomogen. Sie sind jedoch erheblich. Wir führten eine systematische Sichtung der Literaturberichte durch, in denen finanzielle Daten über jeden Gesundheitsbereich oder andere Ausgaben dokumentiert wurden, die durch HS und/oder HS-bedingte Auswirkungen auf Beschäftigung, Einkommen und persönliches wirtschaftliche Entwicklung entstanden sind (indirekte Kosten). Dafür wurden drei elektronische Datenbanken durchsucht (MEDLINE, ScienceDirect und die Cochrane Library -letzte Suche: 14. September 2021). Alle Kosten wurden inflationsbereinigt (2022) und in US-Dollar umgerechnet. Es wurden 23 Artikel eingeschlossen (18 Krankheitskostenstudien, 4 Beobachtungsstudien und 1 Fallserie), in denen ökonomische Daten von 77.287 HS-Patienten erfasst wurden. Die durch HS entstandenen durchschnittlichen jährlichen Kosten pro Patient reichten von 258 $ bis 8.078 $. Diese Zahl erhöhte sich bei chirurgischen Eingriffen, Krankheitsprogression, Antibiotika-Versagen und bestimmten Begleitkrankheiten. Der kostspieligste Faktor war die stationäre Versorgung, gefolgt von ambulanter und Notfallversorgung. Signifikante Unterschiede wurden zwischen den USA und den übrigen untersuchten Ländern beobachtet. Im Vergleich zu Psoriasis-Patienten waren Krankenhausaufenthalte bei HS wahrscheinlicher, länger und kostspieliger, während die weniger kostspielige ambulante Versorgung bei HS-Patienten verringert war. Das Vermeiden der Krankheitsprogression durch frühzeitige Diagnose und Optimierung der ambulanten dermatologischen Versorgung könnte HS-bedinge Ausgaben reduzieren.

Hidradenitis suppurativa-related expenditure, a call for awareness: systematic review of literature

Data regarding hidradenitis suppurativa (HS)-related expenditure is limited and non-homogeneous, but HS does incur significant expenses. We performed a systematic review of literature reports documenting financial data regarding any healthcare domain or other expenditure incurred by HS and/or HS impact on work, income and personal economic growth (indirect costs). Three electronic databases were searched (MEDLINE, ScienceDirect, and the Cochrane Library - last search date: September 14^th , 2021). All costs were adjusted for inflation (2022) and converted into US dollars. Twenty-three papers were included (18 cost-of-illness studies, 4 observational studies and 1 case series), drawing economic data from 77,287 HS patients. The total mean cost incurred by HS per patient per year ranged from $ 258 to $ 8,078. This number increased in case of surgical intervention, disease progression, antibiotic failure and certain comorbid diseases. The costliest healthcare sector was inpatient care, followed by outpatient and emergency care. Significant differences were observed between the USA and the rest of studied countries. Hospitalization was likelier, lengthier, and costlier for HS compared to psoriasis patients, whereas the less costly outpatient care appeared to be reduced among HS patients. Preventing disease progression by optimizing early diagnosis and dermatology outpatient care could decrease HS-related expenditure.

Wound Closure with Transcutaneous Absorbable Polyglactin Sutures after Hidradenitis Suppurativa Excision

OBJECTIVE

Wide surgical excision is the standard treatment for severe hidradenitis suppurativa (HS). Because of the nature of HS, these wounds are often nonsterile, located in moist intertriginous regions, and closed under tension, increasing the risk for surgical site complications. Although uncommon, absorbable sutures may confer benefits over nonabsorbable material for skin closure. Accordingly, the authors evaluated the use of absorbable, braided, transcutaneous polyglactin sutures after wide surgical excision of HS.

METHODS

The authors performed a retrospective chart review for all consecutive patients who underwent wide surgical excision of HS at a tertiary university hospital between January 2009 and March 2020.

RESULTS

Sixty consecutive patients with 174 operative sites were included in the study. The surgical site complication rate was 17.8%. Postoperative complications included wound dehiscence (n = 18), surgical site infection (n = 2), and scar contracture (n = 1). Sutures were removed from 12 (6.9%) operative sites. Factors influencing complications were Hurley grade and area of excision. Complications did not differ significantly among disease locations (P = .6417).

CONCLUSIONS

The results support the growing evidence that absorbable sutures are an appropriate option after wide surgical excision of HS.

Yin and Yang: A disrupted skin microbiome and an aberrant host immune response in hidradenitis suppurativa

The skin microbiome plays an important role in maintaining skin homeostasis by controlling inflammation, providing immune education and maintaining host defense. However, in many inflammatory skin disorders the skin microbiome is disrupted. This dysbiotic community may contribute to disease initiation or exacerbation through the induction of aberrant immune responses in the absence of infection. Hidradenitis suppurativa (HS) is a complex, multifaceted disease involving the skin, innate and adaptive immunity, microbiota and environmental stimuli. Herein, we discuss the current state of HS skin microbiome research and how microbiome components may activate pattern recognition receptor (PRR) pathways, metabolite sensing pathways and antigenic receptors to drive antimicrobial peptide, cytokine, miRNA and adaptive immune cell responses in HS. We highlight the major open questions that remain to be addressed and how antibiotic therapies for HS likely influence both microbial burden and inflammation. Ultimately, we hypothesize that the two-way communication between the skin microbiome and host immune response in HS skin generates a chronic positive feed-forward loop that perpetuates chronic inflammation, tissue destruction and disease exacerbation.

Systematic Review of Complications and Recurrences After Surgical Interventions in Hidradenitis Suppurativa

BACKGROUND

The possible connection between hidradenitis suppurativa (HS) patients undergoing surgery and higher complications/recurrences has been implied, but inconsistent results reported.

OBJECTIVE

To assess the complication and recurrence rates for HS patients undergoing surgery and to evaluate whether known HS comorbidities and habits (smoking, obesity and diabetes) have an effect on the complication and recurrence rates.

MATERIALS AND METHODS

A systematic review was conducted by 2 reviewers. PubMed and Embase were searched using a predefined search string created in collaboration between the authors and a librarian on January 23, 2019.

RESULTS

Of the 271 references in the original search, 54 relevant articles were identified. This systematic review indicates an overall mean complication rate of 24% and a mean recurrence rate of 20.1% for HS patients undergoing surgery.

CONCLUSION

No significant association between the known surgical risk factors and surgical complications-or recurrence rates in this patient group was found. This review revealed a lack of quality and quantity data in studying the complications/recurrences. The heterogeneity of the studies created limitations, and the presented mean complication/recurrence rates should be interpreted with the consequences thereof. It elucidates the need for better studies and a necessity for a standardized definition of postsurgical HS recurrence.

Factors influencing the local cure rate of hidradenitis suppurativa following wide local excision

Wide local excision is the gold standard and only potential curative therapy for recalcitrant hidradenitis suppurativa. However, high recurrence rates persist even post-surgery with little known on the influencing factors for remission. We evaluated the effect of patient, disease, and operative factors on local cure rate of moderate to severe hidradenitis following wide local excision. We performed a retrospective chart review for all patients who had undergone surgical excision of hidradenitis at a university hospital from 2012 to 2018. We identified 79 patients with a total of 220 operative sites. The majority were obese (mean body mass index [BMI] 32.5), female (71%), African-American (84%), and had a mean age of 31 years. A quarter of operative sites experienced a recurrence (n = 56). Patients who achieved remission had a significantly lower number of affected regions than those who experienced a recurrence (2.3 vs 3.6, P = .0023). Additionally, recurrence rate differed significantly between body locations (P = .0440). Smoking, BMI, Hurley grade, closure method, and excision size did not influence local cure rate. Surgical excision remains a worthy management option for hidradenitis patients with three quarters achieving remission after a single operation. Number of affected regions and location of hidradenitis may play a factor in recurrence.

Disease burden and cost of hidradenitis suppurativa: a retrospective examination of US administrative claims data

OBJECTIVES

Hidradenitis suppurativa (HS) causes substantial morbidity and quality-of-life impairment. We examined demographic/clinical characteristics of patients with HS and treatment patterns, prevalence and healthcare resource utilisation/expenditures related to HS in the real-world.

DESIGN

Retrospective claims data of MarketScan Commercial, Medicare Supplemental and Medicaid databases (2009-2014).

SETTING

USA.

PARTICIPANTS

Patients aged ≥12 years with ≥3 non-diagnostic outpatient or inpatient claims with an HS diagnosis code and ≥12 months continuous enrolment with medical and pharmacy benefits before (preindex) and after (postindex) the earliest diagnosis of HS (index) were included.

RESULTS

There were 11 325 Commercial/Medicare patients (mean age 37.4 years) and 5164 Medicaid patients (mean age 28.3 years). HS was more common in Medicaid than Commercial/Medicare patients (0.301% and 0.098%, respectively, in 2014). Cellulitis and psychiatric disorders were the most common comorbidities and oral antibiotics and narcotics were the most frequently prescribed drugs preindex, with ≥10% increase postindex in both populations. HS-related inpatient costs decreased while outpatient costs increased from preindex to postindex. Medicaid patients had several risk factors that may be associated with poor outcomes (eg, high rates of prescription pain medication use, comorbidities, drug discontinuation/interruption/holiday, emergency department (ED) visits and hospitalisation).

CONCLUSIONS

Commercial/Medicare and Medicaid HS beneficiaries experience high comorbidity burden but use different treatment modalities to manage HS. Results suggest a substantial unmet need exists among this patient population, with Medicaid patients experiencing a particularly high burden of disease and expensive healthcare resource utilisation.

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.