A growing family of outcome measurement proposals for hidradenitis suppurativa

Linked Article: Goldfarb et al. Br J Dermatol 2021; 184:905–912.

Survival in 31 670 patients with thin melanomas: a Swedish population-based study

BACKGROUND

The incidence of cutaneous malignant melanoma (CMM) continues to increase in most countries worldwide and the majority are diagnosed with thin tumours (≤ 1 mm).

OBJECTIVES

The aim of the present study was to investigate the melanoma-specific survival (MSS) as well as conditional MSS (CMSS) in patients with thin CMM in Sweden.

PATIENTS AND METHODS

Clinical and histological parameters were obtained from the Swedish Melanoma Registry for patients diagnosed with thin CMM between 1990 and 2017. Patients were followed until the end of 2017. MSS as well as CMSS for different thickness groups were calculated using the Kaplan-Meier method and Cox regression analyses were used to calculate for survival differences between thickness groups.

RESULTS

There were 31 670 patients included for final analyses. The overall 10- and 20-year MSS for thin CMMs was 97% [95% confidence interval (CI) 97-97] and 95% (95% CI 95-96), respectively. From 0·7 mm and above, MSS decreased significantly with increasing thickness level. All thickness groups had an increased survival over time. The lowest CMSS was confirmed for men with 1·0 mm in thickness but their 10-year CMSS increased steadily over time. Women had overall better MSS as well as CMSS than men. However, the relation between MSS and CMSS was similar for both sexes.

CONCLUSIONS

MSS was confirmed as excellent for patients with thin CMMs in Sweden. Although we could show a decreased MSS for patients with 0·7 mm thickness and above, the long-term survival and, in addition, a very favourable CMSS for those patients do not support more extended follow-up programmes than the current recommendations in Sweden.

Acute skin and hair symptoms followed by severe, delayed eye complications in subjects using the synthetic opioid MT-45

BACKGROUND

The introduction of unclassified new psychoactive substances (NPS) on the recreational drugs market through open online sale ('legal highs' or 'Internet drugs') continues unabated and represents a growing health hazard. The use of NPS has resulted in numerous, severe, adverse events and fatalities, due to unintended overdose or unknown toxic side-effects.

OBJECTIVES

To try to find a possible common underlying cause for the skin-hair-eye symptoms complex observed in three men.

METHODS

From late 2013 to mid-2014, three Swedish men aged 23-34 years with a history of recreational drug use independently presented with similar and very remarkable clinical signs, requiring extensive examination and prolonged treatment.

RESULTS

Common clinical signs included hair depigmentation, hair loss, widespread folliculitis and dermatitis, painful intertriginous dermatitis, dry eyes, and elevated liver enzymes. Two of them also showed transverse white Mees' lines (leukonychia striata) on the fingernails and toenails, suggesting a temporary, drug-induced, disorganized keratinization. The clinical signs gradually disappeared over time. However, later on, two developed severe bilateral secondary cataracts requiring surgery. Because drug tests within the Swedish STRIDA project had demonstrated intake of the NPS opioid MT-45 in all patients, this was suspected to be the common causative agent.

CONCLUSIONS

These cases highlight the importance for physicians and health professionals to consider the increasing number of novel, untested recreational drugs, as a potential cause of unusual and otherwise unrecognized clinical signs and symptoms.

Trends in cutaneous malignant melanoma in Sweden 1997-2011: thinner tumours and improved survival among men

BACKGROUND

Both patient survival and the proportion of patients diagnosed with thin cutaneous malignant melanoma (CMM) have been steadily rising in Sweden as in most Western countries, although the rate of improvement in survival appears to have declined in Sweden at the end of the last millennium.

OBJECTIVES

To analyse the most recent trends in the distribution of tumour thickness (T category) as well as CMM-specific survival in Swedish patients diagnosed during 1997-2011.

METHODS

This nationwide population-based study included 30,590 patients registered in the Swedish Melanoma Register (SMR) and diagnosed with a first primary invasive CMM during 1997-2011. The patients were followed through 2012 in the national Cause of Death Register.

RESULTS

Logistic and Cox regression analyses adjusting for age at diagnosis, tumour site and healthcare region were carried out. The odds ratio for being diagnosed with thicker tumours was significantly reduced (P < 0·001) and the CMM-specific survival significantly improved in men diagnosed during 2007-2011 compared with men diagnosed during 1997-2001 (hazard ratio = 0·81; 95% confidence interval 0·72-0·91; P < 0·001), while the corresponding differences for women were not significant. Women were diagnosed with significantly thicker tumours during 2002-2006 and a tendency towards decreased survival was observed compared with those diagnosed earlier (during 1997-2001) and later (during 2007-2011).

CONCLUSIONS

In Sweden, the CMMs of men are detected earlier over time and this seems to be followed by an improved CMM-specific survival for men. Women are still diagnosed with considerably thinner tumours and they experience a better survival than men.

European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa

Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. A mean disease incidence of 6.0 per 100,000 person-years and an average prevalence of 1% has been reported in Europe. HS has the highest impact on patients' quality of life among all assessed dermatological diseases. HS is associated with a variety of concomitant and secondary diseases, such as obesity, metabolic syndrome, inflammatory bowel disease, e.g. Crohn's disease, spondyloarthropathy, follicular occlusion syndrome and other hyperergic diseases. The central pathogenic event in HS is believed to be the occlusion of the upper part of the hair follicle leading to a perifollicular lympho-histiocytic inflammation. A highly significant association between the prevalence of HS and current smoking (Odds ratio 12.55) and overweight (Odds ratio 1.1 for each body mass index unit) has been documented. The European S1 HS guideline suggests that the disease should be treated based on its individual subjective impact and objective severity. Locally recurring lesions can be treated by classical surgery or LASER techniques, whereas medical treatment either as monotherapy or in combination with radical surgery is more appropriate for widely spread lesions. Medical therapy may include antibiotics (clindamycin plus rifampicine, tetracyclines), acitretin and biologics (adalimumab, infliximab). A Hurley severity grade-relevant treatment of HS is recommended by the expert group following a treatment algorithm. Adjuvant measurements, such as pain management, treatment of superinfections, weight loss and tobacco abstinence have to be considered.

Bacteriology of hidradenitis suppurativa exacerbations and deep tissue cultures obtained during carbon dioxide laser treatment

BACKGROUND

Previous studies have shown different bacteria in hidradenitis suppurativa (HS) lesions, but the literature regarding bacteria in acute exacerbation of HS is sparse.

OBJECTIVES

To determine the type of bacteria isolated from HS lesions during exacerbations of the disease.

METHODS

Patients with HS with acute nodules or abscesses were examined and treated by carbon dioxide laser vaporization. Bacterial samples for aerobic and anaerobic cultures were taken from the skin surface (before surgery) and then from the deeper layers (during surgery) of the lesions. At each level two samples were taken, one with a punch biopsy and one by pressing a soft agar gel against the skin. The bacterial findings were typed and quantified.

RESULTS

A total of 10 patients (eight women and two men), with a mean age of 37·2 years and a mean HS duration of 14·5 years, were included. All of them had an ongoing exacerbation (mean duration 5·6 days) of their HS, with one inflamed lesion that was treated by carbon dioxide laser vaporization. Coagulase-negative staphylococci (CNS) were found in the deep layers in all 10 patients. Nine of the patients carried Corynebacterium spp. and two alpha-haemolytic streptococci at various levels. Among the anaerobic microorganisms, Gram-positive cocci were the most common bacteria.

CONCLUSIONS

As found in a previous study, CNS were the most common bacteria, but contrary to what we expected, Staphylococcus aureus was not found in any cultures from acute inflammatory nodules of HS exacerbations.

Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesity

BACKGROUND

Hidradenitis suppurativa (HS) is a long-standing disease with abscess and often fistula formation, predominantly in the axillae and groins. The disease is difficult to treat and has a severe impact on quality of life. A clinically relevant system for scoring disease severity is lacking in HS.

OBJECTIVES

To evaluate the modified Hidradenitis Suppurativa Score (HSS) and to study the impact of body mass index (BMI) and smoking habits on disease severity.

METHODS

Two hundred and fifty-one consecutive patients with HS referred to a clinic with special interest in the disease were included, of whom 115 were scored. Points were given for regions involved, types of lesion (nodules, fistulas), total area involved and whether lesions were separated by normal skin. Background characteristics included BMI and smoking habits. Two hundred and forty-six patients completed the Dermatology Life Quality Index (DLQI).

RESULTS

The median (interquartile range, IQR) HSS for all patients was 38 (18-66): women 38 (18-71) and men 37 (19-51). Median (IQR) HSS for smokers was 41 (22-75.5), former smokers 27 (16-53) and nonsmokers 22 (10-57). Median (IQR) HSS for patients with BMI < 25 kg m(-2) was 32 (12-54), BMI 25-30 kg m(-2) 44 (22-56) and BMI > or = 30 kg m(-2) 50 (18-86). Mean +/- SD DLQI for the whole group of patients was 10.3 +/- 7.5, median 9, and showed no significant differences between the groups studied. There was a significant positive correlation of fair degree between HSS and DLQI. There were significant differences in HSS between nonsmokers and smokers as well as between women of normal weight compared with obese women.

CONCLUSIONS

The modified HSS is simple and practical and it extracts important clinical information. A connection between disease severity and BMI as well as smoking habits in patients with HS is presented. The results suggest that the HSS may be a relevant outcome measure in future therapeutic trials in HS.

What causes hidradenitis suppurativa?

Hidradenitis suppurativa (HS)--a rather common, very chronic and debilitating inflammatory skin appendage disorder with a notoriously underestimated burden of disease--has long been a playground for the high priests of nomenclature: Ask a bunch of eminent dermatologists and skin pathologists to publicly share their thoughts on what causes HS, and they will soon get entrenched in a heated debate on whether this historical term is a despicable misnomer. Fortunately, the recently founded Hidradenitis Suppurativa Foundation (HSF; http://www.hs-foundation.org), to which EXP DERMATOL serves as home journal, has broken with this unproductive tradition and has encouraged publication of the current CONTROVERSIES feature. This is exclusively devoted to discussing the pathobiology of this chronic neutrophilic folliculitis of unknown origin. Although traces of terminological bickering remain visible, it does the HS experts in our virtual debate room credit that they engage in a constructive and comprehensive dissection of potential pathogenesis pathways that may culminate in the clinical picture we know under the competing terms HS or acne inversa. These experts sketch more often complementary than mutually exclusive pathogenesis scenarios, and the outlines of a conceivable consensus on the many open pathobiology questions begin to emerge in these CONTROVERSIES. Hopefully, this heralds a welcome new tradition: to get to the molecular heart of HS pathogenesis, which can only be achieved by a renaissance of solid basic HS research, as the key to developing more effective HS therapy.

Biophysical assessment of atopic dermatitis skin and effects of a moisturizer

BACKGROUND

The mechanisms of the skin barrier impairment in patients with atopic dermatitis (AD) are still unknown and need further studying.

OBJECTIVE

We evaluated the skin of healthy subjects and of patients having atopic dermatitis with an instrument measuring electrical impedance and other noninvasive methods (transepidermal water loss, capacitance) and studied the effects of a new emollient [Proderm (Pro-Q in the USA)].

METHODS

After a 2-week washout period, we treated clinically noneczematous skin on the forearm of 24 patients with AD and assessed the effects with the noninvasive methods. 22 healthy subjects were used as controls.

RESULTS

The findings indicate that barrier function and hydration, and certain patterns of electrical impedance of AD skin are abnormal compared with normal skin. Moreover, there was an increase in hydration in patients' skin after treatment and a reversal of certain impedance indices towards normal.

CONCLUSIONS

Our findings demonstrate that the moisturizer we used changes some biophysical parameters when applied to atopic skin. In addition, a technique based on electrical impedance seems to give valuable information in atopic skin studies, especially the effects of moisturizers.

Incidence of cancer among patients with hidradenitis suppurativa

BACKGROUND

On the basis of some case reports, a relationship has been suggested between hidradenitis suppurativa (HS) and the development of nonmelanoma skin cancer.

OBJECTIVES

To confirm this relationship and to explore the risk of other cancers among patients with HS.

PATIENTS

Patients with a discharge diagnosis of HS were obtained from the computerized database of hospital discharge diagnoses from January 1, 1965, through December 31, 1997. A total of 2119 patients with HS were identified.

SETTING

All hospitals in Sweden.

DESIGN

With record linkage to the Swedish National Cancer Registry, standardized incidence ratios (SIR [the ratio of the observed to expected incidence]) were calculated to estimate relative risk.

RESULTS

The risk of developing any cancer in the cohort with HS increased 50% (95% confidence interval of SIR, 1.1-1.8, based on 73 observed cases). Statistically significant risk elevations were observed for nonmelanoma skin cancer (5 cases; SIR, 4.6; 95% confidence interval, 1.5-10.7), buccal cancer (5 cases; SIR, 5.5; 95% confidence interval, 1.8-12.9), and primary liver cancer (3 cases; SIR, 10.0; 95% confidence interval, 2.1-29.2).

CONCLUSIONS

This study confirms an increased risk of nonmelanoma skin cancer among patients with HS. The risk for buccal cancer and primary liver cancer was also elevated among this cohort, but these associations should be interpreted cautiously because the combination of multiple significance testing and the few observed cases may have generated chance findings.

Neutrophil-related host response in hidradenitis suppurativa: a pilot study in patients with inactive disease

Host-defence defects in hidradenitis suppurativa patients have been suspected, but not proven. Activated neutrophils can destroy the surrounding tissues by a release of reactive oxygen species and active proteases. Peripheral neutrophils from 15 female patients (mean age 46, range 27-57 years) in an inactive state of their hidradenitis suppurativa, were studied and compared with 15 age-matched healthy female controls. There were no significant differences between patients and controls in the assessments of intracellular elastase activity, total content of antigenic elastase or release of elastase. Furthermore, no differences were found in total content and membrane expression of the receptors measured. The generation of free oxygen radicals, after stimulation with the protein kinase C activator phorbol myristate acetate, was significantly higher in the patients than in the controls, while there was no difference after Fc-receptor-mediated stimulation. Dysfunctional neutrophils might be involved in the pathogenesis of hidradenitis suppurativa, but the findings should be interpreted with caution because of the small number of observed cases.

No human leukocyte antigen-A, -B or -DR association in Swedish patients with hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a cicatrizing, inflammatory and recurrent disease restricted to inverse skin, such as that of the axilla and groin of younger adults. In a previous study, using serological tissue-typing techniques, no significant increases in the human leukocyte antigen (HLA)-A and -B specificities were found in patients with HS. The aim of this study was to determine the frequencies of HLA-A, -B and, for the first time, HLA-DR alleles, using genomic tissue-typing methods in patients with HS. Forty-two unrelated Swedish patients with HS were included and compared with 250 controls. According to clinical staging adopted from Hurley all of the patients had stage II HS, i.e. recurrent abscesses with tract formation and cicatrization and single or multiple widely separated lesions. No association with HLA-A, -B or -DRB1 alleles was found in patients with HS. Genetic factors associated with the HLA class I or II regions do not appear to contribute significantly to the possible genetic susceptibility of HS.

Coagulase-negative staphylococci are the most common bacteria found in cultures from the deep portions of hidradenitis suppurativa lesions, as obtained by carbon dioxide laser surgery

The significance of bacterial findings in hidradenitis suppurativa (HS) is controversial. Interpretation of the results of bacteriological examinations from the surface of HS lesions is obscured by the possible contamination of resident skin bacteria. Bacteriological analysis of aspirates from deeper parts of HS is liable to show low sensitivity. We used a carbon dioxide (CO2) laser method to evaporate the diseased tissue level by level from the surface downwards, allowing concurrent sampling of bacteriological cultures from each level and thereby minimizing contamination with bacteria from the level above. In this study, 22 women and three men with a mean age of 35.3 years and a mean HS duration of 10.6 years were treated with this CO2 laser surgical method. Aerobic and anaerobic cultures from superficial and deep levels were taken during surgery. The regions treated were axillary in eight and perineal in 17 cases. Bacterial cultures were positive for one or more specimens from at least one level in all cases and from deep levels in all but three cases. Sixteen different species or sub-species were found. Staphylococcus aureus and coagulase-negative staphylococci (CNS) were the species most frequently found. Peptostreptococcus species and Propionibacterium acnes were not uncommon. S. aureus was detected in a total of 14 cases, six of which were from the deep levels. S. aureus was the sole bacterium isolated in two deep cultures. CNS were found in 21 patients and 16 of these isolates were from the deep levels. In nine of the 16 deep samples CNS were the only bacteria detected. These findings motivate a re-evaluation of the significance of bacteria in the progress of HS and in particular they suggest that CNS are true pathogens. It is known that foreign bodies aggravate the virulence of the CNS in surgical implants, and an environment which resembles that produced by a foreign body, as found in chronic HS tissue, serves to intensify the pathogenic properties of CNS in HS.

Mucocutaneous manifestations in 22 consecutive cases of primary HIV-1 infection

Twenty-two consecutive patients presenting with symptomatic human immunodeficiency virus 1 (HIV-1) seroconversion were studied. Most of the patients had a glandular fever-like illness. All patients had fever and pharyngitis, and eight of them also suffered from ulcers of the oral, genital or anal mucosa. Uniform skin eruptions were observed in 17 of the 22 patients. The exanthem consisted of varying numbers of macular or maculopapular lesions that were oval or rounded in shape, ranging from a few millimetres to 1 cm in diameter. The lesions were distributed on the upper thorax in all cases, and were particularly profuse in the collar region. The face, forehead and scalp were involved in most cases, but the eruption was sparse or absent at the periphery of the extremities. In the majority of patients, the exanthem appeared after 2 or 3 days of fever. The exanthem developed during the first day, persisted for 5-8 days, and then cleared concurrently with the general recovery of the patients. Histopathological studies of skin punch biopsy specimens from four patients showed a sparse lymphocytic cell infiltrate distributed around vessels of the dermal superficial plexus. The infiltrates predominantly consisted of equally represented T-helper/inducer and T-suppressor/cytotoxic cells. A vacuolar aberration of basal layer cells was found in two of the four cases studied histologically. The microscopic findings correspond to the histopathological patterns seen in toxicodermia and in the interface dermatitis of morbilliform viral exanthems. The exanthem is a frequent and characteristic sign of primary HIV infection, which is further indicated if mucosal ulcers are present.

Surgical treatment of chronic hidradenitis suppurativa: CO2 laser stripping-secondary intention technique

The objective of our study was to evaluate a surgical method of management of patients with hidradenitis suppurativa (HS), using a CO2 laser technique for stepwise horizontal vaporization and peroperative monitoring of the removal of diseased tissue. Twenty-four patients were selected for treatment, 21 women and three men, who had suffered from HS for a mean of 13 years (range 1-28 years) and experienced more than three recurrences of suppurating lesions during the year prior to entering the study. The mean follow-up time after CO2 laser surgery was 27 months (range 15-47 months), with clinical follow-up once or twice a week during the wound-healing period, and then at intervals of 1-3 months to evaluate recurrences and assess the end result. The patients' healing time was approximately 4 weeks (range 3-5 weeks). During the follow-up period two patients had recurrences in the treated areas. Twenty-two patients had no recurrences in the treated areas, but in four cases de novo suppurating lesions appeared 5-10 cm beyond the initial sites of surgery. Ten patients had exacerbations of HS lesion(s) in a region other than the treated site. Eight patients did not have any recurrences. Post-surgery results were satisfactory both cosmetically and with regard to quality of life. The CO2 laser stripping-secondary intention technique is a rapid, efficient, and economical method for the treatment of HS. It allows simple treatment of early lesions which would otherwise have been treated using less effective local conservative remedies.

Angiokeratomas in Fabry's disease and Fordyce's disease: successful treatment with copper vapour laser

Two patients with multiple angiokeratomas on genitalia and thighs, one with Fabry's disease and one with Fordyce's disease, were treated with copper vapour laser light of 578 nm wavelength. The result was desirable, with destruction and disappearance of the lesions and minimal scarring and posttreatment hyper- or hypopigmentation.

Roxithromycin compared to doxycycline in the treatment of genital chlamydial infection and non-specific urethritis

A single-blind randomized follow-up study was conducted to evaluate the efficacy and tolerance of roxithromycin 300 mg once a day compared to doxycycline 200 mg day 1 and 100 mg day 2-10 in the treatment of genital chlamydial infection in men and women and non-specific urethritis (NSU) in men. A total of 211 patients (200 men and 11 women) between 18 and 46 years were enrolled. The women were excluded from the efficacy analysis because of the low number, but were included in the tolerance analysis. The clinical (clearance of polymorphonuclear leucocytes in urethral smears) and bacteriological response was evaluated one and 11 days after the treatment. Of 113 included men with chlamydial infection, 105 (93%) and 96 (85%) were evaluable on respective follow-up visits and of 87 included men with NSU, 74 (85%) and 64 (74%) were evaluable one and 11 days after treatment, respectively. The bacteriological eradication rate immediately after the treatment in chlamydia positive patients was 92.7% and 100% for roxithromycin and doxycycline, respectively, and 91.8% and 100% at follow-up. The clinical cure rate of all evaluable patients was 83.1% and 80.7% for roxithromycin and doxycycline, respectively, one day after the treatment and 80.5% and 85.3% for the two drugs, respectively, 11 days after treatment. None of these observed differences was statistically significant. The diagnosis did not influence the clinical response rate with either drug. Probable and possible drug-related side-effects were more common after doxycycline than after roxithromycin, 35% and 19% respectively (P = 0.0032).(ABSTRACT TRUNCATED AT 250 WORDS)