Welcome to the 1st HS Update, a new initiative from the Canadian HS foundation. Last year we engaged in a project to develop our future strategic plan. Through this exhausting, yet extremely insightful, process we identified our primary mission: “Helping Canadian Dermatologists better manage HS”.
We are already active in traditional educational activities through the annual Symposium for Hidradenitis Suppurativa Advances (SHSA) and the HS subspeciality symposium at the Canadian Dermatology Association Annual Meeting. Those events provide excellent high-quality interactive educational opportunities to attendees. Nonetheless, the reach of these events is limited to the relatively small number of attendees. In this day and age, online platforms are essential elements of any effective medical education plan. The new HS Update will provide year-round easily accessible up-to-date information.
Each issue will consist of a combination of highlights of important new developments in the field, clinical tips, and commentary on newly published research.
I hope you will enjoy the HS Update and we welcome your feedback and suggestions for future episodes.
Raed Alhusayen MBBS MSc(Clin/Epi) FRCPC
President, Canadian Hidradenitis Suppurativa Foundation
HS Update – September 2019
Dedicated HS Clinic in an Academic Center
Elizabeth O’Brien MD FRCPC
Associate Professor, Dermatology
The Hidradenitis Suppurativa clinic at the Montreal General Hospital was initiated in 2017 in response to increasing referrals of HS patients to the Immunodermatology clinic, from whom it became evident that a dedicated clinic would improve our overall management of HS patients. The goals of the clinic are to provide optimal patient care with a focused approach to diagnosis, staging and management, to teach residents and students about HS, while simultaneously gathering and documenting information for future research.
The academic clinic setting provides certain advantages that may be difficult for private offices to offer in terms of support staff, physical set up and documentation. The clinic staff include a dermatologist, dermatology residents, plus residents from family medicine, other medical specialties and medical students on elective rotations, the clinic secretary, the dermatology clinic nurse with expertise in wound care, and a clinic orderly. Although not a multidisciplinary clinic, close communication exists with plastic surgery for cross referrals, and if patients are seen by surgery in ER, they are now referred directly to our clinic for medical management.
New patients are given one-hour appointments. All patients are given the following forms to complete in the waiting room: history, DLQI, VAS pain score. The scores are recorded in an highlighted box on the chart to allow easy retrieval for chart review. Other questionnaires may be included for specific research projects. Patients are given information pamphlets about HS as well as contact information for HS support groups. Being mindful of the particular needs of HS patients, who are often embarrassed by drainage and odour, thick leak proof pads are put on examining room chairs and tables, and deodorant sticks placed discretely in each room Patients are first seen by the nurse, who performs a wound assessment, noting the areas and extent of involvement, and enquires about particular concerns that the patient would like addressed. The nurse takes photographs which are added to the patient’s file for documentation and follow-up.
The dermatologist and residents review the history with the patient and examine affected areas, calculating lesion counts. Three grading systems are currently used: Hurley, PGA, and iHS4. Ultrasound examination is performed on Hurley stage 1 and 2 patients to ensure accurate staging, and for presurgical assessment.
Therapy including general measures, topical, intralesional, systemic and surgical treatments are recommended according to individual patients’ situation. Intralesional injection of 5-10 mg/ml triamcinolone (maximum dose 20 mg per month) is offered for acutely inflamed lesions. In addition, patients may drop in for intralesional injection during HS clinics. Small excisions and deroofing procedures are performed using ultrasound preassessment, with prior topical anesthetic followed by xylocaine with epinephrine. Monsel’s solution is applied for hemostasis, and petrolatum with a dry dressing. Patients are given referrals to their community health clinic for daily dressing changes if they are not comfortable doing it themselves. Larger excisions are referred to Plastic Surgery.
The patient response to this dedicated clinic has been extremely positive, and it provides abundant opportunities for teaching and research in HS.
Treating HS in a Community Setting
Dr. Tracey Brown-Maher MD FRCPC
Hidradenitis suppurativa (HS) is a challenge to treat in the community, but it can be a rewarding one. This previous “orphan disease” has left many patients without a diagnosis, treatment or satisfactory quality of life. I have heard patients say “You are the first doctor to give me a diagnosis or offer treatment” or “This is the most I have learned about what I have in years”.
HS patients do take longer to interview and evaluate. They often have issues with hopelessness and frustration as they have been disappointed before. They can be apathetic. Ensure you book enough time to do a proper consultation. I try to do a “systemic clinic” every month or two and book an afternoon of all new patients with HS. I book “lighter” rechecks at the same time so I do not have to rush. Seeing this type of patient over and over in an clinic develops a “rhythm” that allows one to do a thorough history and physical. I try to use a “cheat sheet” to write down affected areas on a diagram. I also have an LPN that helps during the clinic.
I try to ask all HS patients about their mood. Depression is a significant comorbidity associated with HS. It may be hard for some doctors to broach this subject. I often start with “having any chronic condition can cause stress and anxiety or affect your mood…have you ever experienced this?”. Many patients will admit there is an impact and be open to discuss it. I also ask about medications, and if I notice they are taking a medication for mood or anxiety, I acknowledge there is an association between this and HS. Showing this interest enables you to build trust.
I never mention weight in the first visit. If a patient brings up the association between obesity and HS, I say I see thin and overweight patients with this condition. Losing weight may help or not. It can help other comorbid conditions. I acknowledge that losing weight is not an easy task. By not attributing blame or shame, patients are more open to discuss weight loss options. I always encourage and congratulate any weight loss they do achieve. Smoking cessation is also a touchy issue. I ask about smoking and inform them that smoking may precipitate or make the disease worse. I advise them to tell family members to avoid smoking for this reason. When patients are ready to quit they will ask for help.
I reassure HS patients that the disease is not due to them being “dirty”. It is a chronic inflammatory condition that is related to other chronic diseases we see all the time. I tell them it is fairly common. Many think they are the only ones with HS, and this prevents them from seeking treatment. On a return visit, patients often report they finally discussed the condition with other family members and found out others are also affected. Knowing they are not alone in their suffering is comforting and breaks through barriers to enable them to accept treatment. I also give them a pamphlet on HS to bring home that may foster more questions at the next encounter.
I briefly discuss options for treatment, including topical and systemic antibiotics, intralesional steroids, biologics, and surgery. Patients need to know medical management improves surgical success. I offer systemic antibiotics on the first visit, and book them back in three months to reassess. I ask them to keep track of flares and numbers of lesions. I offer all patients a standing prescription for intralesional steroid for flares. My nurse will fit them in somewhere in the clinic for urgent injection. Patients appreciate this service, and it again fosters trust. I do ask them to have a biologic workup after the first visit if they have moderate-severe disease so we can be prepared for the next step of a biologic if necessary.
I give talks about HS to GPs and ER doctors. Education helps them accurately diagnose patients and provide adequate and timely referrals. I receive new referrals for HS patients every week. I have good contacts with general surgeons and plastic surgeons, and let them know I am willing to medically manage patients if they can do surgery. We refer back and forth. I also keep contacts with Gastroenterologists because some patients may already be on a biologic for IBD and may need their dose increased or the drug switched if possible to adequately treat more than one comorbidity.
I enjoy treating this challenging disease. I encourage other dermatologists to do the same. Giving hope to those with HS may not only improve their lives, but increase a dermatologist’s satisfaction with his/her work.
From the Journal Stand
Reviewer: Dr. Nouf Almuhanna MD
Editor: Dr. Raed Alhusayen MD MSc FRCPC
Can therapy with Clindamycin and rifampicin for HS be safely continued long term beyond a 10-week course.
A literature review was conducted, and the following was found regarding safety.
Rifampicin: drug-induced liver injury.
- Rifampicin causes a small increase in liver enzymes in 10– 20% of patients. These do not usually necessitate drug discontinuation or dose adjustment.
- Hepatotoxicity typically occurs at the beginning of therapy, in the first 1–6 weeks, which means that patients who tolerated the 10-week course are unlikely to be affected by extending the course.
Rifampicin: interstitial nephritis
- Nephrotoxicity was most commonly seen with intermittent on and off therapyand with twice-weekly regimen.
- It was reversible once rifampicin is discontinued.
- There is no evidence that therapy beyond 10 weeks is associated with a higher risk of this adverse event.
Rifampicin: drug interaction and hepatic p450 3A4 enzyme induction
- Rifampicin reduces the levels of Clindamycin by 90% within about 10 days
- This indicates that the effect of rifampicin and clindamycin treatment may be driven entirely by rifampicin.
- It also indicates that pseudomembranous colitis risk is primarily dependent on rifampicin, which is rare. In fact rifampicin is used in some cases to treat pseudomembranous colitis.
Clindamycin: Community-acquired Clostridium difficile infection (CA-CDI)
- Three meta-analyses identified antibiotic use as a risk factor for this side effect with two studies reported that the highest risk is due to Clindamycin.
- While studies confirm that clindamycin exposure increases the risk of CA-CDI they do not address the risk of long-term exposure.
Experience with long-term treatment of the combination of Clindamycin and rifampicin
- No studies were identified that addressed long-term experience with this combination.
- There is extensive experience with long term use of rifampicin, for the treatment of tuberculosis, but clindamycin data is limited.
- The risk of adverse events for patients on the combination of clindamycin and rifampicin clusters in the first 10 weeks of treatment.
- In view of that, the authors concluded that the treatment can be continued beyond 10 weeks, if clinically necessary.
Determining the Optimal Dose of Infliximab for Treatment of Hidradenitis Suppurativa.
- A retrospective cohort study of 52 HS patients treated with infliximab between June 2015 and March 2018.
- The most common initial regimens were 10 mg/kg every eight weeks (n=36; 69%) and 7.5mg/kg every eight weeks (n=10; 19%).
- The most common ongoing regimens were 10mg/kg every eight weeks (n=17; 33%) and 10mg/kg every six weeks (n=14; 27%).
- Thirty-five (67%) patients achieved the primary outcome, which is an achievement of a stable dosing regimen, most commonly 10 mg/kg every 8 weeks (n=17; 49%) or every 6 weeks (n=10; 29%).
- There were significant improvements in mean AN count, draining sinuses, ESR, and hemoglobin, but not CRP.
- Most patients were Hurley stage 3 (87%).
- On average, patients received 3.8 prior treatments, most commonly antibiotics (90%), and concomitant treatments with infliximab therapy, average 2.1, most commonly antibiotics (52%).
- Infusions were well tolerated with 10 (19%) patients experiencing a total of 12 adverse events; most common was mucocutaneous infections.
- Starting patients on initial dosing of 10 mg/kg every eight weeks has the potential to reduce the number of adjustments needed to achieve a stable dosing regimen with good clinical response.
Hidradenitis Suppurativa Patients Have Higher Comorbidity Burden Compared to Psoriasis Patients.
- The purpose of this study is to estimate the overall comorbidity in patients with HS and to compare it with psoriasis patients.
- A cross-sectional analysis using a multi–health system data analytics and research platform.
- The Charlson Comorbidity Index (CCI) is used, which is a validated standardized measure of global comorbidity.
- Data were collected from 3 study cohorts, patients with HS, psoriasis, and a control group.
- The HS cohort was younger in age (mean [SD] 43.7 [14.6]), had a higher percentage of women (4037 [76.1%]), and a higher percentage of African American individuals (1902 [35.8%]) compared with psoriasis and control cohorts.
- Before matching, the overall mean (SD) CCI score was highest among the psoriasis cohort (2.33 [3.13]), followed by the HS cohort (1.80 [2.79]) and lastly the control cohort (1.26 [2.35]).
- After matching each cohort had 3818 patients and had identical age, sex, and race/ ethnicity.
- In matched analyses, the overall mean (SD) CCI score was highest among the HS cohort (1.95 [2.96]), followed by the psoriasis cohort (1.47 [2.43]; P < .001) and control cohort (0.95 [1.99]; P < .001).
- A total of 516 patients with HS (13.5%) had an overall mean CCI score of 5 or higher.
- The most common comorbidities among patients with HS were chronic pulmonary disease (1540 [40.3%]), diabetes without chronic complications (927 [24.3%]), mild liver disease (455 [11.9%]), diabetes with chronic complications (365 [9.6%]), and malignant neoplasms (342 [9.0%]).
- Patients with HS with CCI scores of at least 5 had nearly five times the odds of dying within 5-year compared to HS patients with CCI scores of 0.
- There is a 2-fold increase in standardized overall comorbidity burden as measured by CCI among patients with HS compared with the general population.
- Diseases with similar CCI indices to HS include systemic lupus erythematosus (CCI score: 1.43), dermatomyositis (CCI score: 1.4), and ankylosing spondylitis (CCI score:1.33).
- CCI does not capture all comorbid conditions, such as mood disorder and substance abuse, which were found in other studies to be more prevalent among HS patients compared to the general population.
Long-term clinical safety of clindamycin and rifampicin combination for the treatment of hidradenitis suppurativa: a strategy to reduce side-effects, improving patients’ compliance
- Data from 100 patients with HS who were treated with the clindamycin and rifampicin combination for 10 weeks and followed for 5 years.
- No serious side effects such as drug-induced liver injury, interstitial nephritis, and pseudomembranous colitis were recorded.
- Collected data showed an incidence of gastrointestinal (GI) symptoms in 38% of the treated patients. Among these patients, 50% decided to discontinue the antibiotic combination.
- An effective regimen that was tried to reduce GI side effect is to start the therapy taking only rifampicin 300 mg twice a day for 7 days, and after the first week to add Clindamycin at a dose of 300 mg twice a day.
- In 40 patients treated with this regimen, only three (8%) reported GI side-effects, and none of them decided to discontinue the therapy.
High prevalence of clinical spondyloarthritis in patients with hidradenitis suppurativa
- A cross-sectional study was performed to investigate the prevalence of self-reported clinical spondyloarthritis features in adult HS patients in 2 Dutch tertiary HS referral centers.
- A questionnaire was developed based on the Assessment of SpondyloArthritis international Society axial (back pain for 3 months or more, age of onset <45 years) and peripheral (peripheral arthritis, enthesitis, or dactylitis) spondyloarthritis entry classification criteria and other clinical spondyloarthritis features (past or present).
- Overall, 47.2% (620/1313) of questionnaires were eligible for analysis. Of these, 416 (67.1%) patients self-reported ≥ 1 of 4 SpondyloArthritis international Society entry criteria.
- Entry criteria for axial and peripheral spondyloarthritis were reported by 72.8% and 27.2%, respectively.
- The large majority (87%) reported 1 or > additional spondyloarthritis feature:32.9% reported 1 feature, 29.1% 2 features, 16.1% 3 features, and 8.9% 4 or > features.
- In comparison with patients without self- reported entry criteria (n= 204), patients with self- reported entry criteria for spondyloarthritis were significantly more frequently female (60.9% vs. 74.8%, respectively), had a higher mean BMI (26.7 5 kg/m2 vs 28.6 , respectively), were more often former or current smokers (76.2% vs 87.9%, respectively), had a longer mean HS disease duration (17.0 years vs 19.9 years, respectively), and reported more active HS symptoms at time of the survey.
- A similar pathogenic mechanism could explain an association between HS and spondyloarthritis: dysregulation of TNF alpha, interleukin 1, interleukin 12, interleukin 23, and interleukin 17 immune response pathways.
- In summary, self-reported clinical spondyloarthritis features are common in HS patients, especially in the classic HS patient, with active HS symptoms, smoking history, and longer HS disease duration.
Patients with HS with and without Crohn disease have increased risk of pyoderma gangrenosum
- Cross-sectional analysis of adults with pyoderma gangrenosum (PG ) among patients with HS and patients without HS in the united states, through the use of multiple health system databases of 55 million patients.
- Evaluation of patients with and without PG for each categoric variables (HS, sex, age, and Crohn disease (CD)).
- The patients with HS were predominantly female (74.7%) and the majority were young in the 18 to 44 year category (58.1%). The prevalence of CD in the HS 1.9% of cases.
- The overall prevalence of PG in HS was 0.18% (125 of 68,232), compared with 0.01% (1835 of 31,435,166) without HS (P <0.0001).
- The odds of having PG were 21.14 (95% CI 17.51-25.51) times higher in HS than those without HS.
- Prevalence of PG was similar between male and female patients with HS.
- It was also higher among patients with HS who were at least 45 years old (0.23%) than those who were 18 to 44 years old (0.15%).
- Prevalence of PG was markedly higher in patients with HS and Crohn’s disease (CD) (3.68%) than patients with HS without CD (0.12%).
- Among CD, patients with HS had 12.38 (95% CI, 9.15-16.74) times the odds of having PG than did patients without HS.
- In patients without CD, those with HS had 26.51 (95% CI, 21.07-33.36) times the odds of having PG than did those without HS. This suggests that the association between HS and PG is independent of CD status.
- Clinicians should have low threshold of suspicion for PG in HS patients with painful ulcerations that do not appear typical for HS since PG has been reported to occur both at sites of HS lesions and distant sites.
Higher prevalence of acne vulgaris (AV) among patients with hidradenitis suppurativa
- Observational study from a administrative databases of more than 55 million patients.
- The overall prevalence of AV is 15.2% (7315 of 48,085) and 2.9% (497,360 of 16,899,470) among patients with and without HS, respectively (P <0.0001).
- Patients with HS had 4.51 [95% CI, 4.40-4.63] times the odds of having AV than patients without HS.
- AV was most prevalent among: female gender (5870 of 35,790 [16.4%]),18 to 44 year age group (5260 of 28,870 [18.2%]), non-white race (3120 of 17,825 [17.5%]), obesity (5430 of 35,135 [15.5%]), non-smoking (3165 of 19,935(15.9% )) and polycystic ovarian syndrome (685 of 2385 [28.7%]).
- Nonwhite patients with HS had a higher prevalence of AV (17.5%) than did whites with HS (13.9% [P\.0001])
- Among patients with HS, the prevalence of AV was nearly twice as high in women with PCOS. (28.7%) as among women without PCOS (15.5% [P <0 .0001]).
- HS was associated with increased prevalence of AV in female patients with PCOS(OR, 3.14; 95% CI, 2.86-3.44) and female patients without PCOS (OR, 4.24; 95% CI, 4.11-4.37)
Difference between Acne and HS:
- Follicular occlusion occurs in the terminal hair follicles in HS, while follicles as part of the pilosebaceous unit are involved in AV, which may explain the differential in sites of involvement.
- Excess sebum is a fundamental feature in acne, whereas sebum production is normal in HS.
- Acne commonly presents with open or closed comedones, while HS features only open comedones.
- Follicular obstruction, dilatation, and rupture are central features in the pathogenesis of both and HS.
- Toll-like receptor 2 is overexpressed in l AV and HS. When activated, Toll-like receptors trigger downstream inflammation.
HS Update – April 2019
North American Hidradenitis Suppurativa Guidelines: a Welcome Tool to Improve Quality of Care for HS Patients
Dr. Raed Alhusayen MBBS MSc FRCPC
The 1st North American HS guidelines were recently published. These guidelines were produced through a successful collaboration between the Canadian and American Hidradenitis Suppurativa foundations. The primary audience is dermatologists but the guidelines provide useful information for all healthcare providers managing HS patients. They cover wide-ranging topics including disease severity assessment, screening for risk factors & comorbidities, pain management, wound care, alternative interventions, medical therapies, and surgical approaches. It is important to emphasize, as pointed out by the authors of the guidelines, these guidelines provide recommendations for the management of HS based on the available evidence at the time of preparation as interpreted by the opinions of the experts involved in the development of the guidelines. They are not meant to set a standard of care as each HS patient is unique in presentation, disease severity, comorbidities, contraindications, and response to treatment. Here are some of the highlights from the guidelines:
- Disease severity assessment: Hurley staging and inflammatory lesion counts are recommended in clinical practice. Patient-reported outcomes (pain VAS, DLQI) should be considered as well). Other grading systems are to be used for research purposes.
- Screening tests: Genetic testing and biomarkers are not recommended. Microbiology tests are not recommended unless there is clinical concern about infection.
- Screening for comorbidities: HS patients have higher rates of obesity, smoking, metabolic syndrome (diabetes, HTN, dyslipidemia), anxiety/depression, PCOS, IBD, and inflammatory arthritis. Screening should be based on history and physical exam. In selected patients at higher risk for diabetes, laboratory screening is recommended.
- Lifestyle counselling: If relevant, patients should be counselled on weight loss and smoking cessation for the overall health benefits in addition to better HS control. This should be done in a considerate nonjudgmental manner.
- Diet: There is insufficient evidence to recommend following certain diets or avoiding specific food groups (e.g. dairy)
- Natural/Alternative treatments: Zinc supplement is a reasonable option for patients with mild disease seeking natural/alternative therapies.
- Pain management and dressings: Pain control and wound care are important elements of HS management. A multidisciplinary approach is typically needed.
- Oral antibiotics: Tetracycline and rifampin+clindamycin are recommended for mild-moderate and severe disease respectively. Dapsone can be helpful in selective mild cases. Antibiotics can be used as adjunct therapies in severe cases. Long-term maintenance therapy, especially tetracyclines and dapsone, can be appropriate in certain cases and should be based on weighing benefits and risks.
- Adalimumab: Adalimumab at the approved HS dose is recommended for patients with moderate to severe disease. Based on expert opinion adalimumab can be considered in selected milder cases.
- Other Biologics: Alternative biologics include other anti-TNF inhibitors (infliximab), Anti-IL12/23 (ustekinumab), and anti-IL1 (anakinra). Existing evidence doesn’t support the use of etanercept.
- Ertapenem: IV ertapenem can be useful as a rescue therapy or a bridge toward surgery in the most severe HS cases.
- Traditional immunosuppressive therapies: low dose systemic steroids and cyclosporine can be considered in severe resistant cases. These should be used with caution given the potential side effects.
- Office-based interventions: Intralesional kenalog, deroofing, and NdYAG laser are helpful office-based procedures.
- Surgery: wide local excision, either by surgery or CO2 laser, is the surgical modality of choice for extensive chronic lesions.
- Medical therapy in the perioperative period: Continuing medical treatment, including biologic therapy, is likely to be beneficial for disease control and wound healing.
The guidelines are available as an open-access publication in 2 parts and they can be accessed on the website of the Journal of the American Academy of Dermatology:
- North American Clinical Management Guidelines for Hidradenitis Suppurativa: a Publication from the United States and Canadian Hidradenitis SuppurativaFoundations. Part I: Diagnosis, Evaluation, and the use of Complementary and Procedural Management https://www.jaad.org/article/S0190-9622(19)30367-6/pdf
- Part II: Topical, Intralesional, and Systemic medical Management https://www.jaad.org/article/S0190-9622(19)30368-8/pdf
Surgery Corner: A Dermatologist Guide to Counselling Patients on Surgery
Dr. Ralph George MD FRCSC
Although many HS patients are nervous or even reluctant about surgery, an operation can sometimes be very helpful. It is important to understand what surgery can and cannot do. For most people with HS surgery cannot offer a cure. HS is a chronic disease – like rheumatoid arthritis is a chronic disease. Neither condition can be cured by surgery, but just like joint surgery will help an arthritic, a planned surgical intervention can help an HS patient. It is important that the HS patient and surgeon understand the goals of surgery and both have reasonable expectations of the outcome. Surgery works best when it’s directed at a specific problem area- like a persistent recurring area of tunneling and discharge. Surgery doesn’t mean the HS will never come back – but relief for a stubborn area can be achieved. Surgery works best when combined with the best possible ongoing medical care. Any biologic or antibiotic treatments should continue before and after surgery. With a planned operation the dermatologist should make every effort to get the HS as controlled as possible – giving the procedure the best opportunity for success.
Remember- surgery works best in the setting of optimal and ongoing medical care by the dermatologist. It is a team effort!
From the Journal Stand
Reviewed by Dr. Raed Alhusayen MBBS MSc (Clin/Epi) FRCPC
HS Patients Have Shorter Life Expectancy
- Retrospective cohort study from the Finnish Care Register for Health Care database
- Analyzed mortality data of 4,379 HS patients compared with 40,406 psoriasis patients and 49,201 individuals with melanocytic nevi
- Mean age at death was 60.5 years in HS cases, 71.1 years in psoriasis and 75.2 years in nevi controls
- The top causes of mortality among HS patients: Diseases of the circulatory system including ischemic heart disease and stroke (33.7%), Malignancy (27.9%), accidents and violence including suicides (11.2%)
- Notably, respiratory malignancies accounted for 9% of mortality among HS patients, double the rate of control groups, likely due to the high prevalence of smoking in patients with HS (not captured in this study)
- Patients were mostly identified through hospital admission, indicating more severe HS cases were included. These results shouldn’t be extended to all patients with HS
- What could explain these results?:
- HS is associated with multiple comorbidities such as obesity, diabetes, metabolic syndrome (not accounted for in the analysis)
- HS is a state of chronic inflammation
- Another analysis by same group showed increased risk of suicide among women with HS (5-fold increase compared to women with nevi, 2-fold increase compare to women with psoriasis)
Link to abstract:
New B.A.D guidelines for the management of HS
In December 2018, the British Association of Dermatologists (BAD) published its new guidelines for the management of HS. This is a great asset for physicians caring for HS patients.
- Primary audience is primary care providers and family physicians
- Great effort paying attention to methodological details
- Most of the recommendations are straightforward:
- Oral antibiotic therapy with tetracyclines as 1st line systemic therapy
- Adalimumab for moderate to severe disease
- While many of the recommendations are in keeping with previous guidelines and consensus statements from other societies, some notable differences:
- Strong recommendation against the use of isotretinoin (except for patients with concomitant moderate -to -severe acneiform lesions): I am delighted to see this strong stance given the common use of this medication which is not supported by the current body of evidence.
- Clear recommendation to screen for comorbidities
- Multistep approach: The accompanied algorithm suggests tetracyclines as 1st line therapy. For patients who fail to respond the next steps are: rifampicin and clindamycin, then dapsone or acitretin, then adalimumab, then infliximab. I suspect this was done to provide primary care providers with clear guidance. However, some of these recommendations don’t seem to be supported by evidence including the suggestion to use acitretin or dapsone in patients who failed systemic antibiotics.
- Conservative interpretation of evidence: The guidelines found the evidence insufficient to make recommendations regarding many of the treatment modalities including cyclosporine, systemic steroids, IV ertapenem, oral contraceptives, non-antiTNF biologics, and laser modalities.
- In addition to its primary audience, the guidelines are also of value to other health care providers, e.g. surgeons, who wish to initiate patients on treatment until they are seen by dermatologists.
Long-Term Adalimumab data
- Up to 3 year follow up in open-label extension for patients from PIONEER I and II RCTs who received adalimumab 40 mg weekly. The minimum follow up was 92 weeks.
- Included a total of 88 patients. The total group was compared to a subset of patients who achieved HiSCR or partial response (≥ 25% reduction in AN count) by week 12 (PRRs).
- Last observation carried forward (LOCF) was used to manage missing data during the open-label extension.
- For PRRs (partial responders and responders by week 12): they maintained an improvement in their lesion count compared to baseline. The mean improvement at the end of the study was: 36% reduction in AN counts and 49% reduction in inflammatory nodules. Interestingly there was also 39% reduction in fistulas and draining fistulas.
- 18% of patients experienced a flare (defined by ≥ 25% increase in AN counts)
- 22/88 patients discontinued the drug because of adverse effects or lack ofefficacy.
- The rate of serious infections was 3.4%.
- There were no malignancies or deaths reported.
Differences in Affected Anatomic Sites Between Men and Women
- Cross-sectional study of 124 HS patients (71 females, 53 males) from 6 dermatology centres in Italy
- Men were more likely to have involvement of the gluteal (32.3% men vs. 8.7% women, P<0.001), while the breast region was most commonly affected in women (16.3% women vs. 4.6% men, P=0.02)
- The difference in involvement of armpits between women (42.4%) and men (30.8%) was not statistically different. This is likely due to the relatively small sample size as the same difference would have been statistically significant in a study with more than 300 participants.
- Obesity was associated with a 3-fold increase in the risk of having severe disease by both HS-PGA (OR=3.28, 95% CI 1.55–6.95,P<0.01) and Hurley classification (OR=3.22, 95%CI 1.42–7.31,P<0.01)
Link to abstract:
HS is associated with low zinc levels
- Case-control study involving 122 HS patients
- 37% of HS patients had low serum zinc levels (<83.3 ug/dL) compared to 12% of controls (adjusted OR 6.7; 95% CI 2.6-17.4)
- Low serum zinc level was also associated with Hurley stage III, involvement of ≥3 body sites, and genital/perineal involvement
- These results should be interpreted with caution. Zinc correlates negatively with inflammation suggesting that low zinc levels could be a marker of inflammation. Nonetheless, zinc supplement was shown to result in clinical improvement in case series of HS patients.
Guselkumab might be effective in treating HS
- Case report of 3 patients with Hurly stage III HS who had contraindication (2) or failed (1) standard therapy
- They were treated with guselkumab at standard psoriasis dose.
- At 12 weeks, all patients achieved >50% reduction in IHS4 scores. There was also some improvement in DLQI and VAS pain scores.
- There is evidence from basic science studies that several inflammatory cytokines are upregulated in HS including TNF, IL-1, IL-17, and IL-23.
- Currently there are clinical trials evaluating anti IL-17 and anti IL-23 biologics in HS.
- This could be an option in patients with severe HS who have contraindication to adalimumab especially if they have concomitant psoriasis.
4th Symposium of Hidradenitis Suppurativa Advances (SHSA)
November 1-3, 2019 │Detroit, USA
9th International Conference of the European Hidradenitis Suppurativa Foundation (EHSF)
Feb 5-7, 2019 │ Athens, GREECE