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 – 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.
International Scientific HS symposium
June 10, 2019 │ Milan, ITALY
Canadian HS Foundation Subspecialty Session
June 29, 2019 │Calgary, CANADA
4th Symposium of Hidradenitis Suppurativa Advances (SHSA)
November 1-3, 2019 │Detroit, USA