Welcome to the 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
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.
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.
Reviewer: Dr. Nouf Almuhanna MD
Editor: Dr. Raed Alhusayen MD MSc FRCPC
A literature review was conducted, and the following was found regarding safety.
Rifampicin: drug-induced liver injury.
Rifampicin: interstitial nephritis
Rifampicin: drug interaction and hepatic p450 3A4 enzyme induction
Clindamycin: Community-acquired Clostridium difficile infection (CA-CDI)
Experience with long-term treatment of the combination of Clindamycin and rifampicin
Difference between Acne and HS:
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:
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:
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!
Reviewed by Dr. Raed Alhusayen MBBS MSc (Clin/Epi) FRCPC
Link to abstract:
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.
Link to abstract: