General Pain Management

Evidence-Based Comorbidity Screening for Patients With Hidradenitis Suppurativa

Avatar photoBrandon May
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No single treatment for HS is effective in eradicating disease or preventing progression, but early recognition and treatment are critical to preventing further progression to severe disease that can have an impact on quality of life.8 Therapeutic goals for stage 1 HS in young patients are to reduce pain and inflammation and prevent scarring and disease progression through multimodal management. Topical disinfectants are generally considered ineffective.4 Topical antibiotics are the therapy of choice for mild-to-moderate disease, with the introduction of oral antibiotics where topical formulations are inadequate.4 Once the disease has progressed, biologic disease modifying antirheumatic therapies, laser therapy, and surgery may have some benefit.8 Evidence supporting the use of intravenous infliximab in Hurley stage 2 and 3 HS has not been adequate enough to recommend it.9 Treatment of HS requires an aggressive multidisciplinary effort that involves antibiotic treatment, multimodal anti-inflammatory therapy and hormonal therapies, dietary and lifestyle modifications, and avoidance of physical trauma to the affected regions, which can lead to rupture of abscesses, along with early surgical unroofing and debridement. Additionally, because of the stigma and psychological distress, counseling for possible depression and to support coping skills is also recommended.3

No single treatment for HS is effective in eradicating disease or preventing progression, but early recognition and treatment are critical to preventing further progression to severe disease that can have an impact on quality of life.8 Therapeutic goals for stage 1 HS in young patients are to reduce pain and inflammation and prevent scarring and disease progression through multimodal management. Topical disinfectants are generally considered ineffective.4 Topical antibiotics are the therapy of choice for mild-to-moderate disease, with the introduction of oral antibiotics where topical formulations are inadequate.4

Once the disease has progressed, biologic disease modifying antirheumatic therapies, laser therapy, and surgery may have some benefit.8 Evidence supporting the use of intravenous infliximab in Hurley stage 2 and 3 HS has not been adequate enough to recommend it.9

Treatment of HS requires an aggressive multidisciplinary effort that involves antibiotic treatment, multimodal anti-inflammatory therapy and hormonal therapies, dietary and lifestyle modifications, and avoidance of physical trauma to the affected regions, which can lead to rupture of abscesses, along with early surgical unroofing and debridement. Additionally, because of the stigma and psychological distress, counseling for possible depression and to support coping skills is also recommended.3

To improve long-term outcomes for patients with HS, evidence-based screening recommendations to help clinicians recognize and treat 30 comorbid conditions have been developed.

A group of US and Canadian hidradenitis suppurativa (HS) foundations has published evidence-based recommendations on comorbidity screening in patients with HS. The recommendations were published in the Journal of the American Academy of Dermatology.

A professional member committee of US and Canadian HS foundations conducted a systematic literature review to determine the prevalence and incidence of 30 comorbidities in patients with HS compared with the general population. The consistency and quality of existing studies, prevalence of disease and magnitude of association, and the benefits, harms, and feasibility of screening helped inform screening recommendations for each comorbidity.

According to the review, it was apparent that acne and HS share common inflammatory pathways that involve the follicular unit. The review also found an increased prevalence of acne among patients with HS compared with control group participants across 4 studies. As such, the committee members recommend screening for acne in patients with HS.

Patients with HS should be screened for herpes zoster, given both local and systemic inflammation and exposure to immunomodulating therapies may increase the risk for reactivation, it was noted. Studies suggest the odds of having herpes zoster may also be higher in hospitalized patients with HS compared with hospitalized control group patients, further supporting screening for the viral infection.

The adjusted odds of depression ranged from 1.3 to 4.8 times higher than control group patients in several studies. In a European study, patients with HS had an adjusted risk for completed suicide 2.4 times that of control group participants. In addition, some meta-analyses and community-based studies also report a higher rate of generalized anxiety disorder in patients with HS. These findings informed the recommendation to screen for mood disorders in patients with HS.

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Another “comorbidity” frequently associated with HS is substance use and abuse. According to the recommendations, the evidence suggests clinicians should screen for tobacco smoking and substance use disorder, particularly in regard to alcohol and chronic opioid use.

Endocrine disease, such as polycystic ovarian syndrome, as well as facets of metabolic disease are also more common in patients with HS according to some studies. The evidence supports clinicians screening for facets of metabolic disease, including obesity, dyslipidemia, diabetes, and metabolic syndrome. Patients with HS should also be screened for other features related to metabolic disease, such as hypertension, given the links between hypertension, obesity, and tobacco use in these patients.

The recommendations also include an emphasis on screening for spondyloarthritis, sexual dysfunction, and Down syndrome.

The authors of the recommendations note their “screening guidelines are intended to support health advocacy efforts along with comprehensive care strategies for HS patients,” considering comorbid conditions in HS “contribute to poor health and impaired quality of life, beyond the significant impact of the disease itself.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Garg A, Malviya N, Strunk A, et al. Comorbidity screening in hidradenitis suppurativa: evidence-based recommendations from the US and Canadian Hidradenitis Suppurativa Foundations. J Am Acad Dermatol. Published online January 22, 2021. doi:10.1016/j.jaad.2021.01.059

This article originally appeared on Dermatology Advisor

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