Exploring strategies for rapid diagnosis and comprehensive care in hidradenitis suppurativa

Researchers reviewed the clinical features of hidradenitis suppurativa and provided strategies to promote earlier identification, differentiation from common mimics, and timely referrals for multidisciplinary management.

Hidradenitis suppurativa (HS) is a chronic and progressive inflammatory disease of the skin that is often underdiagnosed and/or misdiagnosed, in part due to its heterogeneity of presentation and poor recognition of the disease.

Authors of a review published in The American Journal of Medicine sought to provide a comprehensive overview of the disease characteristics associated with HS to facilitate earlier identification, differentiation from common mimics, and timely referrals for multidisciplinary management if needed.

“Due to the low recognition of HS within the medical community, the average time from onset of symptoms to diagnosis is approximately 10 years. During this period, patients may experience disease progression that can lead to disfigurement and disability. Additionally, patients often receive fragmented care for flare management in acute and outpatient settings with a variety of providers,” the study authors noted.

Clinical presentation and comorbidities

In the absence of a diagnostic biomarker, HS is characterized by 3 major diagnostic criteria: painful nodules, abscesses and cutaneous drainage tunnels; involvement of typical anatomical sites (eg, armpits, inframammary and intermammary folds); recurrence and chronicity.

The onset of HS most often occurs in early adulthood. Women have been shown to be primarily affected by HS, with a disproportionate impact among black people, who in a recent study were found to be more likely to suffer from greater disease severity, ER visits, hospitalizations and surgeries than non-Hispanic white patients.

Pain, drainage and odor are among the most distressing symptoms of the disease, with a substantial impact on quality of life also reported in patients.

“There is an opportunity for primary and specialty care providers to support timely recognition of HS and screening/management of the many comorbid conditions associated with the disease,” the authors wrote.

Common comorbidities of HS include endocrine and metabolic conditions, cardiovascular disease, obstetric risks, gastrointestinal disorders, musculoskeletal diseases, and mental health disorders. Mental health disorders of depression, anxiety, and substance abuse disorders are notable risk factors, with suicide death rates more than doubling in HS patients.

“The substantial emotional and psychological impact of hidradenitis suppurativa has also been associated with low self-esteem and poor body image, which can negatively impact social and intimate relationships,” the authors noted.

They also wrote that primary care providers have an important role in managing and coordinating care for the treatment of mental and psychological comorbidities to help manage and improve the burden of HS disease. They also called for a comprehensive comorbidity screening strategy for HS patients to achieve and maintain overall health.

Therapeutic options and disease management

Treatment and management of HS should involve a multifaceted care approach, the researchers explained, which includes medical and surgical management, as well as screening and management of associated comorbidities. Several treatment options are available for the disease:

  • Topical and systemic antibiotics: antiseptic cleansers (limited evidence to support their effectiveness), oral tetracyclines for mild illnesses, and oral antibiotic combinations have also been shown to be effective
  • Biologics: For patients with moderate to severe disease, adalimumab is FDA approved and has shown significant improvements in lesion count, pain, and disease activity. Other biologics have demonstrated potential efficacy for infliximab, ustekinumab, anakinra, bimekizumab, and secukinumab
  • Surgery: Deroofing and wide local excision were mentioned, with researchers highlighting the importance for clinicians to optimize medical therapy to reduce inflammatory burden prior to surgical procedures and emphasizing that surgical procedures are not curative or protective against HS

Other strategies touted by researchers to improve care management included referral to resources that can support awareness and education of HS patients regarding disease progression, disease impact, and opportunities to adopt behaviors that can promote overall health. A better understanding of the inflammatory nature of HS and the potential of immunomodulatory therapies to control disease symptoms were also mentioned as examples of key information to provide to patients with HS.

“Timely recognition and management of disease is essential to control symptoms, attenuate disease progression, and improve quality of life for patients with HS,” the researchers concluded. “Coordinated holistic care strategies across medical and surgical disciplines are needed to improve the overall health of patients with HS.”

Reference

Garg A, Naik H, Kirby JS. A practical guide for primary care providers on rapid diagnosis and comprehensive care strategies for hidradenitis suppurativa. Am J Med. Published online October 14, 2022. doi:10.1016/j.amjmed.2022.09.025

About Antoine L. Cassell

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