Hidradenitis suppurativa

Hidradenitis suppurativa

Disease burden of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is thought to be a chronic, systemic inflammatory disease that causes severe morbidity, including painful nodules, abscesses, draining sinus ducts on the skin throughout multiple regions of the body, and can cause significant scarring.

HS often has major associated impacts on quality of life (QoL). In a global survey, 43.3% of HS patients reported extreme impacts on QoL and 61% of patients described their pain as moderate or high, with 4.5% describing recent pain as the worst possible. Further, 18.3% of patients had visited the emergency department ≥5 times for symptoms¹. HS patients often suffer from social stigma, substance use disorders, and higher suicide rates compared with the general public². Furthermore, there are several comorbidities associated with HS, many of which are becoming increasingly recognised in HS patients, including cardiovascular, metabolic, endocrine, gastrointestinal, rheumatologic, and psychiatric disorders, which can significantly decrease the QoL of HS patients beyond the skin³.

Hidradenitis suppurativa treatment

HS remains a challenging disease that is difficult to treat⁴. Unmet needs related to undertreatment of HS, particularly for patients who do not respond to current HS treatment options, contribute to the burden and reduced QoL associated with HS. While treatments do exist for HS, most are off-label with few approved drugs, and little high-quality evidence limits the strength of guideline recommendations^4,5. HS patients often need a multidisciplinary treatment approach, incorporating both medical and surgical treatments in addition to lifestyle and dietary modification⁴.

Recent research has focused on understanding the inflammatory pathways involved in HS, which are thought to be triggered by genetic, immunological, anatomical, and environmental factors. Knowledge of HS pathophysiology has led to the approval of targeted immunomodulatory biologics for HS treatment in moderate-to-severe HS, however there are few recommended first-line biologics for HS, with multiple biologic options still under investigation. Potential therapies include those that target tumor necrosis factor (TNF), interleukin 1 (IL-1), IL-12, and IL-23⁶. 

Hidradenitis suppurativa diagnosis

Though inflammatory markers can indicate systematic inflammatory burden, there are currently no laboratory tests for HS². Further, due to the peculiar clinical presentation of HS, non-dermatologists are often the first healthcare professionals to see patients and may find identifying HS difficult, even if the clinical presentation is typical⁴. Thus, there is on average a 7–10 year delay between disease onset and HS diagnosis, and 63.7% of patients visited a physician ≥5 times before receiving a diagnosis^1,2. Early diagnosis of HS is important for initiation of treatment to prevent prolonged patient suffering, work related sickness absence, suboptimal health outcomes and HS-related healthcare issues^2,4.

Many HS patients have undiagnosed comorbidities, including obesity and metabolic syndrome, depression, and inflammatory bowel disease (IBD). Targeted screening should be carried out for comorbidities at diagnosis, and HS patients may benefit from dietary interventions aimed at metabolic comorbidities. Since there is an increased risk of squamous cell carcinoma (SCC) in HS patients, the threshold for biopsies of ulcerative lesions, chronic wounds, nodules, or ulcerative nodules should be lowered to prevent metastasis from the primary site, particularly when the patient shows no response to antibiotics or immunosuppressive treatments⁴.

References

1. Garg A, Neuren E, Cha D, Kirby JS, Ingram JR, Jemec GBE, et al. Evaluating patients’ unmet needs in hidradenitis suppurativa: Results from the Global Survey Of Impact and Healthcare Needs (VOICE) Project. J Am Acad Dermatol. 2020;82(2):366–376.
2. Nguyen T V., Damiani G, Orenstein LAV, Hamzavi I, Jemec GB. Hidradenitis suppurativa: an update on epidemiology, phenotypes, diagnosis, pathogenesis, comorbidities and quality of life. Journal of the European Academy of Dermatology and Venereology. 2021;35(1):50–61.
3. Cartron A, Driscoll MS. Comorbidities of hidradenitis suppurativa: A review of the literature. Int J Women’s Dermatology. 2019;5(5):330–334.
4. Napolitano M, Megna M, Timoshchuk EA, Patruno C, Balato N, Fabbrocini G, et al. Hidradenitis suppurativa: from pathogenesis to diagnosis and treatment. Clin Cosmet Investig Dermatol. 2017;10:105.
5. Orenstein LA V., Nguyen T V, Damiani G, Sayed C, Jemec GBE, Hamzavi I. Medical and surgical management of hidradenitis suppurativa: a review of international treatment guidelines and implementation in general dermatology practice. Dermatology. 2020;236(5):393.
6. Seyed Jafari SM, Hunger RE, Schlapbach C. Hidradenitis Suppurativa: Current Understanding of Pathogenic Mechanisms and Suggestion for Treatment Algorithm. Front Med. 2020;7:68.