A Claims-Based Algorithm for Identifying Hidradenitis Suppurativa Severity

Skin Microbiota Perturbations Are Distinct and Disease Severity–Dependent in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease, recently associated with metabolic syndrome, subclinical atherosclerosis and increased risk of cardiovascular disease. To investigate the hitherto unknown electrocardiographic (ECG) changes associated with HS, which have recently been associated with significant cardiovascular burden. Data were obtained from the cross-sectional Danish General Population Study (GESUS). HS diagnosis was based on a validated self-reported questionnaire; 404 individuals met the HS diagnosis criteria and 19 001 controls without HS were identified. Severity of HS was staged according to a modified Hurley score. The ECG parameters of heart rate (HR), PR interval, QRS duration, JTc interval and QTc interval were obtained from 12-lead resting ECGs. We investigated the difference in means by unpaired t-test or anova. HR was significantly higher [mean difference 2·3 beats per min (bpm), 95% confidence interval (CI) 1·2-3·4; P < 0·01] when adjusting for age and sex, but when adjusting for multivariates, there was no significant difference (0·3 bpm, 95% CI -0·7 to 1·4; P = 0·52). Severe HS was significantly associated with increased HR across all models (2·9 bpm, 95% CI 0·7-5·1; P = 0·01). Mean QRS duration was significantly shorter in the group with mild HS but not in the groups with moderate and severe HS. Mean resting HR in patients with severe HS was significantly higher compared with controls. Given that resting HR is associated with increased risk of all-cause and cardiovascular mortality, and that patients with HS have increased risk of cardiovascular events, this finding is potentially important, easily testable and intervenable.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease affecting hair follicles, causing recurrent abscesses and nodules in intertriginous regions. The International HS Severity Score System (IHS4) is widely used to assess HS severity by counting inflammatory nodules, abscesses, and draining fistulas/tunnels. However, traditional clinical examinations may underestimate HS severity due to the presence of subclinical lesions. This study aims to enhance the accuracy of HS severity assessment by incorporating ultra-high frequency ultrasound (UHFUS) to detect subclinical lesions, such as microtunnels. A cohort of 122 patients with HS (75 females and 47 males) was evaluated. Clinical severity was assessed using the IHS4 scoring system. UHFUS assessments were performed using a 70 MHz probe for patients with mild and moderate IHS4 scores. Statistical tools were used to assess the significance of UHFUS in detecting additional lesions not identified during clinical examinations. The study found that 23% of patients had mild HS, 58.2% had moderate HS, and 18.9% had severe HS according to IHS4. Among the 28 patients with mild IHS4, 14 had microtunnels detected by UHFUS, leading to a change in disease staging: 11.5% of patients were reclassified as mild, while 69.7% were reclassified as moderate. A statistically significant difference in the distribution of severity classifications before and after UHFUS examination was observed (χ2 = 5.11, P = .0238). The study underscores the critical role of UHFUS as a non-invasive technique for the precise assessment of HS. The integration of UHFUS with a 70 MHz probe significantly enhances the detection of subclinical lesions, such as microtunnels, enabling timely intervention and potentially preventing disease progression. Despite the study's limitations, including its monocentric design and small sample size, the findings support the use of UHFUS in improving the accuracy of HS severity assessment.

Hidradenitis suppurativa (HS) is a chronic, debilitating, heterogeneous disease requiring different treatment approaches. Recently, we refined the classic Hurley classification into a seven-stage classification in order to guide these treatment choices. This new classification subdivides Hurley stage I and II into three substages, namely mild (A), moderate (B) and severe (C) HS disease. Hurley stage III is not subcategorized and is always severe. To investigate the correlation between the given severity grades of Hurley I and Hurley II in the refined Hurley classification, and the patient-reported quality of life and physician-assessed objective severity score. In this cross-sectional study, patients with HS participating in the observational cohorts of two Dutch tertiary referral centres were included before June 2017. The patient-reported Dermatology Life Quality Index (DLQI) and physician-assessed International HS Severity Score System (IHS4) scores were compared between the refined Hurley stages. In total, 433 patients were analysed. DLQI and IHS4 scores increased within Hurley stage I and II from A through C. There was a significant positive correlation of DLQI and IHS4 with increasing refined Hurley substages [refined Hurley stage I (A, B and C) to DLQI: rs = 0·259, P < 0·001 and refined Hurley stage II (A, B and C) to DLQI: rs = 0·185, P = 0·010; refined Hurley stage I (A, B and C) to IHS4: rs = 0·603, P < 0·001 and refined Hurley stage II (A, B and C) to IHS4: rs = 0·532, P < 0·001]. The refined Hurley classification accurately correlates with HS severity assessed by both patients and clinicians. Therefore, the refined Hurley classification is a useful tool for the quick assessment of severity in HS.

PURPOSE. To evaluate serum zinc (Zn) concentration in patients with hidradenitis suppurativa (HS) and its association with various demographic and clinical characteristics. METHODS. A single-center case-control study included 80 adults (40 HS patients and 40 age- and sex-matched controls) at the Bulgarian HS Expert Centre. HS patients were classified by disease duration, clinical phenotype, severity and comorbidities. Serum Zn concentration was defined as “hypozincemia” (&lt;9 µmol/L), “normal” (9-18 µmol/L) and “hyperzincemia” (&gt;18 µmol/L). RESULTS. Serum Zn concentration displayed a significant difference in patients and controls (mean rank: 47.64 vs 33.36, p=0.006). Hypozincemia was more common (p=0.02) in HS patients (84.6%). Serum Zn was significantly lower in Hurley stage III than in stage II (mean rank: 15.21 vs 26.34, p=0.002) and similarly, it was lower in severe HS than in moderate HS (mean rank: 17.3 vs 27.15, p=0.012) on the IHS4 scale. We found a significant negative correlation between hypozincemia and HS severity assessed by Hurley Stage (τc=-0.383, p=0.014) and IHS4 (τc=-0.343, p=0.022). No significant associations were found between serum Zn level and sex, smoking, HS family history, duration, or comorbidities. CONCLUSIONS. HS patients have significant hypozincemia compared to controls. A significant negative correlation between HS severity and hypozincemia was established.

Hair removal and deodorants in hidradenitis suppurativa: An online survey on patients' habits.

Hidradenitis suppurativa: pathogenesis and management

Antibiotic therapy remains the first-line treatment for hidradenitis suppurativa (HS). However, literature data on its comparative clinical efficacy and safety are limited. To investigate the efficacy of tetracycline (lymecycline 300mg daily) vs. the combination therapy clindamycin and rifampicin (600mg plus 600mg daily) by evaluating and comparing the clinical response at the end of antibiotic treatment (10weeks). The study retrospectively analysed 52 patients divided in two groups of 26 patients: Group A received lymecycline and Group B received clindamycin plus rifampicin for 10weeks. Subjects had mild, moderate and severe HS. The clinical and ultrasonography extent of disease was measured by the Hurley Score, Sonographic Score of Hidradenitis Suppurativa, International Hidradenitis Suppurativa Severity Score System (IHS4), pain visual analogue scale (pain VAS) and Dermatology Life Quality Index (DLQI). The primary outcome was the clinical response at the end of the antibiotic treatment period, according to the Hidradenitis Suppurativa Clinical Response measure. Both groups showed a significant improvement in IHS4, pain VAS and DLQI from baseline, but this was more marked in Group A. Reductions in nodule counts were similar between the two groups, whereas the number of abscesses and draining tunnels decreased more in Group B. Disease-free survival was similar between the two groups. Lymecycline monotherapy and clindamycin plus rifampicin combination are both effective treatments for patients with moderate-severe HS. Nodular-type HS seems to respond better to lymecycline, whereas the abscess/tunnel type seems to respond better to clindamycin plus rifampicin.

Hidradenitis suppurativa clinical response (HiSCR) is a validated clinical end point for measuring response to treatment in patients with hidradenitis suppurativa (HS). Previous studies have reported on the validity, responsiveness and meaningfulness of the HiSCR. To evaluate the HiSCR for inter- and intrarater reliability characteristics. A stand-alone, two-site, prospective, non-interventional observational study consisted of 22 patients, with self-reported severity between mild, moderate and severe HS. The Patient Global Impression of Change (PGI-C) scale was completed by patients at Timepoint 2. Descriptive statistics of Hurley Stage, total abscesses, total draining fistulas, total inflammatory nodules and total AN count (sum of inflammatory nodules and lesions) were reported at two timepoints. Inter-rater reliability and intrarater reliability for the HS lesion count tool were evaluated at two timepoints (baseline and Day 7) using the HS lesion count tool. Intraclass correlation (ICC) coefficients of lesion counts were calculated to evaluate inter- and intrarater reliability of lesion counts between pairs of dermatologists. The majority of patients demonstrated either no change or minimally worse PGI-C in HS scores. Descriptive statistics were similar between rater groups and timepoints assessed. Inter-rater ICC coefficients for abscess count at Timepoints 1 and 2 were 0.38 and 0.67. The ICC coefficients for draining fistula and AN count were ≥0.61 at both timepoints. In an exploratory model, ICC coefficients were ≥0.68 for all evaluated lesion counts. The test-retest reliability using ICC coefficients was ≥0.70 for total abscess, draining fistula, inflammatory nodule and AN count. The HS lesion count tool had an acceptable inter- and intrarater reliability, indicating that HiSCR has a strong degree of reproducibility and consistency in the evaluation of patients with HS.

Aggravation of mild axillary hidradenitis suppurativa by microwave ablation: Results of a randomized intrapatient–controlled trial

Despite the systemic inflammatory implications of hidradenitis suppurativa (HS), the relationship between systemic inflammatory markers and HS has not been definitively established in the existing literature. This review aimed to evaluate the relationship of peripheral blood inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), pan-immune-inflammation value (PIV) and systemic immune-inflammation index (SII) with the presence and severity of HS. A comprehensive search of the PubMed, Embase and Cochrane databases was conducted. Studies with data on these peripheral blood inflammatory markers in HS patients were included. A meta-analysis was performed using standardized mean differences to evaluate the association between these inflammatory markers and HS. Our study included 23 research articles that included 2623 cases and 22 015 controls. The results demonstrated that (1) CRP, ESR, NLR, and SII levels were significantly higher in HS patients than controls, and (2) CRP, ESR, PIV, and SII positively correlated with HS severity between Hurley stages I and II and II and III. NLR and PLR also correlated with severity between stages II and III. CRP, ESR, NLR and SII are significantly associated with the presence of HS, while CRP, ESR, SII, and PIV are important indicators of HS severity. NLR and PLR become particularly significant in groups with severe HS. Our results underscore the systemic inflammatory involvement in HS and suggest that these inflammatory markers could be valuable in clinical practice for screening and monitoring the progression of HS.

An inappropriate immunologic response has been suggested to play a role in the pathogenesis of hidradenitis suppurativa (HS). Adalimumab was the first TNF-α inhibitor approved for moderate to severe HS. We report on a case of HS (Hurley stage 2) in a 39-year-old man, who had received fusidic acid and isotretinoin treatments without evident benefit during the last 8 years. The patient noticed a reduction in the number of lesions and quality of life (DLQI from 27 to 6) in the 2 months following verapamil initiation for cluster headache. When verapamil was stopped, the lesions recurred within 1.5 months. The patient resumed taking verapamil as before and a remission occurred. Verapamil has been shown to inhibit TNF-α and IL-1β in vitro and in vivo. We hypothesize that verapamil inhibits the inflammatory process through the TNF-α/IL-1 pathway involved in the HS physiopathology. Compared to biologic agents as anti-TNF-α (adalimumab) and anti-IL1 (anakinra), verapamil is safer and cheaper. Given its possible role on TNF-α/IL-1, verapamil may represent an alternative therapeutic option in mild and moderate HS.

Hidradenitis suppurativa (HS) is a chronic, recurrent and debilitating inflammatory skin disease, characterized by painful inflamed nodules, abscesses and tunnels in the skin folds. Up to 66% of HS patients can be classified as having mild disease. However, currently, most clinical trials are focusing on patients with moderate to severe disease, resulting in more available treatment options for this smaller group of patients. This difference in treatment options and lack of clinical trials for patients with mild HS has been noticed and additional focus on milder HS cases is requested. However, an important hurdle to overcome studying treatment efficacy in mild HS is an adequate treatment outcome. Patients with mild HS sometimes have no lesions due to waxing and waning of the disease. Furthermore, the difference in aim of a clinical trial for patients with mild disease should be taken into consideration. Where treatment of moderate to severe patients focusses on lowering the number of draining tunnels, abscesses and inflammatory nodules, in patient with mild disease, we focus on prevention of new lesions and progression to moderate and severe disease. This clinical characteristic of mild HS and difference in aim of clinical trials are the key challenges for efficacy measurement in mild HS. To overcome these challenges, we propose to measure the continuous international hidradenitis suppurativa severity score (IHS4) monthly and use the cumulative IHS4 score (IHS4-C) over all these visits as a primary outcome in clinical trials in patients with mild HS, to increase the probability to detect the inflammatory lesions with a temporary nature. We argue that this novel application of the IHS4, has the potential to better facilitate assessment of treatments or interventions in patients with mild HS and should be tested in future studies.

Defining hidradenitis suppurativa (HS) subtypes was previously limited by small sample sizes and poor interrater reliability; no study has investigated subtype treatment responses. The objective of this analysis was to characterize HS clusters in adult patients with moderate to severe HS and evaluate secukinumab treatment responses between clusters. Clusters were identified via an unsupervised machine learning clustering analysis using baseline data from the randomized, placebo-controlled SUNSHINE (NCT03713619) and SUNRISE (NCT03713632) phase 3 trials. To assess treatment responses, patients received secukinumab every 2 (SECQ2W) or 4 weeks (SECQ4W) or placebo, for 16 weeks, after which, placebo patients randomly switched to SECQ2W/SECQ4W, and SECQ2W/SECQ4W patients maintained their original treatment, until week 52. Baseline outcomes included patient characteristics, disease characteristics and severity, HS-associated comorbidities and previous treatment exposures. Treatment response was assessed via the HS clinical response (HiSCR), abscess and inflammatory nodule (AN) count, flares and NRS30 (skin pain). Based on baseline data, three clusters were identified from 1084 patients (Cluster 1: 54.1%, Cluster 2: 17.8%, Cluster 3: 28.1%). Cluster 1 was predominantly female (65.4%) and was characterized by milder HS. Cluster 2 had more patients from the Asia Pacific, Middle East and Africa region (58.5%) and was characterized by moderate HS. Cluster 3 had the highest rates of previous exposure to biologics (45.9%) and prior HS-related surgeries (47.5%) and was characterized by severe HS. SECQ2W and SECQ4W demonstrated efficacy versus placebo in all clusters at week 16; SECQ2W and SECQ4W efficacy was maintained to week 52. SECQ2W treatment showed a trend for greater efficacy versus SECQ4W in Cluster 3 through week 52. Three HS clusters were identified. Secukinumab demonstrated benefit over placebo in all clusters. However, patients with more severe disease may take longer to respond and more frequent secukinumab dosing may be required for these patients. SUNSHINE (NCT03713619) and SUNRISE (NCT03713632).

Keywords: anaerobes; hidradenitis suppurativa; inflammatory disease; microbiology; soft tissue and skin infections