Hidradenitis Suppurativa Flares Research Articles

Could Vaccination against COVID-19 Trigger Immune-Mediated Inflammatory Diseases?

Exacerbations and new onset of immune-mediated inflammatory diseases, such as psoriasis and hidradenitis suppurativa, have been reported following COVID-19 vaccination. In patients with hidradenitis suppurativa, recent studies have shown that those who received mRNA vaccines were 3.5 times as likely to develop flares following vaccination compared to patients who received non-mRNA vaccines, indicating that mRNA COVID-19 vaccines are associated with hidradenitis suppurativa flares. Similar findings have been found in other studies evaluating the association between COVID-19 vaccines and other immune-mediated inflammatory diseases such as psoriasis, atopic dermatitis, lichen planus, and alopecia areata. However, further research is warranted in larger populations to validate these findings.

Clinical characteristics associated with joint pain in hidradenitis suppurativa.

Although patients with hidradenitis suppurativa (HS) report comorbid arthropathy, clinical characteristics associated with joint pain surrounding HS flares still remain obscure. We found that about one in five patients in our HS cohort reported peri-flare joint pain during their initial visit and that peri-flare joint pain was significantly associated with pain medication prescription (aOR 2.15, P = 0.02) and diagnosis of inflammatory arthritis (aOR 4.14, P < 0.001). Given the debilitating nature of HS flares, the addition of joint pain can further limit daily activities, underscoring the importance of a comprehensive approach to the management of patients with HS.

Inpatient Management of Hidradenitis Suppurativa: A Delphi Consensus Study.

Inpatient hospitalization of individuals with hidradenitis suppurativa (HS) has increased. Inpatient services may not be familiar enough with this disease to understand how to manage severe HS and/or HS flares. It would be beneficial to the inpatient medical community to establish consensus recommendations on holistic inpatient care of patients with HS. A survey study was developed and distributed by Wake Forest University School of Medicine (Winston-Salem, North Carolina). A total of 26 dermatologists participated in the Delphi process, and the process was conducted in 2 rounds. Participants voted on proposal statements using a 9-point scale (1=very inappropriate; 9=very appropriate). Statements were developed using current published guidelines for management of HS and supportive care guidelines for other severe inpatient dermatologic diseases. A total of 50 statements were reviewed and voted on between the 2 rounds. Consensus was determined using the RAND/UCLA Appropriateness Method. Twenty-six dermatologists completed the first-round survey, and 24 completed the second-round survey. The 40 consensus recommendations generated through these surveys can serve as a resource for providers caring for inpatients with HS.

Increased ambient outdoor temperatures are associated with increased disease flaring in hidradenitis suppurativa.

Despite evidence to suggest a relationship between time of year and hidradenitis suppurativa (HS) flaring, no studies have been conducted to date to establish a relationship directly between temperature and flaring. In this study, we aim to validate a classification approach based on administrative data for identifying medical encounters that likely represent HS flares in patient with a known diagnosis of HS within the Mass General Brigham Health System (MGB) and examine the relationship between average daily temperatures and HS disease flaring among patients in Boston. This is a retrospective cohort study. Participants were individuals with HS presenting to emergency departments or dermatology outpatient clinics with disease flares between January 2017 and January 2022. The average number of encounters for HS flares was compared with the temperature for that day and the 3- and 7-day periods prior. There were 2567 patient encounters for HS flares included in the study. Of the total identified HS flares, 75.6% occurred in females and 39.1% occurred in patients who identified as Black. Uniformly small but statistically significant relationships were noted between increased temperature and presentations for hidradenitis suppurativa flare with the highest correlation coefficient (0.0768) noted with a 3-day lag time between the heat experienced and day of presentation for flare. Increased temperature is associated with a small, but statistically significant increase in HS disease flaring. As such, HS disease flaring may rise as global temperatures do, suggesting an increase in the global burden of HS as climate change persists.

THU366 Type 1 Diabetes Complicated By Multiple Episodes Of Diabetic Ketoacidosis Secondary To Flares Of Hidradenitis Suppurativa

Abstract Disclosure: S.R. Vasavada: None. K.A. Chopra: None. L. Philipson: Grant Recipient; Self; Novo Nordisk. Background: Hidradenitis suppurativa (HS) is an inflammatory skin condition of the pilosebaceous unit characterized by subcutaneous nodules that if untreated can form purulent abscesses, fistulae, and sinus tracts. HS may result from dysregulated autoimmune response to skin flora with overexpression of inflammatory cytokines, such as IL-17A, TNF-a, IL-1B (Shah et al 2017). Although HS and type 1 diabetes both share underlying autoimmune etiologies, and autoimmune diseases have been reported in higher frequencies in HS than controls, co-incidence with type 1 diabetes is extremely rare (Straalen et al 2022). Herein, we describe a case of a patient with type 1 diabetes with recurrent admissions for diabetic ketoacidosis (DKA) secondary to HS flares. Clinical Case: 37-year-old female with medical history of type 1 diabetes, hypogammaglobulinemia, and HS presented with rectal pain and hematochezia. Previously, she had several hospitalizations due to HS flares complicated by episodes of DKA and 20+ corrective surgeries for infected HS lesions. Prior to admission, patient was treated with clindamycin lotion, spironolactone, and weekly adalimumab for HS. Patient’s initial labs showed DKA with glucose 494 mg/dL (RR 60-99 mg/dL), bicarbonate 21 mmol/L (RR 23-30 mmol/L), anion gap 16 mmol/L (RR 6-15 mmol/L), and beta hydroxybutyrate level 1.44 mmol/L (N <0.3 mmol/L). Hemoglobin A1c was 10.4% (RR <5.7%). Physical exam showed Hurley Stage 2 HS with multiple atrophic scars, boils, and double comedones on bilateral axillae. She was treated with insulin infusion and IV fluids. After anion gap closed and bicarbonate improved to 24 mmol/L (RR 23-30 mmol/L), she transitioned to regimen of insulin glargine 38 units and started mealtime insulin lispro using a ratio of 1 unit of lispro for 6 grams of carbs. Subsequent glucose values stabilized, ranging 120-200 mg/dL (RR 60-99 mg/dL) during hospitalization. She underwent colonoscopy due to concern for colonic involvement of HS, however pathology was normal. After multidisciplinary discussion with endocrinology and dermatology specialists, HS treatment with prednisone was avoided due to concern of worsening patient’s glycemic control. Patient started infliximab treatment and reported mild symptom improvement. Conclusion: This case showing a patient with multiple episodes of DKA triggered by flares of HS has demonstrated the importance of further study to improve our current understanding of the potential overlap of these two conditions to help guide future treatment decisions and improve patients’ overall quality of life. Reference: Shah A, Alhusayen R, Amini-Nik S. The critical role of macrophages in the pathogenesis of hidradenitis suppurativa. Inflamm Res. 2017;66(11):931-945. Straalen KR van, Prens EP, Gudjonsson JE (2022) Insights into hidradenitis suppurativa. J Allergy Clin Immun 149(4):1150–1161. Presentation: Thursday, June 15, 2023

Efficacy and Patient Satisfaction Associated With Intramuscular Triamcinolone Therapy for Acute Flares of Hidradenitis Suppurativa.

A lack of consensus exists regarding acute flare management in hidradenitis suppurativa (HS). Intramuscular triamcinolone (IMTAC) therapy is useful in numerous inflammatory conditions; however, it has not been investigated for acute HS flares. To evaluate the efficacy and patient experience associated with IMTAC therapy for acute, severe HS flares. Retrospective analysis and surveys of 45 HS patients were conducted at Albert Einstein College of Medicine/ Montefiore HS Center, Bronx, NY, USA. Follow-up visits 6.77 (4.45) weeks after IMTAC therapy revealed significant reductions in mean HS-Physician Global Assessment (PGA) (P < .001), C-Reactive Protein (CRP) (P = .03), increased hemoglobin (P = .004), and improved pain scores (P < .001). Adjusting for age, sex and concomitant medications, multivariate analysis yielded significantly reduced pain (P = .02) and increased hemoglobin (P = .03). Patient surveys indicate that IMTAC was well-tolerated, as reflected in positive mean responses for satisfaction (29 [64%]) and willingness to receive IMTAC injections again (42 [93%]). These novel findings demonstrate that IMTAC is a safe, effective, and well accepted adjunct for acute HS management.

Seasonal Trends of Ambulatory Visit Burden in Hidradenitis Suppurativa Patients

Introduction: Patients with hidradenitis suppurativa (HS) report HS flares with increased heat and sweat. However, there is a paucity of literature on whether there is an increased ambulatory visit burden for HS patients during the warmer months.&#x0D; Methods: We used a nationally-representative database of ambulatory visits in the United States, the National Ambulatory Medical Care Survey to examine the seasonal trends of ambulatory visits for patients with HS. Data analyses were performed using SAS Studio 9.04.01 (SAS Institute, Cary, N.C., USA), and variance in the complex survey design is accounted for by utilizing survey weights to create national estimates and confidence intervals.&#x0D; Results: We identified approximately 2.33 million outpatient visits (95% confidence interval 1.95 million-2.71 million) between 2008-2018 with a diagnosis of HS. Approximately 21% of visits occurred during Winter to early Spring (January to April), 51% during late Spring to Summer (May to August), and 28% during Autumn (September to December). The number of visits differed significantly between these three time periods (X2=13.1, p=0.0014).&#x0D; Conclusion: Awareness of the increased burden of HS during summer months may help guide management, including anticipatory counseling on strategic lifestyle modifications and initiation of anti-hyperhidrosis treatments.

LB930 Mental health professional utilization within a cohort of hidradenitis suppurativa patients

Hidradenitis suppurativa (HS) is a chronic, debilitating inflammatory skin condition. HS patients are known to have increased rates of anxiety, depression, and suicidal ideation. There is a paucity of information about how HS exacerbations affect depression and mood. We decided to study the utilization of mental health professionals by a cohort of patients with HS. An IRB-approved retrospective chart review and telephone survey were conducted on patients treated at the Albert Einstein/Montefiore HS Center (HSC). All patients seen between September 1 and December 31, 2021 were invited to participate in this study. A total of 64 patients volunteered to complete telephone surveys. The survey consisted of demographics, a Patient Health Questionnaire-2 (PHQ-2) screening test, and patient perception regarding the utilization of mental health support. The mean age of participants (n=64) was 35.3±14.1, and 43 (67%) were female. The average HS-PGA for this cohort was 3.4±1.3. Twenty patients (31%) screened positive for depression using the PHQ-2. By contrast, when recalling times during which they experienced HS flares, 37 (58%) patients screened positive for depression. When asked if they experienced an improvement in mood with successful control of HS disease activity, 45 (70%) answered yes, 10 (16%) answered no, and 9 (14%) were unsure. Twenty-four (38%) had pursued support from a mental health professional (MHP); 12 (50%) felt that a MHP helped them cope with HS, 18 (75%) recommended seeking out a MHP to other HS patients. When asked if they would be willing to speak to a mental health professional in the future, 43 (67%) answered yes, 15 (23%) answered no, and 6 (9%) were unsure. This pilot study identifies a propensity for states of clinical depression during periods of worsened HS disease activity. It is remarkable that two-thirds (67%) of this cohort would seek the care of a MHP. Our data underscore the need for incorporating mental healthcare into the standard management of HS patients. Further studies are essential to define how to make these resources available.

Biologic therapy is not associated with increased COVID-19 severity in patients with hidradenitis suppurativa: Initial findings from the Global Hidradenitis Suppurativa COVID-19 Registry

Biologic therapy is not associated with increased COVID-19 severity in patients with hidradenitis suppurativa: Initial findings from the Global Hidradenitis Suppurativa COVID-19 Registry

Ultrasound-guided injection of intralesional steroids in acute hidradenitis suppurativa lesions: A prospective study.

The management of hidradenitis suppurativa (HS) flares with intralesional steroids lacks strong scientific evidence but limited data suggest that it may be useful. The objective of this study is to assess the clinical and ultrasound responses of HS flares to ultrasound‐guided injections of intralesional triamcinolone (40 mg/ml) with a dilution 1:4 versus 1:2 at 30‐day (t1), 60‐day (t2), and 90‐day (t3) follow‐up. We recruited patients with ≤3 acute lesions, unresponsive to topical therapy. At baseline we assessed lesions clinically and by ultra‐high frequency ultrasound (48 or 70 MHz) and randomly performed an ultrasound‐guided injection of triamcinolone. Assessments were repeated at t1, t2, and t3 follow‐up, re‐injecting the lesion in the case of no or partial response. We treated 49 lesions: 38.8% showed improvements at t1; 46.9% at t2; 6% at t3; and 8.3% showed no clinical and ultrasound improvements. Long‐term follow‐up data confirmed a statistically significant reduction in Visual Analogue Scale (VAS)‐pain, Dermatology Life Quality Index (DLQI), and HS‐Physician Global Assessment (HS‐PGA), as well as edema and vascular signals. No adverse effects were reported. Our study suggests that ultrasound‐injections with a 1:2 dilution are beneficial for HS flares that do not respond to topical treatment and should be included in the therapeutic algorithm.

Caring for Pediatric Hidradenitis Suppurativa Patients in the Emergency Department.

Hidradenitis suppurativa (HS) is a chronic and recurrent inflammatory skin condition resulting in the formation of nodules, sinus tracts, and abscesses in intertriginous areas. We provide recommendations for the management of children presenting to the emergency department with acute HS flares, based on a review of literature and insights from our own clinical experience. The purpose of the recommendations is to educate clinicians on specific considerations that should be made when caring for children with HS.

394 Intramuscular triamcinolone for acute hidradenitis suppurativa flares

Hidradenitis suppurativa (HS) is a chronic, recurrent, immune-mediated follicular disease managed by wide-ranging therapies, including anti-inflammatory drugs. Among these modalities, intralesional triamcinolone (ILTAC), a standard of care for acute flares, is often impractical in extensive disease. By contrast, intramuscular triamcinolone (IMTAC) has not been studied as an alternative treatment for severe, widespread HS flares. We evaluated the efficacy and patient experience associated with IMTAC therapy. A retrospective analysis and telephone survey focused on 35 patients who received both IMTAC and ILTAC at the Albert Einstein/Montefiore HS Center from January to November 2020. Mean age was 39.1±15.0 years, and approximately half were female (54.3%). Mean disease severity, using a 5-point scale of HS-Physician Global Assessment (HS-PGA), was 4.00±0.91, indicating IMTAC was reserved for advanced disease. Telephone interviews revealed that most patients experienced no pain or discomfort during IMTAC injections (n=26 [74.3%]). Moderate to significant improvement in HS lesional activity was reported by 71.4% (n=25), as reflected by reduced pain (n=25 [71.4%]) drainage (n=17 [48.6%]), and improved mobility (n=18 [51.4%]) and quality of life (n=22 [62.9%]). No adverse effects were reported. Of 29 patients (82.8%) with follow-up visits (mean 7-week interval), a significant decrease was seen in both disease severity (mean initial HS-PGA 4.07 declined to 3.31, p=.009) and pain (mean initial 10-point numerical rating scale of 5.76 declined to 2.81, p=.001). Most preferred or were neutral about receiving IMTAC over ILTAC (33 [94.3%]). Overall, most (25 [71.4%]) reported moderate to substantial satisfaction and almost all (33 [94.3%]) would receive IMTAC injections again if clinically indicated. Our findings affirm an overwhelming positive response to IMTAC therapy for severe, multifocal, and anatomically extensive HS flares. This is the first report of IMTAC as a safe and favorable adjunct for acute HS management.

Sub-classification of Hidradenitis suppurativa: a cross-sectional study

The typical Hidradenitis Suppurativa (HS) patient is a young woman with axillary and groin involvement, but the spectrum of the disease presentation is broad and no internationally acknowledged sub-classification of the disease exists to date. It is however speculated that different, yet unidentified, subtypes may respond differently to different treatments or carry a different prognosis. Classification according to self-reported clinically meaningful outcomes for patients offer practical advantages. Our objective was to build an empirical framework for sub-classification of HS patients based on the frequency of HS flares in various anatomic locations, using a cross-sectional questionnaire-based design. All patients with a clinically confirmed diagnosis of HS registered at our department until March 1, 2017 were invited to participate. The frequency of HS flares in various anatomic locations was used for identification of possible HS subtypes using Principal Component Analysis (PCA) and cluster analysis. A total of 524 (62%) of 845 invited patients answered the questionnaire; 402 (76.7%) were female. From the cluster analysis, we identified two possible subtypes of HS, labeled the "upper type" and the "lower type". The "upper type" was characterized by repeated outbreaks in axillary and mammary regions. Meanwhile, the "lower type" was characterized by outbreaks in the inguinal, genital, perianal, and gluteal regions. Our findings support the notion that HS can be sub-classified and imply that the pattern of where lesions are located may be an important element in future HS sub-classification systems.

Characterizing perimenstrual flares of hidradenitis suppurativa.

BackgroundHidradenitis suppurativa (HS) predominantly affects women of childbearing age, and sex hormones are thought to play a role in HS pathogenesis. However, there is a paucity of data regarding the pattern of HS perimenstrual flares, as well as patient responses to hormone-based therapies.ObjectiveWe aimed to characterize the temporal pattern of perimenstrual flares, as well as factors associated with perimenstrual flares. We also sought to investigate responses to hormonal therapies in women with HS.MethodsAn anonymous web-based questionnaire was distributed to various online HS support groups in May 2020.ResultsA total of 283 participants met the inclusion criteria as adult women who self-reported having HS and menstrual cycles. The majority (176 of 282 women; 62.4%) reported HS worsening with menses, and 86.9% (153 of 176 women) noted that perimenstrual HS flares occurred always or often. Most women (138 of 175 women; 78.9%) reported that their HS flared in the week preceding menses. Perimenstrual HS flares were more likely in women with a family history of HS compared with those without (49.6% vs. 28.2%; p = .019). More than a third of respondents who had been treated with spironolactone reported improvement of HS symptoms, but more than a quarter of participants who used medroxyprogesterone acetate or used a hormonal intrauterine device reported worsened HS symptoms.ConclusionFemale patients with HS have high rates of perimenstrual HS flares, specifically during the week preceding the onset of menses. Additional investigations on the role of sex hormones in HS pathogenesis and the efficacy of hormone-based therapies are warranted.

Special considerations for women with hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic, debilitating disease that manifests as painful nodules, abscesses, sinus tracts, and scars with a predilection for intertriginous sites. HS disproportionately affects women of childbearing age and often leads to impairments in patients’ health-related quality of life. Women with HS face unique challenges related to menstruation, pregnancy, and lactation that require additional strategies for optimization of management. Practical interventions include lifestyle modifications, treatment of premenstrual HS flares, enhancing HS management during pregnancy, and creating optimal delivery plans in collaboration with obstetricians. This discussion is based on expert recommendations and aims to highlight the special challenges for women with HS, as well as provide a practical discourse on optimizing care of female patients with HS.

A concise clinician's guide to therapy for hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic, often debilitating, skin condition that historically does not respond well to treatment. Although there is no cure for HS, symptoms can be managed if the appropriate diagnosis is made. HS most commonly develops in postpubertal women and manifests as painful, deep-seated, inflamed lesions, including nodules, sinus tracts, and abscesses. HS flares are marked by increased pain and suppuration at varying intervals and can occur in women before menstruation. HS is commonly misdiagnosed; physicians might mistake a lesion for an infection, abscess, or sexually transmitted infection. Incision and drainage of these lesions often leads to recurrence. Given that management of this chronic disease is often difficult, we sought to outline current diagnosis and management strategies for HS.

Intralesional triamcinolone for flares of hidradenitis suppurativa (HS): A case series

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the hair follicle. Standard practice of managing acute flares with corticosteroid injection lacks scientific evidence. We sought to assess the outcomes of routine treatment using intralesional triamcinolone (triamcinolone acetonide 10mg/mL) in the management of acute flares in HS. This was a prospective case series evaluating the effect of intralesional corticosteroids for alleviation of acute flares in HS. Physician- and patient-reported outcomes were noted. Significant reductions in physician-assessed erythema (median score from 2-1, P<.0001), edema (median score from 2-1, P<.0001), suppuration (median score from 2-1, P<.0001), and size (median score from 3-1, P<.0001) was demonstrated at follow-up. A significant difference in patient-reported painvisual analog scale scores occurred after 1day (from 5.5-2.3, P<.005) and from day 1 to day 2 (from 2.3-1.4, P<.002). Small study size, open single-arm design, and short follow-up time are the limitations of this study. Intralesional injection of corticosteroids is perceived as beneficial by physicians and patients in the management of HS flares by reducing pain after 1day and signs of inflammation approximately 7days later.

Wide excision and healing by secondary intent for the surgical treatment of hidradenitis suppurativa: A single-center experience

This study reviewed a single center's 14-year experience with surgical treatment of chronic, severe hidradenitis suppurativa (HS) through wide excision technique and healing by secondary intention. All patients who underwent wide excision of HS between 2000 and 2014 and allowed to heal by secondary intention were included. Wound care consisted of topical antimicrobials and hydrotherapy. Physical therapy was initiated for joint contracture prevention. Patients were followed until complete wound closure. Seventeen patients underwent 23 separate surgical encounters, five with excision of multiple areas. Seventeen excisional procedures were conducted on the upper half of the body (axillary, breast) and 11 on the lower half (inguinal, perineum, perianus, and abdomen). Two patients developed HS recurrence adjacent to the surgical site (one requiring reexcision and the other treated with topical therapy), whereas two developed HS flares at distant nonsurgical sites managed medically. The mean follow-up was 1.02 years with a median of 6 months ranging from 1.2 months to 5.25 years. Complete wound healing ranged from 8 weeks to 16 months, with limited range of motion (ROM) in two patients. Attempts at removing all tissue affected by HS through wide surgical excision are the mainstay intervention for achieving complete local cure, particularly in the most severe cases of the disease. Our experience with wide excision of disease and healing by secondary intent demonstrated clinically satisfactory functional and excellent aesthetic results in multiple anatomic areas and even for large defects. This healing modality requires strict adherence to the wound healing protocol, which is often tolerated only by patients who have endured symptoms of severe HS for an extended length of time.