Expert Practices in Hidradenitis Suppurativa Flare Management: A Cross-Sectional Survey Study

Abstract

Introduction

Hidradenitis suppurativa (HS) is a chronic skin condition with recurrent, debilitating flares. Although the majority of patients with HS endorse flares, there is a lack of research regarding HS experts’ flare management practices and perspectives.

Methods

An anonymous online survey was distributed through an HS expert listserv. Board-certified dermatologists who saw 1 or more HS patient(s) per month were eligible for participation.

Results

A total of 35 responses were collected; 97.1% self-identified as HS experts. Therapies used for HS flares by more than two-thirds of the respondents included systemic antibiotics (100%), nonprescription pain relievers (91.4%), intralesional triamcinolone injections (91.4%), prescription pain relievers (71.4%), oral corticosteroids (68.6%), and warm compresses (68.6%). The top 3 dermatologist-reported barriers that patients face in accessing care during flares include lack of clinic appointment availability (88.6%), distance that patients have to travel to reach clinic (85.7%), and lack of transportation for patients (62.9%).

Conclusions

Overall, this study highlights variations in the ways that HS experts manage flares. Many of the treatment modalities used by the majority of respondents are not part of the official North American guidelines. Further prospective studies and expert consensus guidelines are needed to standardize the approach to flare management.

Introduction

Hidradenitis suppurativa (HS) is a chronic skin condition characterized by recurrent nodules, abscesses, and sinus tracts, typically in intertriginous areas [1]. Current therapeutic modalities for HS include biologic agents such as adalimumab and secukinumab, systemic antibiotics, and hormonal treatments [1, 2]. During HS flares, patients may experience new or worsening physical and emotional symptoms such as pain, drainage, swelling, depression, and anxiety [3], necessitating additional treatment. Given the lack of standardized guidelines for the treatment of HS flares, the aim of our study was to gain insights into HS specialists’ flare management practices.

Materials and Methods

An anonymous online survey was distributed between March and April 2023 through an HS expert listserv (HS Place). Per the recent international consensus of disease flare in HS, for the purposes of this survey, an HS flare was defined as “new or substantial worsening of clinical signs or symptoms” [3]. Board-certified dermatologists who saw 1 or more patient(s) with HS per month were eligible for participation. This study was deemed exempt by the institutional review board of the University of Southern California.

Results

Of 166 listserv members, 35 responses were collected (response rate: 21.1%). Demographics and HS flare management practices of the respondents are summarized in Table 1. There were 21 (60%) females, and the mean number of HS patients seen in a month was 38.4 (standard deviation: 19.6, range: 12–100). The majority practiced in academic settings (88.6%) and urban locations (82.9%). Overall, 34 (97.1%) self-identified as HS experts, 31 (88.6%) directed HS specialty clinics, and 15 (42.9%) were current or former board members of a national or international HS foundation. The majority (82.9%) mainly saw patients with Hurley stage II–III. Figure 1 provides the variety and frequency of treatments recommended for HS flares by respondents.

Table 1.

Respondents’ demographics and perspectives on HS flare management practices

Demographics and HS flare management practices	N (%)
Gender (n = 35)
Female | male | prefer not to specify (%)	21 (60) | 13 (37.1) | 1 (2.9)
Age, mean±SD (range) (n = 35)	43.4±9.3 (33–67)
Number of HS patients seen in a month, mean±SD (range) (n = 35)	38.4±19.6 (12–100)
Race/ethnicity (n = 35) (%)
White	19 (54.3)
Asian/Pacific Islander	6 (17.1)
Hispanic/Latino	2 (5.7)
African American	2 (5.7)
Bi- or multiracial	1 (2.9)
Othera	2 (5.7)
Prefer not to say	3 (8.6)
Country of practice (n = 35)
USA | Canada | France | UK | Australia (%)	31 (88.6) | 1 (2.9) | 1 (2.9) | 1 (2.9) | 1 (2.9)
Primary practice setting (n = 35)
Academic | community (%)	31 (88.6) | 4 (11.4)
Primary practice location (n = 35)
Urban | suburban (%)	29 (82.9) | 6 (17.1)
Hurley stage of majority of patients seen (n = 35)
Stage II–III | equal amounts of stage I and stage II–III (%)	29 (82.9) | 6 (17.1)
Current or former board member of a national or international HS foundation (n = 35)
Yes | no (%)	15 (42.9) | 20 (57.1)
Nonprescription pain relievers recommended (n = 34) (%)
NSAIDs	33 (97.1)
Tylenol (acetaminophen)	29 (85.3)
Topical lidocaine	19 (55.9)
Cannabis	7 (20.6)
Otherb	1 (2.9)
Prescription pain relievers recommended (n = 33) (%)
High-dose ibuprofen	18 (54.5)
Tramadol	18 (54.5)
Acetaminophen with codeine (Tylenol #3)	12 (36.4)
Norco or Vicodin (hydrocodone/acetaminophen)	9 (27.3)
Percocet (oxycodone/acetaminophen)	9 (27.3)
Otherc	10 (30.3)
Dose of intralesional triamcinolone used (n = 34) (%)
10 mg/cc | 20 mg/cc | 40 mg/cc	20 (58.8) | 15 (44.1) | 19 (55.9)
Tools used to perform incision and drainage on active lesions (n = 31) (%)
Punch tool | 11 blade | 15 blade	24 (75) | 18 (56.3) | 6 (18.8)
Typical starting dose of oral prednisone (n = 33) (%)
>1 mg/kg | 0.5 mg/kg to 1 mg/kg | 0.25 mg/kg | otherd	1 (3.0) | 20 (60.6) | 4 (12.1) | 8 (24.2)
Typical length of total oral prednisone course (n = 33) (%)
4 weeks | 3 weeks | 2 weeks | ≤10 days | othere	2 (6.1) | 6 (18.2) | 12 (36.4) | 10 (30.3) | 3 (9.1)
Systemic antibiotics prescribed (n = 35) (%)
Tetracyclines	32 (91.4)
Trimethoprim/sulfamethoxazole	22 (62.9)
Amoxicillin/clavulanic acid	21 (60)
Clindamycin	21 (60)
Fluoroquinolones	18 (51.4)
Ertapenem (IV or IM)	17 (48.6)
Metronidazole	15 (42.9)
Cephalexin	12 (34.3)
Cefdinir	5 (14.3)
Otherf	6 (17.1)
Combinations of systemic antibiotics prescribed (n = 24) (%)
Clindamycin-rifampin	20 (83.3)
Rifampin-metronidazole-fluoroquinolone	4 (16.7)
Bactrim-cephalexin	2 (8.3)
Otherg	3 (12.5)
Typical length of systemic antibiotic course (n = 35) (%)
2–3 weeks	17 (48.6)
≥3 weeks	12 (34.3)
1–2 weeks	4 (11.4)
Otherh	2 (5.7)
Protocol (predefined algorithm or plan) for HS patients who may need to be seen for flares (n = 35) (%)
Yes | no	14 (40) | 21 (60)
The workflow/algorithm takes the severity of the flare into account to determine the best next steps (n = 14) (%)
Yes | no	10 (71.4) | 4 (28.6)
Dermatologist reported barriers that patients face accessing care during flares (n = 35) (%)
Lack of clinic appointment availability	31 (88.6)
Distance that patients have to travel to reach clinic	30 (85.7)
Lack of transportation for patients	22 (62.9)
Patients are unable to miss work/school	21 (60)
Patients do not have childcare available	18 (51.4)
Patients have too much pain to travel to clinic during a flare	17 (48.6)
Lack of health insurance or limited healthcare coverage	7 (20.0)
Otheri	5 (14.3)

HS, hidradenitis suppurativa; IM, intramuscular; IV, intravenous; kg, kilogram; mg, milligram; N, number; NSAIDs, nonsteroidal anti-inflammatory drugs; SD, standard deviation; UK, United Kingdom.

^aOther: Middle Eastern, unspecified (n = 1 each).

^bOther: Voltaren gel (n = 1).

^cOther: “oxycodone” (n = 3); “pain specialist/FD,” “oxycodone or hydrocodone without acetaminophen added,” “topical morphine,” “duloxetine, gabapentin,” “refer to pain management for prescription pain medication,” “dutasteride,” “meloxicam” (n = 1 each).

^dOther: “15 mg/day,” “60 mg or 40 mg/day,” “20–30 mg/day,” “30 mg/day,” “40–50 mg/day,” “50 mg/day,” “40–60 mg,” “40 mg/day”(n = 1 each).

^eOther: “6 weeks and reassess,” “12 days,” “4–6 weeks” (n = 1 each).

^fOther: “clindamycin/rifampin” (n = 2); “linezolid,” “pristinamycin +/− metronidazole,” “rifampin, linezolid”, “azithromycin, linezolid” (n = 1 each).

^gOther: “linezolid+cefdinir,” “pristinamycin and metronidazole or augmentin and metronidazole or if gastric intolerance moxifloxacin + metronidazole and for a severe relapse ceftriaxone + metronidazole,” “metronidazole-moxifloxacin +/− rifampin, may add rifampin to tetracyclines, augmentin, or cefdinir, may add linezolid to others” (n = 1 each).

^hOther: “depends 7–14 days,” “depends on clinical situation” (n = 1 each).

ⁱOther: “difficulty getting in touch with someone in our clinic who can get them an urgent appointment,” “flare on weekend when clinic closed,” “dermatologists in the community do not like to treat HS” (n = 1 each); “I do not know” (n = 2).

Fig. 1.

Frequency of treatments prescribed or recommended for HS flares by respondents. *Other: “topical steroids” (n = 2), “dose escalation,” “excision,” “dapsone,” “IV ertapenem, 10 mg/kg infliximab infusion,” “depends” (n = 1 each).

The top HS flare treatments recommended “often/sometimes” include systemic antibiotics (100%, most commonly for a 2–3 week course), nonprescription (91.4%) and prescription (71.4%) pain relievers, intralesional triamcinolone (ILTAC) injections (91.4%), systemic steroids (68.6%, most commonly for ≤2 week course), and warm compresses (68.6%). The top systemic antibiotics used include tetracyclines, trimethoprim/sulfamethoxazole, amoxicillin/clavulanic acid, and clindamycin. Most respondents (60%) did not have a protocol in place for HS patients who may need to be seen for flares. Over 80% of respondents endorsed limited clinic availability and travel distance as barriers to patients seeking care during flares.

Discussion

Currently, the North American treatment guidelines recommend antiseptic washes, warm compresses, short-term oral steroids, ILTAC, incision and drainage (I&D), deroofing, and topical resorcinol for acute HS lesions [4]. In contrast, all respondents in our study reported using systemic antibiotics for flares, most commonly for 2–3 week courses, which is not discussed in the guidelines.

Many clinicians endorsed using higher doses of ILTAC (20 mg/cc or 40 mg/cc) for flares, compared to 10 mg/cc recommended by the North American treatment guidelines [4]. This is in line with the findings of Garelik and colleagues, who described benefit with the use of higher doses of ILTAC (20 mg/cc and 40 mg/cc) in patients with HS [5]. Furthermore, 75% had used a punch tool to perform an I&D, which may facilitate continued drainage of abscesses [6].

Our findings highlight the importance of providing patients with a practical at-home action plan for flare management, especially since nearly one-half of respondents endorsed that patients have too much pain to travel to clinic during a flare. A cross-over randomized controlled trial demonstrated that written action plans for HS increased patients’ confidence in recognizing and treating disease flares [7]. Additionally, it is essential to mitigate other barriers to care, such as limited clinic appointments and long travel distances, by helping patients find local dermatologists who are comfortable managing flares and increasing awareness of HS flare management techniques among emergency room providers. Providing more avenues for patients to receive care for disease exacerbations may also reduce no-shows to HS clinic visits since a recent survey study demonstrated that an HS flare was the top reason for missed appointments [8].

To our knowledge, this study describes novel findings regarding flare management practices among HS experts. Study limitations include a small sample size, limited response rate, and most respondents practiced in urban, academic locations.

Conclusion

This study highlights that HS experts have varied practices for HS flare management that are not necessarily in the current HS treatment guidelines. Increased recognition and timely management of HS are needed to reduce the frequency and intensity of flares. Larger prospective investigations evaluating the efficacy of various treatments for HS flares, relationships between Hurley stage, and corresponding management strategies, as well as structured expert consensus guidelines are needed to establish a standardized approach to treating HS flares.

Acknowledgments

We would like to thank the dermatologists who participated in our study.

Statement of Ethics

This study was approved under the exempt category by the Institutional Review Board at the University of Southern California. The need for informed consent was waived by the Institutional Review Board at the University of Southern California.

Conflict of Interest Statement

V.Y.S. is on the board of directors for the Hidradenitis Suppurativa Foundation (HSF), an advisor for the National Eczema Association, is a stock shareholder of Learn Health, and has served as an advisory board member, investigator, speaker, and/or received research funding from Sanofi Genzyme, Regeneron, AbbVie, Genentech, Eli Lilly, Novartis, SUN Pharma, LEO Pharma, Pfizer, Incyte, Boehringer Ingelheim, Alumis Aristea Therapeutics, Menlo Therapeutics, Dermira, Burt’s Bees, Galderma, Kiniksa, UCB, Target PharmaSolutions, Altus Laboratories/CQuell, MYOR, Polyfins Technology, GpSkin, and Skin Actives Scientific. J.L.H. is on the Board of Directors for the Hidradenitis Suppurativa Foundation and has served as a consultant for AbbVie, Aclaris, Boehringer Ingelheim, Novartis, as a speaker for AbbVie, and as an investigator for Amgen, Aristea, Boehringer Ingelheim, and Incyte. M.A.A. has served as a consultant for AbbVie, Novartis, Santa Ana Bio and has received research funding from UCB. All other authors report no conflicts of interest.

Funding Sources

This study has no funding source.

Author Contributions

R.M. drafted the manuscript and conducted data analysis for this project. S.P., V.Y.S., and J.L.H. contributed toward reviewing and editing of the manuscript. M.A.A. led the conceptualization and administration of this project and also led the reviewing and editing of the manuscript.

Funding Statement

This study has no funding source.

Data Availability Statement

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.