Abstract
Background
Case series have indicated that intravenous antibiotics may be effective in severe hidradenitis suppurativa (HS) treatment. This treatment approach is excluded from the British Association of Dermatologists UK HS treatment guidelines but can be found in the European S2k, North American and French Dermatology Society HS guidelines.
Objectives
To study whether intravenous antibiotics are being used in HS treatment in the UK and to explore the experiences of dermatologists and outpatient parenteral antibiotic therapy (OPAT) teams with intravenous antibiotics.
Methods
Two separate surveys were distributed to dermatologists and OPAT centres respectively in 2020. The surveys were designed on Survey Monkey® with skip logic and free text boxes incorporated. Only UK responses were included. Descriptive and content analyses were performed on the data.
Results
Seventy-four dermatology clinicians and 25 OPAT centres responded. Nearly half of the respondents reported having treated HS with intravenous antibiotics. Most used intravenous ertapenem for an average treatment duration of 4–6 weeks with 1–3 months of average remission period. Top indications were severe disease (57%) and biologic treatment failure (57%). The most common consolidation treatments were biologics, surgery and tetracycline antibiotics. A joint dermatology–OPAT HS clinic was preferred. Dermatologists reported exclusion of intravenous antibiotics from local/national guidelines (67%) being the main barrier to using intravenous antibiotics.
Conclusion
Findings from the two surveys show overall positive experience using intravenous antibiotics in HS treatment and call for development of a best practice statement in HS treatment with intravenous antibiotics and collaborative working with OPAT for a national referral pathway.
We study the use of intravenous antibiotics in the treatment of hidradenitis suppurative (HS) in the UK despite this not being included in the British Association of Dermatologists UK HS treatment guideline. Surveys were distributed separately to dermatologists and outpatient parenteral antimicrobial therapy centres. The findings show an overall positive experience using intravenous antibiotics in HS treatment, and call for further research and development of best practice statement in HS treatment with intravenous antibiotics.
What is already known about this topic.
Established treatments for hidradenitis suppurative (HS) include topical and oral antibiotics.
Small studies have shown some benefits in treating severe HS with intravenous antibiotics such as ertapenem.
While the use of intravenous antibiotics is included in the HS treatment guidelines of North America, European and the French Society of Dermatology, they are not part of the British Association of Dermatologists HS guideline.
What does this study add?
Nearly half of the UK dermatologists who responded have used intravenous antibiotics in treating HS, with ertapenem being the most frequently used antibiotic and typically given over 4–6 weeks.
Respondents showed a keen interest in the use of intravenous antibiotics for HS and called for a consensus in treatment of HS using intravenous antibiotics.
Our results demonstrated off-license use of intravenous antibiotics in the treatment of HS, and a need to develop best practice statements and a multidisciplinary approach.
Hidradenitis suppurativa (HS) is a chronic inflammatory disease that results in painful, deep-seated inflamed lesions in the apocrine glands, which are most commonly found in the axillary, inguinal and anogenital regions.1 The pathophysiology of HS remains unclear, but it is suggested that apocrine gland occlusion leads to inflammation and bacterial growth causing more tissue destruction and subsequently ulceration, fibrosis, sinus tract formation and ultimately scarring.2 Ongoing research is mainly focused on four contributory factors which include genetics, environmental factors, hormonal regulation and microbiology.3 The skin microbiome in people with HS has been demonstrated to have a lower proportion of usual commensals such as Staphylococcus spp. and Cutibacterium spp. alongside a higher proportions of Corynebacterium spp. and Gram-positive and Gram-negative anaerobes such as Prevotella spp., Porphyromonas spp. and Actinomycetes;4–7 while aerobic Gram-negative organisms have been isolated in both the microbiota and active lesions in HS, an overall pattern or correlation with HS is unclear7 and the impact of these microbiota modifications in the development of HS has not been fully established.
Topical and oral antibiotics are the first-line recommended treatment for people diagnosed with HS in the British Association of Dermatologists (BAD) UK guidelines.8 The topical and oral agents recommended are generally utilized for their immunomodulatory effects, which are well documented within the literature.9–11 Although there is no fixed duration of treatment with oral antibiotics in HS, most are generally given for 12–16 weeks, which is in line with most clinical trials and other dermatological conditions12 with the exception of rifampicin and clindamycin with recommended duration of 10 weeks.13
A French study published in 2016 showed great improvement in patients with severe HS, as indicated by a significant drop in the median Sartorius score, after a 6-week course of intravenous ertapenem with consolidation treatments.14 In our institution, University Hospitals of Leicester, UK, we adopted this approach and found it very helpful in the treatment of patients with severe HS but were concerned about giving an invasive treatment not included in any guidelines at the time and in a culture of increasing scrutiny and antibiotic stewardship, and the increasing global threat of antimicrobial resistance (AMR). We therefore conducted a national survey to better understand whether intravenous antibiotics were being used to treat HS in other centres across the UK.
Materials and methods
The main aims were to explore the indications and referral criteria for the use of intravenous antibiotics, the number of patients with HS on intravenous antibiotics, efficacy of intravenous antibiotics in HS and management overview including follow-up arrangements. No formal sample size calculation was performed as the surveys aimed to explore and describe current clinical practices. The goal was to achieve maximum response rate to ensure representativeness of UK practice.
Two separate surveys, one for dermatologists and one for outpatient parenteral antimicrobial therapy (OPAT) centres, were designed on Survey Monkey® with skip logic incorporated to direct respondents to relevant questions depending on their previous answers, thereby reducing survey burden and improving data quality. Free text boxes were included to enable respondents to expand on their answers or provide comments not covered by predefined response options to improve data capturing.
The OPAT survey centred mostly on the practical aspects of intravenous antibiotic administration, particularly service logistics. The dermatology survey provided additional focus on the decision to use intravenous antibiotics in HS. All respondents were also asked to comment on guidelines/pathways for the use of intravenous antibiotics in HS. The OPAT survey consisted of 19 questions and the dermatology survey consisted of 23 questions. Both surveys shared 13 core questions (see Appendix 1 and 2, respectively, in the Supporting Information).
The OPAT survey was distributed via direct email on 4 February 2020 to 38 UK-based OPAT centres identified from the British Society for Antimicrobial Chemotherapy OPAT Service Registry.15 A reminder email was sent on 30 March 2020 and the survey was closed on 30 April 2020. The Dermatology survey was distributed via the BAD monthly newsletter and to members of the British Society of Medical Dermatology via email in October 2020. The dermatology survey was closed on 1 April 2021. Responses from outside the UK were excluded. Closed questions were analysed descriptively using the analytic tools incorporated in Survey Monkey®. Responses were summarized as percentages. Free text comments were analysed through content analysis16 and the response either: (i) was included in a preprovided option, if similar enough; (ii) gave rise to formation of a new category/response, if sufficient number of related free-text responses were given; or (iii) was presented narratively, particularly for open questions at the end of the surveys. The authors have collectively examined the qualitative data manually and systematically to determine the common themes and concepts for consistency and consensus achieved through discussion.
Ethical approval was not required for our study as this was an evaluation of current practice. Limitations of our survey, which are further elaborated on in the Discussion, include reduced generalizability, recall bias among respondents and the delay in publishing the data.
Results
Seventy-seven dermatology clinicians responded to an open request to complete the dermatology survey. Three were excluded from further analysis as respondents were from outside the UK. The majority of respondents were dermatology consultants (n = 57/74, 77%), with a national average of 614 full time equivalent consultant dermatologists,17 and registrars (n = 13/74, 18%). The remainder were completed by other grades of medical staff. Less than half (n = 31/74, 42%) of the dermatology clinicians had treated patients with HS with intravenous antibiotics and of these most (77%) had experience of treating a small number of patients (1–5). A total of 25/38 (66% response rate) UK OPAT centres responded to the OPAT survey and more than half (n = 14/25, 56%) reported treating patients with HS with intravenous antibiotics. The majority of respondents (64%) had experience of treating a small number of patients (1–5).
Criteria for referral for intravenous antibiotics
Of the 30 dermatology clinicians reporting experience of using intravenous antibiotics to treat HS, only 5 (17%) had local criteria for referral to OPAT services. The most common reasons cited for using intravenous antibiotics were severe disease (57%), treatment failure with adalimumab (57%), as a lead-in to treatment with adalimumab (37%) and prior to surgery (30%). Other reasons cited included treatment failure with the first- and second-line treatment recommendations, and moderate to severe disease severity. Of the 14 OPAT centres that had used intravenous antibiotics for HS, 7 (50%) reported having local criteria in place for accepting HS referrals, but only 1 had a specific pathway for the management of HS. In the free text comments, one respondent indicated they were commonly asked to give broad-spectrum intravenous antibiotics by the plastic surgery team to facilitate a better surgical response.
Choice of antibiotic regimen and length of treatment
A wide range of broad-spectrum antibiotics were reportedly used in the management of HS. Ertapenem was the most frequently reported antibiotic by both OPAT centres and dermatology clinicians (Table 1). Most respondents reported providing antibiotic therapy for 4–6 weeks (OPAT centres, 67%; dermatology clinicians, 63%).
Table 1.
Management of patients with intravenous antibiotics
| OPAT centres, n = 14 [n (%)] | Dermatologists, n = 30 [n (%)] | |
|---|---|---|
| Antibiotic regimens (intravenous ± adjunctive oral)a,b | ||
| Ertapenem | 7 (50) | 20 (67) |
| Ceftriaxone | 3 (21) | 0c |
| Piperacillin–tazobactam | 0c | 1 (3) |
| Penicillin | 0c | 2 (7) |
| Flucloxacillin | 0c | 2 (7) |
| Co-amoxiclav | 0c | 3 (10) |
| Meropenem | 1 (7) | 1 (3) |
| Metronidazole | 0c | 1 (3) |
| Macrolide | 0c | 1 (3) |
| Clarithromycin | 1 (7) | 0c |
| Teicoplanin | 1 (7) | 0c |
| Unspecified/none | 5 (36) | 1 (3) |
| Usual duration of intravenous antibiotics | ||
| 1–3 weeks | 3 (25) | 8 (27) |
| 4–6 weeks | 8 (67) | 7 (23) |
| 6 weeks | 0c | 12 (40) |
| >6 weeks | 0 | 1 (3) |
| Other (unspecified) | 1 (8) | 2 (7) |
OPAT, outpatient parenteral antibiotic therapy. aRespondent could select more than one answer. bRespondent could answer in free text box in addition to selecting an answer given in the survey. cThis answer was not given as an option in the survey and was not reported in the free text box by any respondent.
Follow-on treatment choices
Dermatologists commonly reported follow-on treatment with biologics, surgery and oral tetracyclines (Table 2). Other oral antibiotics included clindamycin and rifampicin and rotational regimens. Smaller numbers of respondents mentioned a range of other step-down options in the free text box (Table S1, see Supporting Information). Ten OPAT centres responded to the question regarding oral follow-on antibiotics. Respondents indicated that antimicrobial choice was dependent on issues such as previous prophylactic regimens, concomitant biologics, microbiological cultures and advice of a microbiology colleague.
Table 2.
Step-down treatment used by dermatology clinicians
| Choice of step-down treatmentsa | Frequency, n = 30 [n (%)] |
|---|---|
| Biologics (adalimumab) | 17 (57) |
| Surgery | 13 (43) |
| An oral tetracycline | 12 (40) |
| Oral clindamycin + rifampicin | 5 (17) |
| Rotational antibiotics | 4 (13) |
| Oral co-trimoxazole | 1 (3) |
| Others (free text) | 6 (20) |
aRespondent could select more than one answer.
Administration of intravenous antibiotics
Dermatologists (n = 30) reported providing intravenous antibiotics to inpatients (50%), via a local OPAT service (43%), via home visits (23%) through self-administration at home (13%) and via day case units (10%) (Table 3). The OPAT centres (n = 14) provided intravenous antibiotics outside of hospital through one or more methods. Most (8/14, 57%) through self- and/or carer-administration programmes, half (7/14) provided antibiotics through infusion centres and around one-third (5/14) through nurse-administration services (Table 3).
Table 3.
Administration of intravenous antibiotics
| Mode of antibiotic administrationa | OPAT services who used intravenous treatments, n = 14 (%) | Dermatologists who used intravenous treatments, n = 30 (%) |
|---|---|---|
| OPAT infusion centre/clinic | 7 (50) | 13 (43) |
| Nurse administered at home/home visits | 5 (36) | 7 (23) |
| Self/carer administered at home | 8 (57) | 4 (13) |
| Inpatient | 0 | 15 (50) |
| Day case and ambulatory care centre | N/Ab | 3 (10) |
| Others, specified below (free text box): | 0 | 1 (3) |
|
OPAT, outpatient parenteral antibiotic therapy. aRespondent could select more than one answer. bNot applicable (N/A) as this was not provided as an option in answer selection.
Treatment guidelines/pathways for HS
In the dermatology survey, 29/30 (97%) referred to HS treatment guidelines. The majority (22/30, 73%) used the BAD guidelines,2 three (10%) used their local guidelines, one (3%) used the European guidelines1 and one (3%) used the North American guidelines.18 One respondent (3%) referred to all the aforementioned guidelines and another (3%) referred to HS treatment guidelines but did not specify which. One centre that reported using local guidelines confirmed that intravenous antibiotics were included in those guidelines.
Of the OPAT centres that responded to this section of the survey (n = 12), nine (75%) did not refer to any specific treatment guidelines/pathways. Three (25%) indicated that they had specific pathways but did not provide further information.
Clinical governance
Of those dermatologists with experience of using intravenous antibiotics (n = 30), four (13%) indicated that they held a joint clinic with OPAT. Two (50%) of these use OPAT for ad hoc advice only, one (25%) held joint clinics weekly and one (25%) held joint clinics monthly. Out of the remaining 26 respondents, 21 (81%) thought that a combined clinic would be useful, whereas 5 (19%) did not think it would be useful. Of the 28 dermatology respondents who provided details regarding follow-up, all indicated that their patients are followed up in a dermatology clinic, with 6 (21%) also following up patients in multidisciplinary HS clinics, and 1 (4%) also following up patients in an infectious diseases/OPAT clinic. Of the 13 OPAT centres providing details of their clinics, 5 (39%) indicated they held a joint clinic with dermatology. In four cases this was monthly while one centre held a weekly clinic. Of the eight OPAT centres that did not have a joint clinic, six (75%) felt a joint clinic would be useful, whilst two (25%) did not. Ten OPAT respondents provided details regarding follow-up. Patients were followed up in dermatology clinics (80%), in a multidisciplinary clinic (10%) or in the infectious diseases or OPAT clinic (10%).
Perceived efficacy of intravenous antibiotics in the treatment of HS
Twenty-eight dermatologists who have experience of using intravenous antibiotics in HS reported their perception regarding the efficacy of intravenous antibiotics in HS. Most (16/28, 57%) perceived these to be beneficial for most patients, while 9/28 (32%) felt they were only useful for some cases, and one (4%) did not perceive any benefit from intravenous antibiotics. The remaining two respondents stated: ‘helpful for severe infective exacerbation’ and ‘limited experience but not impressed. It can be helpful but doubtful as monotherapy’.
Twenty-four respondents were able to estimate the duration of remission after using intravenous antibiotics. The majority (46%) reported >3 months’ remission, one (4%) reported 2–3 months’ remission, seven (29%) 1–2 months’ remission and two (8%) <1 month remission. Three (13%) reported no remission. Several comments were made by the respondents who highlighted a lack of experience of treating HS with intravenous antibiotics, limiting estimates of efficacy. Additionally, several respondents suggested that benefit was limited unless used alongside other therapies, such as adalimumab.
Service capacity
Of the 30 respondents in the dermatology survey with experience of intravenous antibiotics, 23 (77%) had treated 1–5 patients with intravenous antibiotics, 3 (10%) had treated 6–10 patients, 2 (7%) had treated 11–20 patients and 2 (7%) had treated more than 20 patients.
Of the 14 OPAT centres using intravenous antibiotics for HS, 9 (64%) had treated 1–5 patients, 3 (21%) had treated 6–10 patients, 1 (7%) had treated 11–20 patients and 1 (7%) had treated 20–30 patients. Thirteen OPAT services reported having capacity to accommodate patients with HS, while one centre did not have capacity. Of those with capacity, nine (69%) indicated they could accommodate 1–10 patients at a time, of which two highlighted they could only accommodate either ‘1–2’ or ‘a few’ patients with HS at any one time. Three services reported that they could accommodate 11–20 (23%) and one could accommodate 21–30 patients (8%) at a time. No centre indicated being able treat more than 30 patients with HS at a time.
Barriers to intravenous antibiotics
In the dermatology survey, the 42 respondents who had never treated patients with HS with intravenous antibiotics cited various reasons for not having done so. The most common barrier being a lack of experience and/or it not being part of the treatment pathway they use (Table 4). In the free text box, some respondents highlighted further concerns around the risk of long-term line complications, AMR, lack of support from microbiology colleagues and the logistical aspects of intravenous antibiotics.
Table 4.
Barrier to using intravenous antibiotics by dermatology clinicians
| Frequency, n = 42 [n (%)]a,b | |
|---|---|
| Intravenous antibiotics are not part of the local/national treatment algorithm that I follow | 29 (67) |
| No experience of treating patients with HS with intravenous antibiotics | 28 (65) |
| Was not aware of this treatment approach | 16 (37) |
| No patients with HS requiring intravenous antibiotics | 10 (23) |
| No local facilities or service to accommodate the administration of intravenous antibiotics | 8 (19) |
| Resistance/disapproval from the Trust’s pharmacy/microbiology department | 7 (16) |
| Good response to other treatments | 6 (14) |
| Patient’s choice | 1 (2) |
| Other, specified below (grouped from free text box): | 2 (5) |
|
|
|
HS, hidradenitis suppurative. aRespondent could select more than one answer. bOne free text response excluded as respondent did not answer the question.
Free text comments also revealed that many dermatologists expressed keen interest in the results of this survey as there was a lack of awareness of using intravenous antibiotics in HS, and wanting to understand the nationwide approach towards the treatment of HS with intravenous antibiotics. There was a desire for intravenous antibiotics to be included in the national guidelines, in order to obtain support and approval for the use of this treatment from local microbiologists. A further breakdown of responses according to professional group is provided in Table S2 (see Supporting Information).
Discussion
To the best of our knowledge, this is the first UK-based evaluation of practice concerning the use of intravenous antibiotics for the treatment of HS. Our results show nearly half of our respondents reported using intravenous antibiotics for their patients, despite the lack of inclusion in national guidelines. There is evidence of multidisciplinary working between dermatology and infection services (OPAT and microbiology) in order to provide care for this complex group of patients. Our survey, however, has highlighted that there remains scope for more formalized collaboration, such as through multidisciplinary teams and joint clinics that appear currently to be in a fledgling form. Concerns were raised by some respondents that there is a need for more robust research into the efficacy of intravenous antibiotics in HS, and how this treatment modality interlinks with other interventions including biologics, surgery and follow-on oral antibiotics.
There is experience of, and support for, the use of intravenous antibiotics such as ertapenem in the treatment of severe HS. It was being used as bridging therapy prior to surgery, as supported by the North American guidelines,18 and prior to the initiation of biologics. Ertapenem is administered once daily, allowing for the flexibility and convenience of outpatient administration. The OPAT service network across the UK is well developed, with national best practice recommendations produced by the British Society for Antimicrobial Chemotherapy.19 This includes monitoring for adverse effects of treatment, care of vascular access devices and monitoring of patient outcomes. Provision of training for self- or carer-administered intravenous antibiotics is increasingly being utilized,20 providing additional convenience for the patient and their family. The involvement of OPAT services may allay some of the concerns raised by some of our dermatology respondents in relation to the logistical difficulties of arranging intravenous treatment. For instance, once intravenous ertapenem treatment has been agreed upon, the local OPAT team in Leicester will (i) arrange insertion of long-term vascular access such as a peripherally inserted central catheter (PICC) line, (ii) handle outpatient prescription and supply of intravenous antibiotics, (iii) conduct relevant training with the patient for those who are self-administering at home and (iv) arrange relevant follow-up to ensure regular clinical review during treatment duration.
The majority of our respondents perceived a benefit from intravenous antibiotics for patients with HS but remission was achieved for <2 months. A number of respondents perceived that benefit was only achieved when intravenous antibiotics were given alongside conventional therapies, or with quick follow-on interventions. This is supported by a French study, which demonstrated that a 6-week course of intravenous ertapenem with follow-on treatments greatly improved severe HS, as indicated by a significant drop in the median Sartorius score.13 A team at the Henry Ford Hospital conducted a retrospective telephone interview and chart review with patients with severe HS who had received intravenous ertapenem, and found that intravenous ertapenem was successful in improving the severity of HS and quality of life in 97% and 86% patients, respectively, alongside positive patient satisfaction.21
Intravenous antibiotics are not recommended within the BAD guidelines for HS due to insufficient evidence for their success. Conversely, for Hurley Stage III HS the French Society of Dermatology recommends a 15- to 21-day course of parenteral ceftriaxone with enteral metronidazole (or enteral levofloxacin and clindamycin second-line) under specialist multidisciplinary care.22 Meanwhile, the North American HS guidelines18 recommend that intravenous ertapenem may have a place as a one-time rescue therapy or as a bridge to surgery or other maintenance in those with non-responsive Hurley Stage III HS. Although the recommendations made in these guidelines are expert opinion, extrapolated from relatively small retrospective studies,23 prospective studies published since then have demonstrated significant improvements in clinical signs and symptoms, and reduced inflammatory markers, on intravenous ertapenem.14,22–25 Since our data collection, the North American clinical practice guidelines in HS medical management recommends the use of intravenous ertapenem in certain HS special patient populations.18 The updated European S2k HS guidelines 2024 also achieved a consensus where ertapenem may be considered to reduce inflammation and drainage in severe HS.26
Ertapenem is a potent broad-spectrum beta-lactam antibiotic given intravenously.14,26 Join-Lambert et al. reported that the bactericidal properties of ertapenem promote inflammation as opposed to other postulated immunomodulating properties of other systemic antibiotics. The authors later described how low carbapenem resistance in the community may have explained the efficacy of ertapenem in treating HS and proposed that the immunity dysregulation is partially driven by infection.14
Since intravenous antibiotics are not part of the UK national HS treatment guidelines,8 and the pathophysiology of HS is still not fully understood, their use in this condition is best regarded as off-license. The risk of AMR was raised in some free text comments in the survey, as a barrier to using intravenous antibiotics for this condition. AMR is on the UK Government’s National Risk Register,27 with the World Health Organization having also declared AMR as one of the top 10 global public health threats. The use of intravenous antibiotics in the treatment of HS thus needs to be carefully considered since the paucity of clinical experience and data for the use of this treatment in HS might further complicate efforts to tackle AMR. A multidisciplinary approach, such as joint clinics between dermatology and infection services, can help ensure that antibiotic treatment is carefully considered for individual patients, which would uphold the principles of antimicrobial stewardship and embed good clinical governance. Additional benefits of joint clinics are that the clinical response can be carefully monitored and that treatment pathways can be coordinated and individualized. A best practice statement or national referral pathway should be produced to give direction to dermatologists and other clinicians treating patients with HS, including clinical criteria for the use of intravenous antibiotics, governance issues, and collaborative working with OPAT or other clinical infection services. Equity of OPAT service provision across different geographical areas needs to be considered although there is a national drive to expand availability across the National Health Service.28
In our survey findings, there is a perceived role for intravenous antibiotics, especially ertapenem, in the treatment of HS. There is keen interest amongst the respondents who expressed willingness to attempt this treatment approach. However, further research and clinical trials are warranted regarding the use of intravenous antibiotics, including the comparison of ertapenem with other intravenous antibiotics and conventional therapies.
Our survey has several limitations that need to be considered. Firstly, while our survey captured responses from a large number of dermatology specialist clinicians, and captured data from most OPAT centres invited (of OPAT services registered in 2018), this now represents fewer than one-quarter of OPAT services registered in 202515,29 which could limit the generalizability of our results. Secondly, as with all surveys, ours could also have been impacted by recall bias, which could impact on the reliability of the number of patients treated and the perceived benefit of intravenous antibiotics in HS. Additionally, our survey did not explore the medium- and long-term sequalae from intravenous antibiotic use. This calls for more formal service evaluations, audits and research to be undertaken. Finally, the 5-year timeframe between data collection and reporting must also be highlighted. The delay in publishing this data was primarily due to the trainee leading the evaluation regularly relocating between hospitals due to specialty training requirements. In addition, the involvement of multiple authors resulted in inconsistent communication. However, this delay has enabled us to incorporate the recently published European and North American HS guidelines in our article. This inclusion highlights the importance of our work and to our best knowledge, the first ever data on HS clinical practice across the UK. The OPAT services and dermatology clinicians reporting use of intravenous antibiotics will likely have gained more experience across more patients, and it is possible that more clinicians have starting using intravenous antibiotics in HS. However, no new clinical evidence has emerged to support its use, so our results and recommendations should still be considered when developing HS management guidelines and services.
Supplementary Material
Acknowledgements
Data from the dermatologists’ survey were presented as a poster presentation in the British Association of Dermatologists Annual Meeting 2021
Contributor Information
Mun Wai Lam, Department of Dermatology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester, UK; Department of Dermatology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
Ryan A Hamilton, School of Pharmacy, De Montfort University, Leicester, UK.
Helena A White, Department of Infectious Diseases, University Hospitals of Leicester NHS Trust, Leicester, UK.
Karen E Harman, Department of Dermatology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, Leicester, UK.
Author contributions
Mun Wai Lam (Conceptualization [equal], Data curation [lead], Formal analysis [lead], Investigation [equal], Methodology [equal], Project administration [lead], Resources [equal], Software [lead], Validation [equal], Visualization [equal], Writing—original draft [equal], Writing—review & editing [equal]), Ryan Hamilton (Formal analysis [equal], Investigation [equal], Methodology [equal], Resources [equal], Supervision [equal], Writing—original draft [equal], Writing—review & editing [equal]), Karen Harman (Conceptualization [equal], Formal analysis [equal], Investigation [equal], Methodology [equal], Project administration [equal], Resources [equal], Supervision [equal], Writing—original draft [equal], Writing—review & editing [equal]), and Helena White (Conceptualization [equal], Formal analysis [equal], Investigation [equal], Methodology [equal], Project administration [equal], Resources [equal], Supervision [equal], Visualization [equal], Writing—original draft [equal], Writing—review & editing [equal])
Conflicts of interest
None to declare.
Funding sources
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
All data are incorporated into the article and its online Supplementary material.
Supporting Information
Additional Supporting Information may be found in the online version of this article at the publisher’s website.
Ethics statement
Not required as this is an evaluation of current clinical practice across the UK.
Patient consent
Written patient consent for publication was obtained.
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