Abstract
This repeated cross-sectional study compares pain severity and rates of prescriptions for opioids in emergency department visits for hidradenitis suppurative with those in visits for atopic dermatitis or psoriasis.
Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition with acutely painful flares. Emergency department (ED) visits are common among patients with HS.1 In addition, HS is poorly recognized and the diagnosis is often delayed by an average of 10 years.2 Prescribing of both opioids and antibiotics is common at ambulatory encounters for HS3; however, little is known about prescribing patterns and management of HS at ED visits. The goal of this study was to assess pain severity, opioid use, and other treatment use among patients with HS in the ED setting.
Methods
In this repeated cross-sectional study, we analyzed data from January 1, 2006, through December 31, 2017, from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of visits to EDs in the United States, to evaluate pain severity and opioid, antibiotic, and incision and drainage use associated with ED visits for HS. We identified encounters for HS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 705.83 and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code L73.2. Among HS encounters, we calculated mean (95% CI) pain scores and estimated opioid and antibiotic prescribing as well as incision and drainage procedures.
For comparison, we also analyzed pain severity and rates of opioid prescribing at visits for patients with primary diagnoses of atopic dermatitis or psoriasis, 2 other chronic inflammatory skin conditions. Similarly, we compared these encounters with visits primarily for low back pain as well as all other ED visits, matched to HS visits on age, sex, race/ethnicity, and year.
Statistical analyses were conducted using Stata 16 (StataCorp LLC) and accounted for the complex survey design. Because this study used publicly available, deidentified data, it was deemed exempt by the institutional review board at the University of Pennsylvania. The study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.
Results
During the study period there were an estimated 383 000 ED visits for HS; such visits increased from 25 260 in 2006 to 131 430 in 2017. Of the total visits, 3.8% (95% CI, 1.3-10.2) resulted in inpatient admission. The majority of HS visits were for women (82.8%), young adults aged 18 to 35 years (74.6%), and patients of Black, non-Hispanic race/ethnicity (49.9%) (Table).
Table. Weighted Percentages of Visits (With 95% CI) by Demographics, Pain Severity, Opioid Prescribing at Discharge, and Concomitant Skin and Soft-Tissue Infection Diagnoses.
| Characteristic | Hidradenitis suppurativa (n = 383 000) | Atopic dermatitis and psoriasis (n = 505 400)a | Low back pain (n = 9 920 800)b | All other visits (n = 31 000 000)c |
|---|---|---|---|---|
| Age, mean, y | 29.3 (26.8-31.7) | 26.8 (21.6-32.0) | 43.2 (42.2-44.1) | 29.7 (29.2-30.1) |
| Females | 82.8 (71.0-90.5) | 55.2 (44.2-65.7) | 62.1 (59.5-64.6) | 79.2 (77.5-80.9) |
| Race/ethnicity | ||||
| White, non-Hispanic | 40.8 (23.5-60.7) | 30.3 (21.3-41.2) | 59.9 (56.0-63.7) | 53.5 (49.8-57.2) |
| Black, non-Hispanic | 49.9 (31.7-68.0) | 33.6 (23.1-46.1) | 24.4 (20.5-28.8) | 42.3 (38.4-46.3) |
| Hispanic | 9.1 (3.8-20.2) | 25.7 (16.3-38.0) | 13.2 (10.7-16.1) | 4.2 (3.4-5.2) |
| Other | 0.2 (0.0-2.0) | 10.4 (5.2-19.7) | 2.5 (1.8-3.6) | 0.0 (0.0-0.1) |
| Pain severity (score)d | ||||
| None | 11.5 (4.8-25.0) | 56.2 (42.9-68.6) | 2.2 (1.5-3.3) | 17.2 (15.4-19.1) |
| Mild (1-3) | 4.0 (1.1-13.1) | 10.9 (5.5-20.5) | 5.1 (3.8-6.6) | 9.6 (8.1-11.3) |
| Moderate (4-6) | 14.6 (6.1-31.1) | 19.0 (11.1-30.7) | 22.1 (19.3-25.2) | 24.4 (22.3-26.6) |
| Severe (7-10) | 69.9 (52.2-83.2) | 13.9 (6.6-26.8) | 70.6 (67.2-73.9) | 48.8 (46.3-51.4) |
| Mean pain scoree | 7.4 (6.3-8.5) | 2.4 (1.4-3.4) | 7.8 (7.6-8.0) | 5.9 (5.7-6.1) |
| Opioid prescriptions at discharge | 58.3 (41.0-73.8) | 4.0 (1.5-10.2) | 38.4 (35.0-41.8) | 19.9 (18.0-21.9) |
| Concomitant skin and soft-tissue infectionf | 20.8 (11.2-35.3) | 8.1 (3.8-16.4) | 0.7 (0.4-1.3) | 3.1 (2.4-4.0) |
Diagnoses included International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 691.8 (other atopic dermatitis and related conditions) and 696.1 (other psoriasis) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes L20.9 (atopic dermatitis, unspecified), L40.0 (psoriasis vulgaris), and L40.9 (psoriasis, unspecified).
Low back pain was defined on the basis of the primary reason for the visit. Visits associated with injury and trauma were excluded. A sensitivity analysis using primary diagnoses for low back pain (ICD-9-CM code 724.2 [lumbago] and ICD-10-CM code M54.5 [low back pain]) yielded similar results.
Matched to visits for hidradenitis suppurativa on the basis of age, sex, race/ethnicity, and survey year.
Pain severity was self-reported by patients on a 10-point scale.
Includes only data from 2009 to 2017 because data were available only as categories from 2006 to 2008, before numerical pain scores (0-10) were available from 2009 to 2017.
Diagnoses included ICD-9-CM code 680* (carbuncle and furuncle); 682* (other cellulitis and abscess); and ICD-10-CM codes L02* (cutaneous abscess, furuncle and carbuncle) and L03* (cellulitis and acute lymphangitis).
Information regarding pain severity at presentation was available for 83.8% of HS visits; severe pain was reported at 69.9% of visits, with 40.1% of patients rating pain as 10 on a 10-point pain scale (Table). At discharge, opioids were prescribed for 58.3% (95% CI, 41.0%-73.8%) of patients during these ED visits. Among such visits, hydrocodone was prescribed most commonly (80.3%), followed by oxycodone (11.3%). Comparatively, pain severity and opioid prescribing rates were significantly lower at ED visits for atopic dermatitis and psoriasis (severe pain reported at 13.9% of visits vs 69.9% for HS visits; opioids prescribed at 4.0% of visits vs 58.3% for HS visits), and all other visits (severe pain reported at 48.8% of visits; opioids prescribed at 19.9% of visits). Although pain severity was comparable at visits for low back pain (severe pain reported at 70.6% of visits vs 69.9% for HS visits), the opioid prescribing rate was greater at visits for HS (38.4% vs 58.3%) (Table).
Concomitant diagnoses of cellulitis, abscess, carbuncle, or furuncle were relatively common at visits for HS (20.8% of visits). Oral antibiotics were often prescribed at discharge for HS visits (66.6%; 95% CI, 49.1%-80.5%); clindamycin (38.6%), trimethoprim-sulfamethoxazole (37.2%), and cephalosporins (28.2%) were prescribed most frequently. Incision and drainage was performed at 28.9% of ED visits (95% CI, 15.5%-47.5%). Sensitivity analyses using only visits with a primary diagnosis of HS yielded similar findings.
Discussion
Although ED visits are common among patients with HS, this study is one of the first to analyze pain severity and management of HS in the ED setting. Our findings show that severe pain is common among patients with HS presenting to the ED and opioids are frequently prescribed. These findings raise concern as HS is associated with long-term opioid use4 and substance use disorders,5 although ED opioid prescribing is not necessarily associated with long-term use.
In addition, although tetracycline-class antibiotics are recommended as first-line treatment in evidence-based HS guidelines,6 our results showed that most prescribing in the ED setting was for other antibiotic classes. The other drug classes may be less effective for HS, and such prescriptions could be related to misdiagnosis of HS lesions as skin and soft-tissue infections because many patients had a concomitant diagnosis of abscess or cellulitis.
Potential limitations of our analysis include individual bias in patient-reported pain scores and the lack of information regarding HS severity. Overall, however, such findings are important as the ED is not an optimal setting for HS management given its chronic nature. Improved management of HS and early referral to dermatology specialists may lead to decreased ED visits, better pain management, and reduced opioid prescribing. Such initiatives may prevent adverse health events and improve quality of life among patients with HS.
References
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