Abstract
This cross-sectional survey characterizes the knowledge, attitudes, and practices of international experts in the management of pain in patients with hidradenitis suppurativa.
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that may cause recurrent scarring abscesses and tunnels and may lead to worse quality of life and greater pain than most dermatologic diseases.1 Patients rate HS pain as the most important symptom,2 yet its mechanism is unknown. Approved biologics only modestly decrease HS pain, and most patients live with moderate or worse pain.3 Although international guidelines recommend measuring HS pain,4 therapeutic recommendations are sparse.5 Because expert approaches to HS pain remain poorly described, this study aimed to characterize specialists’ knowledge, attitudes, and practices.
Methods
A survey was developed through structured interviews with experts in HS, pain management, and survey methods (eAppendix in the Supplement).6 This anonymous electronic survey was distributed by 4 HS expert listservs (see Additional Contributions) from July to August 2020. Eligible respondents were board-certified dermatologists with 1 or more HS visit in the past 6 months. The institutional review board at Emory University in Atlanta, Georgia, approved this study and waived the requirement for obtaining informed patient consent under exception 45 CFR 46.104(d)(2) for educational tests, surveys, interviews, or observation or public behavior. No one received compensation or was offered any incentive for participating in this study.
Stratified analyses by respondent continent were performed to compare pain measurement practices and psychological treatments. Two-sided χ2 and Fisher exact tests were conducted, with α ≤ .05 considered statistically significant.
Results
Of 253 HS listserv members surveyed, 58 responses were received (response rate, 22.9%). Eight respondents were excluded for clinical inactivity (n = 1) or lack of board certification (n = 7). Fifty eligible responses were received from 15 countries and 4 continents. In total, 47 self-identified as HS experts, 32 had HS specialty clinics, and 23 were current or former HS foundation board members.
Table 1 provides HS pain attitudes and practices. All 20 respondents from Australia or Europe reported measuring HS pain in the clinic, whereas only 16 of 25 in North America and 2 of 5 in Asia did so (P = .004). Table 2 provides medications recommended for the treatment of HS pain.
Table 1. Attitudes and Practices of 50 Physicians.
| Measure | No. (%) of respondents |
|---|---|
| Attitude | |
| Pain impacts quality of life in HS | |
| Strongly agree | 45 (90) |
| Agree | 5 (10) |
| Neutral | 0 |
| Disagree | 0 |
| Strongly disagree | 0 |
| HS pain needs treatment beyond disease-directed therapy | |
| Strongly agree | 22 (44) |
| Agree | 21 (42) |
| Neutral | 5 (10) |
| Disagree | 2 (4) |
| Strongly disagree | 0 |
| Current HS pain guidelines are sufficient | |
| Strongly agree | 3 (6) |
| Agree | 6 (12) |
| Neutral | 12 (24) |
| Disagree | 22 (44) |
| Strongly disagree | 7 (14) |
| Dermatologists should ask patients with HS about pain | |
| Strongly agree | 37 (74) |
| Agree | 12 (24) |
| Neutral | 1 (2) |
| Disagree | 0 |
| Strongly disagree | 0 |
| Specialties considered important in managing HS pain | |
| Pain specialist | 44 (88) |
| Dermatologist | 38 (76) |
| Primary care physician | 27 (54) |
| Psychologist | 22 (44) |
| Psychiatrist | 19 (38) |
| Patients with chronic HS pain benefit from consulting nondermatologists | |
| Strongly agree | 19 (38) |
| Agree | 20 (40) |
| Neutral | 8 (16) |
| Disagree | 2 (4) |
| Strongly disagree | 1 (2) |
| Practice | |
| Pain assessment tool used in routine clinical practice | |
| Numeric rating scale | 29 (58) |
| Visual analog scale | 17 (34) |
| FACES Pain Rating Scale | 1 (2) |
| McGill Pain Questionnaire | 1 (2) |
| Brief Pain Inventory | 0 |
| None | 12 (24) |
| Most common nonpharmacologic pain management recommendations | |
| Tobacco cessation | 42 (84) |
| Wound care | 41 (82) |
| Incision and drainage | 39 (78) |
| Weight loss | 38 (76) |
| Wardrobe | 37 (74) |
| Most frequently physician-cited barriers to managing HS pain | |
| Lack of knowledge or experience in prescribing pain medications | 31 (62) |
| Concern about habit-forming potential of medications | 31 (62) |
| Concerns about medication adverse effects | 29 (58) |
| Lack of knowledge about nonpharmacologic pain management | 23 (46) |
| HS guidelines do not provide adequate guidance | 17 (34) |
Abbreviation: HS, hidradenitis suppurativa.
Table 2. Respondent Comfort With Prescribing Pharmacologic Analgesia for Acute or Chronic Hidradenitis Suppurativa Pain.
| Medication | No. (%) of prescribing respondents (N = 50) | |
|---|---|---|
| Acute pain | Chronic pain | |
| Acetaminophen | 42 (84) | 43 (86) |
| OTC NSAID | 41 (82) | 37 (74) |
| Gabapentin | 6 (12) | 37 (74) |
| Prescription NSAID | 33 (66) | 34 (68) |
| Pregabalin | 6 (12) | 31 (62) |
| Tricyclic antidepressant | 6 (12) | 25 (50) |
| Topical analgesic | 26 (52) | 24 (48) |
| SNRI | 3 (6) | 20 (40) |
| Intralesional triamcinolone | 42 (84) | 14 (28) |
| Opioid (short course) | 18 (36) | 8 (16) |
| Naltrexone (low dose) | 2 (4) | 7 (14) |
| Cannabinoid | 5 (10) | 6 (12) |
| Curcumin | 2 (4) | 6 (12) |
| Opioid (chronic course) | 2 (4) | 2 (4) |
| α-Lipoic acid | 2 (4) | 2 (4) |
Abbreviations: NSAID, nonsteroidal anti-inflammatory drug; OTC, over the counter; SNRI, serotonin-norepinephrine reuptake inhibitor.
On knowledge assessment, 31 of 50 dermatologists correctly answered that cognitive behavioral therapy and antidepressants are effective for treating chronic pain. Only 26 of 50 believed that psychiatrists or psychologists are important in HS pain management, and psychology or psychiatry referrals were low (27 of 50).
Discussion
This cross-sectional survey characterizes variation among international experts’ knowledge, attitudes, and practices regarding HS pain management. There was strong agreement that HS pain is associated with worse quality of life and that current management guidelines are insufficient. Although most experts agreed that dermatologists have an important role to play in managing HS pain, many cited lack of knowledge as a barrier and felt that patients with HS and chronic pain benefit from seeing other specialists.
Clinicians in North America and Asia were less likely to measure HS pain. The reason is unknown but may reflect regional differences in training or in collecting patient-reported outcomes. This study highlights the low level of knowledge and use of psychological treatments for chronic HS pain. Mental health and HS pain severity are strongly associated.1 Wider incorporation of psychological therapies may represent an important opportunity for reducing chronic HS pain.
Limitations
The survey is limited by its response rate, its inability to characterize nonresponders, and its inability to determine overlap among listserv memberships. Although intralesional triamcinolone is also a therapy for HS, it was included in this survey because of its role in reducing acute inflammation and reducing pain during flare-ups.
Conclusions
In conclusion, most patients with HS consider pain to be their most important symptom, but research to elucidate HS pain mechanisms and treatment strategies remains a critical unmet need. Because dermatologists understand the disease process and its association with the quality of life, they play a crucial role in coordinating HS pain management, either independently or with a multidisciplinary team. Even among HS specialists, knowledge gaps presented a common barrier to managing HS pain. Educating general dermatologists and specialists about pain management may empower them to better address skin pain and its association with the quality of life.
eAppendix. Physician Characteristics
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Associated Data
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Supplementary Materials
eAppendix. Physician Characteristics
