Dear Editor,
Hidradenitis suppurativa (HS) research has been increasing over the past decade (1), but pediatric HS data remains limited. Herein, we describe disease presentations and treatment responses in a pediatric HS cohort.
An electronic health record search was conducted in April 2020 for HS patients 25 years or younger within the University of California Los Angeles health system using ICD-9/10 codes for HS. Inclusion criteria was diagnosis before 18 years old. Demographics, disease presentation, and treatments tried prior to 18 years old were extracted via chart review.
Differences in disease characteristics and treatment responses were assessed using Chi-square test for categorical variables and t-test for continuous variables. Chi-square test analyzed differences in treatments received based on whether patients saw a dermatologist. p-Values ≤.05 were considered statistically significant. Analyses were performed using IBM SPSS V27 (IBM Inc., Armonk, NY, USA).
There were 73 patients in this study (Table 1). Axillary involvement disproportionately affected males (92.9 versus 62.7%, p = .029). Females had higher groin (59.3 versus 28.6%, p = .038) involvement as well as a trend toward higher genital or buttock (20.3 versus 0%, p = .065) involvement. Females trended toward having a younger age of symptom onset (12.3 versus 13.9, p = .063), and higher likelihood of HS treatment (93.2 versus 78.6%, p = .094). Nonwhite patients trended toward disproportionately presenting with Hurley-2/3 disease (44.1 versus 21.1%, p = .093).
Table 1.
Patient demographics.
| Demographics (N = 73) | n (%) |
|---|---|
| Gender (n = 73) | |
| Female | 59 (80.8%) |
| Male | 14 (19.2%) |
| Race/Ethnicity (n = 53) | |
| White | 19 (35.8%) |
| Hispanic | 15 (28.3%) |
| Black | 10 (18.9%) |
| Asian | 3 (5.7%) |
| Bi-racial | 2 (3.8%) |
| Other | 4 (7.5%) |
| Age at symptom onset, year (mean ± SD, range) (n = 64) | 12.6 ± 2.9, 6–17 |
| Pre-teen (age 0–12 year) onset | 31 (42.5%) |
| Age at diagnosis, year (mean ± SD, range) (n = 68) | 14.3 ± 2.6, 7–17 |
| Age at presentation, year (mean ± SD, range) (n = 73)a | 14.5 ± 2.5, 7–17 |
| Family history of HS (n = 29) | |
| Yes | 14 (48.3%) |
| No | 15 (51.7%) |
| BMI (mean ± SD, range) (n = 47)a | 28.6 ± 7.4, 15.7–48.5 |
| BMI percentile (mean ± SD, range) (n = 42)a | 81.8 ± 22.8, 20.5–99.5 |
| Smoking status (n = 73)a | |
| Current smoker | 1 (1.4%) |
| Never smoker | 51 (69.9%) |
| Unknown | 21 (28.8%) |
| Hurley Stage I/II/IIIb | 44 (60.2%)/28 (38.4%)/1 (1.4%) |
| Received treatment for pediatric HS (n = 73) | 66 (90.4%) |
| Demographics (N = 73) | n (%) | ||
|---|---|---|---|
| Location of HS | Total (n = 73) | Female (n = 59) | Male (n = 14) |
| Axilla | 50 (68.5%) | 37 (62.7%) | 13 (92.9%) |
| Groin/pubic region | 39 (53.4%) | 35 (59.3%) | 4 (28.6%) |
| Thighs | 15 (20.5%) | 13 (22.0%) | 2 (14.3%) |
| Buttocks | 12 (16.4%) | 12 (20.3%) | – |
| Genital region | 12 (16.4%) | 12 (20.3%) | – |
| Breast/inframammary | 4 (5.5%) | 4 (6.8%) | – |
| Abdomen/panniculus | 3 (4.1%) | 2 (3.4%) | 1 (7.1%) |
| First area of HS involvement | |||
| Axilla | 34 (46.6%) | 24 (40.7%) | 10 (71.4%) |
| Groin/pubic region | 22 (30.1%) | 19 (32.2%) | 3 (21.4%) |
| Genital region | 4 (5.5%) | 4 (6.8%) | – |
| Thighs | 4 (5.5%) | 4 (6.8%) | – |
| Buttocks | 3 (4.1%) | 3 (5.1%) | – |
| Unknown | 6 (8.2%) | 5 (8.5%) | 1 (7.2%) |
HS: hidradenitis suppurativa.
At time of first hidradenitis suppurativa-related visit at our institution.
If Hurley stage was not documented in the chart, a board-certified dermatologist (JLH) assigned a Hurley stage based on the documented physical exam.
The majority (90.4%) received treatment for HS. The most common treatments were topical clindamycin (61.6%), doxycycline (35.6%), and benzoyl peroxide wash (31.5%) (Table 2). Treatment response did not significantly differ by gender, race, BMI, or HS severity. Patients seen by dermatologists were more likely to receive HS treatment (100 versus 73.1%, p < .001), including antiseptic wash (74.5 versus 11.5%, p < .001), topical antibiotics (78.7 versus 42.3%, p = .002), combination oral antibiotics (17 versus 0%, p = .026), zinc (14.9 versus 0%, p = .038), and procedural interventions (38.3 versus 0%, p < .001).
Table 2.
Hidradenitis suppurativa treatments and response to treatment.
| Treatment namea | Response, n (%)b | No response, n (%)b |
|---|---|---|
| Topical antibiotic | 18/22 (81.8%) | 4/22 (18.1%) |
| Clindamycin (n = 45) | 17 (89.5%) | 2 (10.5%) |
| Mupirocin (n = 7) | 1 (33.3%) | 2 (66.7%) |
| Antiseptic wash | 11/15 (73.3%) | 4/15 (26.7%) |
| Chlorhexidine wash (n = 20) | 4 (80%) | 1 (20%) |
| Benzoyl peroxide wash (n = 23) | 7 (70%) | 3 (30%) |
| Other topical | 1/1 (100%) | |
| Topical resorcinol (n = 1) | 1 (100%) | – |
| Single oral antibiotic | 19/25 (76.0%) | 6/25 (24.0%) |
| Cephalexin (n = 12) | 2 (33.3%) | 4 (66.7%) |
| Trimethoprim/sulfamethoxazole (n = 8) | 3 (75%) | 1 (25%) |
| Clindamycin (n = 4) | 1 (100%) | – |
| Doxycycline (n = 26) | 10 (90.9%) | 1 (9.1%) |
| Minocycline (n = 6) | 3 (100%) | – |
| Combination oral antibiotics | 7/9 (77.8%) | 2/9 (22.2%) |
| Cephalexin and trimethoprim/sulfamethoxazole (n = 7) | 4 (80%) | 1 (20%) |
| Rifampin and clindamycin (n = 3) | 2 (66.7%) | 1 (33.3%) |
| Cephalexin and ciprofloxacin (n = 1) | 1 (100%) | – |
| Intravenous antibiotic | 4/5 (80%) | 1/5 (20%) |
| Ertapenem (n = 1) | 1 (100%) | – |
| Ceftriaxone (n = 1) | 1 (100%) | – |
| Vancomycin (n = 1) | 1 (100%) | – |
| Piperacillin/tazobactam (n = 1) | 1 (100%) | – |
| Ampicillin/sulbactam (n = 1) | – | 1 (100%) |
| Biologic | 1/3 (33.3%) | 2/3 (66.7%) |
| Ustekinumab (n = 1) | 1 (100%) | - |
| Golimumab (n = 1) | – | 1 (100%) |
| Infliximab (n = 1) | – | 1 (100%) |
| Hormonal treatment | 5/5 (100%) | |
| Oral contraceptive pill (n = 12) | 4 (100%) | – |
| Finasteride (n = 1) | 1 (100%) | – |
| Systemic retinoid | 1/1 (100%) | |
| Isotretinoin (n = 1) | 1 (100%) | – |
| Micronutrient supplement | 2/2 (100%) | |
| Zinc (n = 7) | 2 (100%) | – |
| Procedure | 18/20 (90%) | 2/20 (10%) |
| Incision and drainage (n = 6) | 5 (83.3%) | 1 (16.7%) |
| Laser hair removal (n = 3) | 1 (100%) | – |
| Intralesional corticosteroid (n = 11) | 9 (100%) | – |
| Surgical excision (n = 6) | 3 (75%) | 1 (25%) |
Other treatments tried without response data: dapsone (n = 1), erythromycin (n = 1), bacitracin (n = 1), bleach baths (n = 4), topical retinoid (n = 2), fluocinonide (n = 1), ciprofloxacin and linezolid (n = 1), spironolactone (n = 2).
Response rates calculated out of total patients for whom a treatment response was recorded.
The female predominance (4:1) and differing areas of involvement between genders corroborate previous pediatric HS cohort studies (2–4). Over 40% of patients had pre-teen symptom onset, highlighting the importance of increasing HS awareness among our pediatrician colleagues. Knowledge of potential gender-related differences in manifestation of HS disease can guide clinicians to screen high-yield anatomic regions when suspecting HS. Given the disproportionate number of minority patients affected by HS (5), and the higher proportion of nonwhite patients presenting with Hurley-2/3 disease in our cohort, physicians need to be vigilant in improving early diagnosis. Patients seen by dermatologists were more likely to receive treatment, highlighting benefits of early dermatologist involvement (6,7).
In exploring real-world pediatric HS treatment, antiseptic washes and topical and oral antibiotics were most frequently prescribed. Biologics were infrequently used, but this may change as adalimumab is now FDA and EMA-approved for HS treatment in patients ≥12 years. Further investigation is needed to determine safe, effective treatments for pediatric HS. Study limitations include its single-center retrospective design and lack of complete treatment response documentation.
Pediatric HS may have varied disease presentations based on gender and race. Large prospective studies are needed to further characterize disease subsets and treatment responses in pediatric HS.
Funding
Statistical analyses for this research was supported by NIH National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant no. UL1TR001881.
Footnotes
Disclosure statement
J. L. H. is on the Board of Directors for the Hidradenitis Suppurativa Foundation and has served as an advisor for Novartis and a speaker for AbbVie. V. Y. S. is on the Board of the Directors for the Hidradenitis Suppurativa Foundation, and has served as an advisor, investigator and/or speaker for Sanofi Genzyme, Regeneron, AbbVie, Burt’s Bees, Dermira, Eli Lilly, Novartis, Pfizer, Galderma, Leo Pharma, SUN Pharma, Menlo Therapeutics, GpSkin, and Skin Actives Scientific. M. H. is an investigator for Amgen and Celgene. J. R. S., E. K. C., T. G., and T. S. report no conflicts of interest. There was no financial transaction for the preparation of this manuscript. No potential conflict of interest was reported by the author(s).
IRB approved
Reviewed and approved by UCLA IRB (#17-001267).
Contributor Information
Justine Seivright, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
Erin Collier, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
Tristan Grogan, Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
Terri Shih, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
Marcia Hogeling, Department of Medicine, Division of Dermatology, University of California Los Angeles, Los Angeles, CA, USA.
Vivian Y. Shi, Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
Jennifer L. Hsiao, Department of Medicine, Division of Dermatology, University of California Los Angeles, Los Angeles, CA, USA
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