A retrospective review of the management of patients with hidradenitis suppurativa in the Belfast health and social care trust, Northern Ireland

Sir,
Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterised by recurrent abscesses and nodules developing into sinuses.  Healing of affected areas is associated with scarring and contractures in severe cases.  HS is considered a disease on the same spectrum as acne vulgaris, hence the synonym acne inversa as it affects the apocrine sweat glands in the axillae, vulva, groin or anal area.  It can be debilitating and psychologically distressing, greatly impacting on quality of life.  There are five ways to assess the extent and severity of HS1.  These include: Hurley stages, of which three exist depending on the presence of abscesses/ interconnecting sinus tracts and the number of areas affected; the Sartorius HS Score is made my counting involved regions, nodules and sinus tracts; a six-point Physician Global Assessment which ranges from clear to very severe; the HS clinical response which is defined as ≥50% reduction in inflammatory lesion count (abscesses/inflammatory nodules), and no increase in abscesses or draining fistulas when compared with baseline and Dermatology Life Quality Index (DLQI) which is useful in considering the effect on patient’s quality of life.  The European guidelines for the management of HS were recently published2

This review was designed to assess current management in Belfast health and social care trust in Northern Ireland.  A retrospective review of both paper and electronic charts was performed on 33 patients including five on biological therapy over one year.  Hospital numbers were retrieved from the coding department in the Royal Victoria Hospital.  Seventy-five percent of patients were female with disease duration ranging from <1 to >20 years.  Co-morbidities included; obesity (45%), Crohn’s disease (15%) and diabetes (3%).  Eighty percent received weight reduction advice, 48% smoking cessation advice and 39% received British Association of Dermatologist’s (BAD) patient information leaflet on HS.  Sixty-one percenthad at least one cardiovascular risk factor.  The most common site of involvement was the axilla (70%), groin (61%) and submammary regions (15%).  Only two patients had Hurley stage documented.  Tetracyclines were used as first line in 60% of cases whilst Rifampicin/Clindamycin combination used as second line in 21%.  Thirteen percent received oral retinoids, a better response was noted with 6-9 month duration of treatment.  Twenty percent of patients received dapsone and one patient required cyclosporin 3mg/kg, both with good response.  Five patients (15%) required treatment with anti-TNFα agents: in three cases another agent was required (doxycycline, acitretin, methotrexate).  All had a DLQI > 10 and Hurley stage three disease. 

Our management parallels the findings of a survey performed on UK dermatologists’ management of HS published in 20153.  Improvement in documentation of severity assessment, DLQI, weight reduction/smoking cessation advice, as well as providing information leaflets is needed.  Association with cardiovascular disease is recognised in HS and as such a risk assessment for modifiable cardiovascular risk factors should be undertaken in all patients.  A checklist has been designed to improve future documentation.  Up to date guidelines from the BAD on the management of HS are awaited.

W Abdelrahman1, R Dawson1, C McCourt1
1Department of Dermatology, Belfast City Hospital, Northern Ireland BT9 7AB

Corresponding author
Dr Wedad Abdelrahman, Royal Victoria Hospital, Belfast, Northern Ireland, BT12 6BA
Email: wedadabdelrahman@doctors.org.uk
Phone: 00447927532773

References
1. Revuz J. Clinical evaluation of the severity of hidradenitis suppurativa. Ann Dermatol Venereol 2015 Dec;142:729-35.
2. Zouboulis CC, Desai N, Emtestam L, Hunger RE, Ioannides D, Juhasz I, Lapins J, Matusiak L, Prens EP, Revuz J, Schneider-Burrus S, Szepietowski JC, van der Zee HH, Jemec GBE. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. JEADV 2015, 29, 619–644.
3. Ingram R, McPhee M. Management of Hidradenitis suppurativa: a U.K. survey of current practice. Br J Dermatol 2015 Oct;173:1070-2.

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