Raed Alhusayen

Pharmacologic Interventions for Hidradenitis Suppurativa

AbstractBackground: Hidradenitis suppurativa is a chronic debilitating skin disease that is recalcitrant to treatment. Objective: The aim of this article was to conduct an evidence-based review of pharmacologic interventions for the treatment of hidradenitis suppurativa (HS). Methods: A systematic search of MEDLINE, EMBASE, and the Cochrane database was conducted to identify controlled trials (randomized controlled trials, cohorts, and case-control studies) published in English. The abstracts were examined using predetermined inclusion and exclusion criteria. The identified studies were used to develop the recommendations. Clinically relevant outcomes that were assessed were: clinical remission, patient global assessment, physician global assessment, number of skin lesions, and improvement in Hurley’s stage, or Sartorius score. Results: Overall there was sparse evidence to support the use of any treatment modality. There is fair evidence to support the use of antibacterials in HS and they should be used as first-line therapy (level II-1/grade B). There is fair evidence to support the use of intravenous infliximab in the treatment of advanced HS (Hurley’s stage II and III). Given the high cost of anti-tumor necrosis factor therapy and its adverse-effect profile, intravenous infliximab should be offered to patients with severe disease affecting their daily activities who have failed antibacterial therapy (level I/grade B). There is insufficient evidence to support the use of antiandrogens in HS; consideration could be given to their use in women with mild to moderate disease (Hurley’s stage I and II) who have failed antibacterial therapy and women with an abnormal hormone profile (level II-2/grade I). Conclusions: The existing evidence suggests that antibacterials and anti-tumor necrosis factor therapy are effective in the treatment of HS. Further research is required to confirm the efficacy of the different medications within these groups and to explore the efficacy of other treatment modalities.

Risk of Malignancy in Dermatomyositis and Polymyositis: A Systematic Review and Meta-Analysis

Background: There is variation in the risk of malignancy in dermatomyositis (DM) and polymyositis (PM) in the existing literature. Objective: To conduct a meta-analysis to estimate the risk of malignancy in DM and PM as compared with the general population. Methods: Medline and Embase Database abstracts were searched through August 2014 using the search terms myositis, neoplasms, and paraneoplastic syndromes. Population-based, observational studies in English were included. Meta-analyses were conducted using random-effects models. Results: A total of 5 studies with 4538 DM or PM patients were included in the analysis. The overall relative risk was 4.66 for DM and 1.75 for PM. By gender, the standardized incidence ratio (SIR) of malignancy among DM patients was 5.29 for males and 4.56 for females; the SIR of malignancy among PM patients was 1.62 for males and 2.02 for females. By time since diagnosis, the SIR of malignancy among DM patients was 17.29 in the first year, 2.7 between 1 and 5 years, and 1.37 after 5 years. By age group, the SIR among DM patients was 2.79 for patients between 15 and 44 years and 3.13 beyond 45 years. Conclusions: Both DM and PM are associated with increased risk of malignancy, but the risk is higher in DM. The risk of malignancy is present in both genders and all age groups and is highest in the first year after diagnosis but persists beyond the fifth year in DM. Adults should be evaluated for malignancy at diagnosis, followed by long-term surveillance.

Scientific evidence for the use of current traditional systemic therapies in patients with hidradenitis suppurativa

Traditional systemic therapies are frequently prescribed for the treatment of hidradenitis suppurativa (HS). Clinicians consider antibiotics, retinoids, antiandrogens, immunosuppressants, and less common treatment, such as fumarates, in the management of HS. Different classes of medications have been selected to treat HS based on their ability to target various pathways of the condition. Concerns about infection, such as infection with Clostridium difficile, necessitates switching therapy or shortening the course of therapy with specific antibiotics. This review explores the outcomes with the use of numerous medical therapies and postulates explanations for their efficacy or lack of response. Data on long-term safety and efficacy with traditional systemic therapies are lacking.

Low-dose systemic corticosteroid treatment for recalcitrant hidradenitis suppurativa

at a later stage. Dermatologists must have greater surveillance for melanoma within these groups. Early detection of this highly aggressive cancer with a propensity to metastasize is of paramount importance. This study was not able to evaluate other important individual risk factors for melanoma such as history of sun exposure. Future studies should determine the reasons why more melanomas are being diagnosed at an early stage so that public health efforts may be focused on continuing this trend.

Acitretin: Monotherapy or Combined Therapy for Hidradenitis Suppurativa?

Background: Hidradenitis suppurativa (HS) is a chronic, recurrent inflammatory disease of the pilosebaceous follicle that severely affects patients’ quality of life and can be challenging for clinicians to manage. A few case series have reported on the efficacy of acitretin monotherapy in the treatment of intractable HS. Objective: To assess the efficacy of acitretin for the treatment of intractable HS. Methods: A retrospective review was conducted involving all patients with HS who received acitretin between January 2011 and January 2015 in a tertiary academic medical center. All patients with HS who received acitretin, either as a monotherapy or as an adjuvant to other systemic medications, were included, and clinical response was assessed using the physician global scale. Results: Fourteen patients with HS (mean age 48 years [range 32-64 years]; 9 [64%] were men) received acitretin. Most patients (86%) had Hurley stage II or III disease. All patients had failed other standard systemic medications prior to initiating acitretin. Six patients (43%) received acitretin monotherapy, and 8 patients (57%) received acitretin as an adjuvant to other standard systemic medications. None of the patients who received acitretin monotherapy exhibited clinical improvements. Clinical improvements were observed in 7 of the 8 (87.5%) patients who received acitretin as an adjuvant to other systemic medications, with 3 patients (37.5%) exhibiting partial response and 4 patients (50%) exhibiting good response. Conclusions and Relevance: Acitretin monotherapy was ineffective for the treatment of intractable HS. Acitretin may be effective when used as an adjuvant to other systemic medications.

Approach to the Management of Patients With Hidradenitis Suppurativa: A Consensus Document

Background: Hidradenitis suppurativa (HS) is a painful, debilitating, and poorly understood condition, which is suboptimally diagnosed, managed, and treated. Evidence supporting various treatment modalities is sparse. Objectives: To incorporate scientific evidence and expert opinions to develop useful guidance for the evaluation and management of patients with HS. Methods: An expert panel of Canadian dermatologists and surgeons developed statements and recommendations based on available evidence and clinical experience. The statements and recommendations were subjected to analysis and refinement by the panel, and voting was conducted using a modified Delphi technique with a prespecified cutoff agreement of 75%. Results: Ten specific statements and recommendations were accepted by the expert panel. These were grouped into 4 domains: diagnosis and assessment, treatment and management, comorbidities and a multidisciplinary approach, and education. Conclusions: These statements and recommendations will serve to increase awareness of HS and provide a framework for decisions involving diagnosis and management. Evidence suggests that antibacterial and anti–tumour necrosis factor therapies are effective in the treatment of HS. This is supported by the clinical experience of the authors. Further clinical research and the establishment of multidisciplinary management teams will continue to advance management of HS in Canada.

Definition of Moderate to Severe Hidradenitis Suppurativa: A Position Paper by the Canadian Hidradenitis Suppurativa Foundation (CHSF).

To the Editor: Hidradenitis suppurativa (HS) is a chronic recurrent debilitating follicular skin disease with significant burden on both patients and the health care system. It commonly presents after puberty with painful deep-seated nodules, abscesses, and subsequent scarring, and sinus formation in apocrine-bearing skin. Despite being an important health problem during an individual’s most productive time of life, the information on patterns and burden of this condition in Canada is very limited. This information is highly relevant because of the publicly funded health care system in Canada, which is covering direct and potentially indirect costs associated with chronic conditions, such as HS. While even one active lesion can be severely disabling, HS severity is commonly categorized as being mild, moderate, or severe. Considering that even a mild HS can be severely incapacitating, the description of moderate to severe disease requires consideration of both patient and disease perspectives. A spectrum of major subtypes and several rare manifestations illustrates the great variety of clinical presentations and clinical course. HS is a personal crisis for people living with the disease and at the same time a financial crisis for our health care system. The delay in diagnosis, fragmented care, and concomitant comorbidities are consuming an ever-larger share of health care budgets and will force an increase in expenditures. HS has a variable clinical course, and multiple instruments have been developed to gauge severity and stages of the disease (Table 1). Table 1 compares different types of HS scoring systems. With regard to HS, clinical assessment tools must account for the inflammatory nature of HS in order to have clinical relevance. Multiple modalities have been used in the management of HS, and adalimumab was recently approved by Health Canada. It would be in our long-term interest to have a definition of severity to apply to all types of HS treatments. As such, the Board of the Canadian Hidradenitis Suppurativa Foundation (CHSF) discussed how to define severity in order to find a common consent to implement a unified guideline for the use of new emerging targeted therapies. Taken in aggregate after the meeting of the CHSF board in February 2016, we propose that these new criteria be used to define moderate to severe HS to provide a sensitive, useful tool that will help clinicians and patients make informed decisions in managing HS. This tool incorporates both objective measures of inflammation as well as qualitative measures of the patient’s quality of life. Moderate to severe HS includes 5 or more inflammatory lesions (nodules and abscesses)—if 1 lesion is located in the genitalia, then only 3 or more inflammatory lesions are required; an involvement of at least 2 anatomic sites; and either Dermatology Life Quality Index score of greater than or equal to 10 or visual analog pain scale score of greater than or equal to 50 mm. The improvement or response to treatment is evaluated based on more than 50% reduction in lesion count (Table 2). The definition of moderate to severe impact for a prototypical disease with multiple phenotypes requires validation. The second part of this project will focus on validation of this definition based on the data from clinical trials.

Early‐stage mycosis fungoides screening investigations: a retrospective analysis of 440 cases

References 1 Singal A, Daulatabad D. Nail tic disorders: manifestations, pathogenesis and management. Indian J Dermatol Venereol Leprol 2017; 83: 19–26. 2 Alkiewicz JU. Onychotillomanie. Dermatol Wochnschr 1934; 98: 519–521. 3 Rieder EA, Tosti A. Onychotillomania: an underrecognized disorder. J Am Acad Dermatol 2016; 75: 1245–1250. 4 Osborn J, Raetz J, Kost A. Seasonal affective disorder, grief reaction, and adjustment disorder. Med Clin North Am 2014; 98: 1065–1077. 5 Yadav S, Narang T, Kumaran MS. Psychodermatology: a comprehensive review. Indian J Dermatol Venereol Leprol 2013; 79: 176–192.

Changes in the Practice Patterns and Demographics of Ontario Dermatologists

Background: Changes in the practice patterns and demographics of Canadian dermatologists remain largely unknown and would be helpful in assessing the future practice of dermatology across Canada. Objective: To assess changes in the population of Ontario dermatologists over time and the factors that influence their practice patterns, caseload, and the procedures they perform. Methods: A retrospective population-based analysis was performed using comprehensive administrative data on Ontario Health Insurance Plan insured dermatology visits and procedures from April 1, 2009, to March 31, 2015. Results: The number of dermatologists practicing in Ontario per 100 000 people increased from 1.52 (2009) to 1.62 (2014). During this period, the proportion of female dermatologists increased from 40% to 47%, and the proportion of male dermatologists decreased from 60% to 53%. The mean number of patient visits per dermatologist decreased from 6323 (2009) to 5877 (2014). Females saw a decrease from 4818 to 4181 visits, and males remained constant at 7274 to 7265 visits. Middle career dermatologists had more patient visits compared to those in their early or late career. A rural practice was associated with more patient visits compared to an urban one. The proportion of dermatologists providing nonemergency in-hospital patient services declined. The number of biopsies and malignant excisions performed increased. Conclusions: The number of dermatologists at the population level increased and the number of patient visits per dermatologist decreased. Career stage, physician sex, and practice location all affect the practice of dermatology. Future studies to assess underlying factors for these observations would be of value.

Improved keratinocyte carcinoma outcomes with annual dermatology assessment after solid organ transplantation: Population-based cohort study

Solid organ transplant recipients have a high risk of keratinocyte carcinoma (non‐melanoma skin cancer). Consensus‐based transplant guidelines recommend annual dermatological examination but the impact on skin cancer–related outcomes is unclear. We conducted a population‐based, retrospective, inception cohort study using administrative health databases in Ontario, Canada to evaluate the association between adherence to annual dermatology assessments (time‐varying exposure) and keratinocyte carcinoma‐related morbidity and mortality after transplantation. The primary outcome was the time to first advanced (highly morbid or fatal) keratinocyte carcinoma. Among 10 183 adults receiving their first transplant from 1994 to 2012 and followed for a median of 5.44 years, 4.9% developed an advanced keratinocyte carcinoma after transplant. Adherence to annual dermatology assessments for at least 75% of the observation time after transplant was associated with a 34% reduction in keratinocyte carcinoma‐related morbidity or death compared with adherence levels below 75% (adjusted hazard ratio 0.66, 95% CI 0.48‐0.92). Adherence levels were universally low (median proportion of time spent in adherence 0%, inter‐quartile range 0‐27%). Only 45% of transplant recipients had ever seen a dermatologist and 2.1% were fully adherent during the entire observation period. Strategies are needed to improve adherence rates in order to help decrease long‐term morbidity after transplant.