Low Rates of Psychosocial Screening and Lifestyle Counseling in Hidradenitis Suppurativa Patients in the USA.

Introduction: Although hidradenitis suppurativa (HS) is associated with psychosocial comorbidities such as depression as well as modifiable comorbidities such as obesity, rates of psychosocial screening and lifestyle counseling in the USA have not been characterized. Methods: This cross-sectional study utilized publicly available data from the National Ambulatory Medical Care Survey (NAMCS) between 2008 and 2018 to identify visits with a diagnosis of HS (ICD-9 code 705.83, ICD-10 code L73.2). T tests and multivariate logistic regressions analyzed trends in rates of screening and counseling while controlling for race, sex, and age. Survey weights are applied to each visit to represent a national sample. Results: Depression screening was completed in only 2% of reported visits. No visits reported screening for alcohol misuse, substance abuse, or domestic violence. There were low rates of counseling for weight reduction (7.8%), diet and nutrition (3.3%), exercise (2.4%), smoking (1.0%), and substance abuse (0.7%). Black patients and individuals with public health insurance received less screening and counseling overall. Conclusion: Rates of psychosocial screening and counseling on lifestyle modifications are low in ambulatory clinic visits for HS patients, and there are disparities based on race and insurance status. Implementing strategies to incorporate routine psychosocial screening and lifestyle counseling into visits may improve HS patient outcomes.

Expert consensus on priority research gaps in dietary and lifestyle factors in hidradenitis suppurativa: a Delphi consensus study.

Hidradenitis suppurativa (HS) is a debilitating systemic inflammatory disease with limited treatment options. Although management through dietary and lifestyle changes is a primary interest of the HS patient community, there is lack of consensus regarding recommendations due to the paucity of evidence. To establish the priority research gaps on this topic, we performed and moderated a Delphi consensus study by integrating expert opinions and the relevant literature. Based on a literature review, research questions on dietary and lifestyle interventions in HS were constructed. HS dietary and lifestyle research questions were sent to an expert panel, consisting of 22 international members, including dermatologists, dietitians, pharmacists, and endocrinologists. Voting on the research questions was conducted using a modified Delphi technique. The primary outcome measure was whether participants could reach consensus on the priority of each research question in the HS dietary and lifestyle factors. After three rounds of surveys investigating the relationships between HS and various diet and lifestyle factors, "BMI", "Obesity", and "Smoking", reached consensus as high priority research questions. Low research priorities per consensus included "effects of iron supplements", "effects of magnesium supplements", "alcohol consumption" and "limiting Brewer's yeast intake. Smoking and obesity were identified as important research questions, concurrent to the literature indicating their association with more significant impact on disease activity. By shedding light on high priority research questions, our study provides a roadmap for further research on dietary and lifestyle modifications in HS and will help determine evidence-based lifestyle and dietary recommendations for patients with HS.

Atopic Dermatitis: A Guide to Transitioning to Janus Kinase Inhibitors.

Janus kinase inhibitors (JAKis) are promising medications that the Food and Drug Administration recently approved for treatment of atopic dermatitis in January 2022. These medications offer a novel therapeutic mechanism and may be an additional treatment avenue for patients who are currently reliant on conventional immunosuppressants, such as cyclosporine A, methotrexate, or mycophenolate mofetil, or newer medications, such as dupilumab. However, redundant treatment puts patients at risk for excessive toxicity and polypharmacy, whereas abrupt tapering of a preexisting regimen may cause flares of the disease. Thus, transitioning to JAKis should be implemented strategically to retain the therapeutic benefit and minimize the risk of flares. Herein, we outline gradual transition schemas for patients needing to transition to JAKis from conventional immunosuppressants or dupilumab. There is no evidence-based guideline to instruct this transition to JAKis, and our recommendations are based on expert experience and the review of efficacy data from pivotal trials.

Allergen Composition, Marketing Claims, and Affordability of Pediatric Sunscreens.

BACKGROUND: Childhood sun exposure is associated with development of future skin cancers. Sunscreens are an important tool to prevent harmful ultraviolet rays. OBJECTIVES: The aims of the study are to evaluate sunscreens targeted to children and to analyze cost, marketing claims, ingredients, and allergens to help consumers select products. METHODS: The top 50 pediatric sunscreens across retailers were analyzed for their cost, marketing claims, ingredients, vehicles, and containers. Ingredients were compared with the American Contact Dermatology Society 2020 Core Allergen List. RESULTS: The mean price was $6.20 per ounce (range, $0.25-$39.98). The mean sun protection factor was 48.5 (range, 30-100; SD, 48.5). There was a mean of 17.5 ingredients and a mean of 1.1 allergens in products. On average, products marketed as "sensitive skin" were not only significantly more expensive ($8.90 vs $3.50 per ounce, P = 0.01) but also were significantly more likely to not contain any allergens (36.0%, n = 18 vs 12%, n = 6; P = 0.05). Products with mineral-only UV blockers were significantly less likely to have any allergen when compared with products that had chemical UV blockers (5.6%, n = 1 vs 94.4%, n = 17; P = 0.02). CONCLUSIONS: The current market of pediatric sunscreens varies significantly in price, marketing claims, and active ingredients. Products marked as suitable for sensitive skin had significantly fewer allergens, but a majority of these products still had at least one allergen. Many sunscreens contain contact allergens, which is an important selection consideration.

Diagnosing and Managing Hidradenitis Suppurativa in Pediatrics.

Hidradenitis suppurativa (HS) is a debilitating chronic inflammatory skin disease that presents as exquisitely tender abscesses, draining fistulae, and sinus tracts. HS can lead to significant impairments in patients' quality of life, especially for children and adolescents who face challenges related to self-esteem and physical and emotional development. Severe long-term physical sequelae of inadequately treated HS include extensive scarring, urogenital strictures, immobility, and squamous cell carcinoma; emotional sequelae include depression, anxiety, and suicidal ideation. Many of the devastating long-term sequelae associated with HS can be prevented with early recognition and proper collaborative management. This article reviews strategies to aid pediatricians in early diagnosis of HS and provides clinical pearls for management and prevention of disease flares. [Pediatr Ann. 2022;51(3):e123-e127.].

Pain management modalities for hidradenitis suppurativa: a patient survey.

BACKGROUND: Pain is one of the most common and debilitating symptoms of hidradenitis suppurativa (HS). OBJECTIVE: We sought to identify pain management therapies used in HS and assess patient-perceived effectiveness. METHODS: An anonymous online survey was posted to Facebook HS support groups. Participants selected all that applied from a list of 20 therapies to indicate which ones they have tried for HS pain. For each therapy used, participants were asked to rate effectiveness on a 5-point scale: not successful (1), mildly successful (2), moderately successful (3), very successful (4), and extremely successful (5). Mean effectiveness ratings were calculated by averaging the corresponding numbers. RESULTS: Of the 438 participants, 93.8% were female. Participants classified themselves as Hurley stage I (8.2%), II (53.4%), and III (38.4%). Warm compresses were the most commonly used therapy (82.4%), followed by ibuprofen/naproxen (74.7%), Epsom salt baths (57.8%), cold compresses (45.4%), and acetaminophen (44.7%). Marijuana smoking received the highest mean effectiveness rating (2.92 ± 1.10), followed by marijuana edibles (2.87 ± 1.10), and opioids (2.83 ± 0.98). Mean effectiveness ratings were lowest for bleach baths (1.52 ± 0.80), sitz baths (1.53 ± 0.56), massage (1.61 ± 0.92), gabapentin (1.64 ± 0.73), and acetaminophen (1.71 ± 0.75). CONCLUSIONS AND RELEVANCE: Even the highest-rated pain management modalities are considered only moderately effective by HS patients.

Intralesional biologics for inflammatory dermatoses: A systematic review.

Biologic medications are systemic therapeutic options for inflammatory dermatoses. Local forms of administration are less well-studied. To provide a summary of intralesional (IL) administration of biologics for various non-malignant inflammatory dermatologic conditions reported in the literature. A systematic review was performed in the PubMed and Embase databases from 2000 to 2020. Inclusion criteria included the local use of biologic medications for non-malignant cutaneous conditions. Quality was assessed with the modified Oxford Centre for Evidence-Based Medicine ratings. A total of 19 articles describing the use of 5 biologic medications in 9 dermatologic conditions were identified, comprising 172 patients. Conditions successfully treated with intralesional biologics included pemphigus vulgaris (rituximab), granuloma faciale (rituximab), perianal Crohn's disease (infliximab), lichen sclerosus (adalimumab), and necrobiosis lipoidica (etanercept and infliximab). Intralesional etanercept reduced pruritus associated with keloids. A case report of the use of infliximab for pyoderma gangrenosum did not demonstrate any efficacy. There was no consistent effect noted with treatments for sarcoidosis (infliximab) or cutaneous lymphoid hyperplasia (rituximab). Local administration of biologic medications may offer an additional method of treating refractory inflammatory dermatoses, but further study is needed to develop standardized dosing protocols, clarify efficacy rates, and identify optimal treatment candidates.

Radiotherapy for Hidradenitis Suppurativa: A Systematic Review.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis characterized by painful nodules, abscesses, sinus tracts, and scarring mainly in the intertriginous areas. Patients with HS often experience inadequate responses to traditional treatment consisting of lifestyle modification, topical and systemic antibiotics, hormonal modulators, biologics, and procedural modalities. Low-dose radiotherapy has been used in benign cutaneous conditions, including HS; however, there is a paucity of literature summarizing its evidence. Herein, we systematically review the current literature on the efficacy of radiotherapy for patients with HS. SUMMARY: This systematic review of the published literature reports the patient demographics, treatment regimens, efficacy, and adverse effects of radiotherapy in the treatment of HS. The historic timeline of these publications highlights the changes in management recommendations, introduction of more standardized outcome measures, and enhancements in treatment options. Radiotherapy appears to be an option for patients with treatment-resistant HS or who are poor surgical candidates. However, there remains a paucity of consensus on proper candidate selection, dosing, efficacy, and safety of the short- and long-term effects of radiotherapy.

Isotretinoin in the treatment of hidradenitis suppurativa: a retrospective study.

OBJECTIVE: Isotretinoin has been used off-label in hidradenitis suppurativa (HS) patients with variable results, making it difficult to predict which patients with HS are likely to benefit. MATERIAL AND METHODS: We conducted a retrospective review of HS patients who presented to UCLA HS clinic between August 2009 and March 2018 and collected data on their demographics, reported history of isotretinoin treatment for HS, and treatment response. A number of patient variables were analyzed between the responders and non-responders to see if any were associated with a higher likelihood of a beneficial response. RESULTS: Of the 209 patients, 39 (18.7%) reported prior treatment with isotretinoin. A beneficial response to isotretinoin was reported by 14 (35.9%) patients, while 25 (64.1%) patients reported no response. When comparing responders to non-responders, responders were more likely to have a history of pilonidal cyst (p = .024). Having a concomitant history of regular or cystic acne did not appear to enhance HS treatment response to isotretinoin. CONCLUSIONS: Our data suggest that for HS patients, having a history of pilonidal cyst is associated with a beneficial response to isotretinoin.

Guselkumab in the treatment of concomitant hidradenitis suppurativa, psoriasis, and Crohn's disease.

BACKGROUND: Hidradenitis suppurativa (HS) is a debilitating skin condition whose pathogenesis is poorly understood, although interleukin (IL)-23 may play a role. IL-23 is also implicated in the pathogenesis of Crohn's disease (CD) and psoriasis, both of which can occur in patients with HS. CASE REPORT: We present the case of a 28-year-old woman with HS, psoriasis, and CD, who was successfully treated with guselkumab after failing multiple other biologic agents. CONCLUSION: Guselkumab represents a promising therapeutic option for recalcitrant HS patients with inflammatory comorbidities in which IL-23 plays a role.

Non-pharmacologic approaches for hidradenitis suppurativa - a systematic review.

Importance: Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition presenting with painful nodules and sinus tracts primarily in intertriginous regions. The persistent nature of HS and challenges in symptom management lead many patients to seek non-pharmacologic approaches due to the paucity and limited efficacy of conventional HS therapeutic options.Objective: To evaluate the existing evidence for non-pharmacologic modalities in treatment of HS.Findings: Discussed in this review are non-pharmacologic modalities with evidence of efficacy in HS treatment, including weight loss, vitamin B12, vitamin D and zinc supplementation, and dietary avoidance of brewer's yeast. Limitations of the available data on non-pharmacologic therapies in HS include the predominance of pilot and single-armed studies, as well as heterogeneity in study design, subject disease severity, concomitant treatment and comorbid conditions.Conclusions and relevance: HS patients are becoming increasingly interested in the use of non-pharmacologic approaches to augment conventional treatments. Strength of evidence for non-pharmacologic therapies in HS is limited by small study size and lack of randomized controlled trials. Future large-scale investigations should be pursued to better establish efficacy and dosing regimens for the use of non-pharmacologic treatments in HS.

Rosacea associated with dupilumab therapy.

Background: Dupilumab is used for treatment of atopic dermatitis through blockade of IL-4 and IL-13 signaling of the Th2 pathway. Recent case reports have described alopecia, psoriasis, persistent facial dermatitis, and recall dermatitis at patch test sites after the initiation of dupilumab therapy.Case report: We describe the case of a 67-year-old female with atopic dermatitis who developed recurrent episodic flares of rosacea temporally associated with dupilumab injections that resolved after dupilumab discontinuation.Conclusion: The cause of rosacea-like reaction associated with dupilumab treatment is unknown. Th2 pathway inhibition by dupilumab may promote Demodex proliferation and increased IL-17-mediated inflammation implicated in the pathophysiology of rosacea.Abbreviations: atopic dermatitis: AD; interleukin: IL; persistent facial dermatitis: PFD; T-helper cell type 1: Th1; T-helper cell type 2: Th2; T-helper cell type 17: Th17; tumor necrosis factor-∝: TNF-∝.

Challenges of Teledermatology: Lessons Learned During COVID-19 Pandemic.

The COVID-19 pandemic required a transition to telemedicine to limit viral spread. Dermatology seems particularly well-suited for telemedicine, however, this pandemic transformed teledermatology into the predominant means of delivering care. Providers are limited in their ability to promptly and accurately manage disease without access to in-person tools. This monumental switch to teledermatology may disadvantage certain patient populations, including those with limited technological literacy (such as the elderly) or access to the internet. Dermatologists must acknowledge these limitations and recognize the consequences of severely limited in-person visits over a prolonged period of time.

Widespread pustular eruption following probiotic use.

A 26-year-old woman with Crohn disease and palmoplantar psoriasis on ustekinumab presented with a diffuse and intensely pruritic rash with a few pin-point pustules within days after initiation of an over-the-counter Align brand probiotic. Biopsy revealed psoriasiform and spongiotic dermatitis with spongiform subcorneal pustules and scattered eosinophils, consistent with acute generalized exanthematous pustulosis. Our case highlights a unique presentation of acute generalized exanthematous pustulosis following probiotic exposure with fewer than usual pustular lesions. IL23 suppression by ustekinumab may have contributed to the patient's reduced pustular presentation.

Erythrodermic Darier disease associated with metastatic lung adenocarcinoma.

We present a patient with erythrodermic Darier disease occurring in temporal association with diagnosis of metastatic lung adenocarcinoma. The patient presented with eroded and crusted keratotic papules and plaques over greater than 90% body surface area with extensive secondary impetiginization. Given a longstanding history of pruritic eruption, this presentation represents a paraneoplastic flare of an underlying genodermatosis. Near total resolution was achieved with chemotherapy and topical corticosteroids.