Research letter
Management of hidradenitis suppurativa: a U.K. survey of current practice*
DEAR EDITOR, Management of hidradenitis suppurativa (HS; also known as acne inversa) remains a challenge owing to a combination of multiple treatment options and, until recently,1 a relative lack of published guidelines to assist treatment choices. More than 30 interventions are currently available, while the evidence base to support many of the interventions is weak, as highlighted by a recent HS Priority Setting Partnership.2 It was hypothesized that considerable variation may exist in current U.K. management of HS. To investigate this, an online survey was made available to the membership of the U.K. Dermatology Clinical Trials Network and British Association of Dermatologists between 1 November and 5 December 2014. There were 134 responses, including 88 from consultant dermatologists, 15 from dermatology registrars (residents), 14 from associate specialists, nine from dermatology specialist nurses and eight from general practitioners. Respondents were located in England, Wales, Scotland and Northern Ireland. Thirty-seven per cent saw three or more new patients with HS each month and 68% had at least six patients with HS under current follow-up. Two clinicians each saw > 50 patients with HS for regular review. In terms of topical therapy, antiseptics were routinely used by 88% of respondents and topical antibiotics were prescribed by 67%. A few clinicians used topical retinoids and three prescribed potent topical corticosteroids for disease flares. Resorcinol peels were not prescribed by any of the respondents. Clinicians were asked to select their most frequently used nontopical interventions for moderate-to-severe HS from a list of 30 options, and to rank these from first to tenth choice. A further option was offered to give details of any other therapy not included in the list. One hundred and seventeen individuals provided a response. Oral tetracyclines were the most frequently prescribed first-line therapy and were the first choice for 75% of clinicians. Most gave lymecycline or doxycycline, and 25% prescribed more than the dose recommended for acne, typically giving double the standard dose. A combination of clindamycin and rifampicin was used as the first-choice treatment by 12% of clinicians and as the second-choice treatment by 43%, representing the most frequently used second-line systemic intervention. The dosage of both antibiotics was 300 mg twice daily for 96% of respondents, and 74% gave a treatment duration of between 10 and
12 weeks, with most of the remainder prescribing a variable treatment duration. A minority of 14% gave only a single course of clindamycin and rifampicin, while the majority prescribed multiple courses depending on patient response. Ranking of the next most frequently chosen oral systemic treatments by mode was found to coincide with the frequency of being selected in respondents’ top 10 interventions (Fig. 1). Acitretin, isotretinoin, dapsone and ciclosporin were ranked third-, fourth-, fifth- and sixth-choice interventions, respectively. Many respondents noted that use of biological agents was restricted by funding issues; however, 54 (46%) included infliximab in their top 10 treatments, 32 (27%) included adalimumab and 10 (9%) included ustekinumab. The two surgical treatment options listed in the survey were ‘narrow margin excision of most active lesion(s)’ and ‘wide local excision of most active region’. The limited excision option was offered by 38 (32%) respondents. Extensive excision was employed by 48 (41%) clinicians and the timing of this procedure in the treatment pathway varied from third- to tenth-choice therapy, the mode being seventh choice. Three other interventions were included in their 10 mostused therapies by at least 20% of respondents, namely oral prednisolone (26%), intralesional triamcinolone injections (24%) and the oral contraceptive pill (21%). The group of laser, light, phototherapy and photodynamic therapies, comprising seven options in the treatment list, were infrequently used, selected only 16 times in total. Management of an acute flare was ranked as the second-highest priority in the HS Priority Setting Partnership.2 Survey respondents were asked to indicate their recommended management of an acute, painful HS abscess, and the results are shown in Fig. 2. The most frequent response was incision and drainage (43%). Prescription of a 1-week course of antibiotics was selected by 29%, although it has been suggested that this option may not alter the natural history of an individual HS lesion.3 This survey has provided insight into current U.K. management of HS, which broadly mirrors the recommendations of the European S1 guidelines,1 which were published after the survey closed. The results indicate that oral tetracyclines remain the first choice for systemic treatment in the U.K., while the combination of clindamycin and rifampicin is often, but not exclusively, prescribed as second-line therapy. Most clinicians prescribe 10–12-week combined courses of clindamycin 300 mg twice daily and rifampicin 300 mg twice daily, which is in line with published case series evidence,4–7 and the majority offer multiple courses. Isotretinoin continues to be used by about half of respondents, despite the available
British Journal of Dermatology (2015) 173, pp1070–1072
© 2015 British Association of Dermatologists
DOI: 10.1111/bjd.13866
1070
Research letter
1071
Fig 1. Ranking of oral, nonantibiotic treatments for hidradenitis suppurativa in a survey question that asked respondents to list their most frequently used treatments in order, commencing with their first-line therapy, from a list of 30 interventions. The four most frequently selected therapies are shown, with the mode for the distribution of their ranking on the x-axis and the percentage of total respondents (n = 117) who included the option in their 10 most-used interventions on the y-axis.
Fig 2. Recommended management of acute, painful hidradenitis suppurativa (HS) abscess (n = 114). Responses to a survey question asking respondents to select one of six options regarding their recommended management of an acute, painful HS abscess. Results are given as a percentage of the 114 respondents. The ‘opiate analgesia’ option was expanded to ‘analgesia including opiate analgesia (if needed)’ in the survey. In most cases, clinicians opting for ‘other’ management specified that this involved a combination of the options listed, while one respondent recommended oral corticosteroids and another used topical, very potent corticosteroids to treat acute abscesses.
case series evidence indicating a lack of efficacy for HS.8,9 There was no consensus regarding the timing of wide local excision surgery in the treatment pathway, and this treatment was included in the top 10 interventions by fewer than half of the respondents. Despite funding issues, biological therapies are being used for HS in the U.K., with infliximab offered most frequently and included in the top 10 list by about half of the survey respondents. Incision and drainage is most frequently recommended for management of an acute, painful HS abscess, with analgesia recommended by only a small minority. This may reflect the wording of the question that asked clinicians to select only © 2015 British Association of Dermatologists
one, most favoured option. However, it is also in agreement with the HS Priority Setting Partnership findings that pain management research should be prioritized because it is a neglected element of care for patients with HS.2 Although this survey has highlighted a number of areas of consensus regarding HS management, the multiple treatment options and lack of high-quality trial evidence for HS make a degree of variation inevitable, as confirmed by our results. Multicentre randomized controlled trials offer a potential solution, and 51 (47%) survey respondents indicated that they would be willing and able to recruit into HS trials, offering hope for the future. British Journal of Dermatology (2015) 173, pp1070–1072
1072 Research letter
Acknowledgments We thank the members of the U.K. Dermatology Clinical Trials Network and the British Association of Dermatologists who responded to the study survey. 1
Department of Dermatology and Wound Healing, Institute of Infection and Immunity, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, U.K. 2 Centre of Evidence-Based Dermatology, University of Nottingham, King’s Meadow Campus, Lenton Lane, Nottingham NG7 2NR, U.K. Correspondence: John R. Ingram. E-mail: [email protected]
J.R. INGRAM1 M. MCPHEE2
*Plain language summary available online
References 1 Zouboulis CC, Desai N, Emtestam L et al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol 2015; 29:619–44. 2 Ingram JR, Abbott R, Ghazavi M et al. The Hidradenitis Suppurativa Priority Setting Partnership. Br J Dermatol 2014; 171:1422–7.
British Journal of Dermatology (2015) 173, pp1070–1072
3 von der Werth JM, Williams HC. The natural history of hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2000; 14:389–92. 4 Mendoncßa CO, Griffiths CE. Clindamycin and rifampicin combination therapy for hidradenitis suppurativa. Br J Dermatol 2006; 154:977–8. 5 van der Zee HH, Boer J, Prens EP, Jemec GB. The effect of combined treatment with oral clindamycin and oral rifampicin in patients with hidradenitis suppurativa. Dermatology 2009; 219:143– 7. 6 Gener G, Canoui-Poitrine F, Revuz JE et al. Combination therapy with clindamycin and rifampicin for hidradenitis suppurativa: a series of 116 consecutive patients. Dermatology 2009; 219:148–54. 7 Bettoli V, Zauli S, Borghi A et al. Oral clindamycin and rifampicin in the treatment of hidradenitis suppurativa–acne inversa: a prospective study on 23 patients. J Eur Acad Dermatol Venereol 2014; 28:125–6. 8 Boer J, van Gemert MJ. Long-term results of isotretinoin in the treatment of 68 patients with hidradenitis suppurativa. J Am Acad Dermatol 1999; 40:73–6. 9 Soria A, Canoui-Poitrine F, Wolkenstein P et al. Absence of efficacy of oral isotretinoin in hidradenitis suppurativa: a retrospective study based on patients’ outcome assessment. Dermatology 2009; 218:134–5. Funding sources: none. Conflicts of interest: J.I. was a local principal investigator for an observational study of hidradenitis suppurativa, which was sponsored by AbbVie.
© 2015 British Association of Dermatologists
Management of hidradenitis suppurativa: a U.K. survey of current practice*
DEAR EDITOR, Management of hidradenitis suppurativa (HS; also known as acne inversa) remains a challenge owing to a combination of multiple treatment options and, until recently,1 a relative lack of published guidelines to assist treatment choices. More than 30 interventions are currently available, while the evidence base to support many of the interventions is weak, as highlighted by a recent HS Priority Setting Partnership.2 It was hypothesized that considerable variation may exist in current U.K. management of HS. To investigate this, an online survey was made available to the membership of the U.K. Dermatology Clinical Trials Network and British Association of Dermatologists between 1 November and 5 December 2014. There were 134 responses, including 88 from consultant dermatologists, 15 from dermatology registrars (residents), 14 from associate specialists, nine from dermatology specialist nurses and eight from general practitioners. Respondents were located in England, Wales, Scotland and Northern Ireland. Thirty-seven per cent saw three or more new patients with HS each month and 68% had at least six patients with HS under current follow-up. Two clinicians each saw > 50 patients with HS for regular review. In terms of topical therapy, antiseptics were routinely used by 88% of respondents and topical antibiotics were prescribed by 67%. A few clinicians used topical retinoids and three prescribed potent topical corticosteroids for disease flares. Resorcinol peels were not prescribed by any of the respondents. Clinicians were asked to select their most frequently used nontopical interventions for moderate-to-severe HS from a list of 30 options, and to rank these from first to tenth choice. A further option was offered to give details of any other therapy not included in the list. One hundred and seventeen individuals provided a response. Oral tetracyclines were the most frequently prescribed first-line therapy and were the first choice for 75% of clinicians. Most gave lymecycline or doxycycline, and 25% prescribed more than the dose recommended for acne, typically giving double the standard dose. A combination of clindamycin and rifampicin was used as the first-choice treatment by 12% of clinicians and as the second-choice treatment by 43%, representing the most frequently used second-line systemic intervention. The dosage of both antibiotics was 300 mg twice daily for 96% of respondents, and 74% gave a treatment duration of between 10 and
12 weeks, with most of the remainder prescribing a variable treatment duration. A minority of 14% gave only a single course of clindamycin and rifampicin, while the majority prescribed multiple courses depending on patient response. Ranking of the next most frequently chosen oral systemic treatments by mode was found to coincide with the frequency of being selected in respondents’ top 10 interventions (Fig. 1). Acitretin, isotretinoin, dapsone and ciclosporin were ranked third-, fourth-, fifth- and sixth-choice interventions, respectively. Many respondents noted that use of biological agents was restricted by funding issues; however, 54 (46%) included infliximab in their top 10 treatments, 32 (27%) included adalimumab and 10 (9%) included ustekinumab. The two surgical treatment options listed in the survey were ‘narrow margin excision of most active lesion(s)’ and ‘wide local excision of most active region’. The limited excision option was offered by 38 (32%) respondents. Extensive excision was employed by 48 (41%) clinicians and the timing of this procedure in the treatment pathway varied from third- to tenth-choice therapy, the mode being seventh choice. Three other interventions were included in their 10 mostused therapies by at least 20% of respondents, namely oral prednisolone (26%), intralesional triamcinolone injections (24%) and the oral contraceptive pill (21%). The group of laser, light, phototherapy and photodynamic therapies, comprising seven options in the treatment list, were infrequently used, selected only 16 times in total. Management of an acute flare was ranked as the second-highest priority in the HS Priority Setting Partnership.2 Survey respondents were asked to indicate their recommended management of an acute, painful HS abscess, and the results are shown in Fig. 2. The most frequent response was incision and drainage (43%). Prescription of a 1-week course of antibiotics was selected by 29%, although it has been suggested that this option may not alter the natural history of an individual HS lesion.3 This survey has provided insight into current U.K. management of HS, which broadly mirrors the recommendations of the European S1 guidelines,1 which were published after the survey closed. The results indicate that oral tetracyclines remain the first choice for systemic treatment in the U.K., while the combination of clindamycin and rifampicin is often, but not exclusively, prescribed as second-line therapy. Most clinicians prescribe 10–12-week combined courses of clindamycin 300 mg twice daily and rifampicin 300 mg twice daily, which is in line with published case series evidence,4–7 and the majority offer multiple courses. Isotretinoin continues to be used by about half of respondents, despite the available
British Journal of Dermatology (2015) 173, pp1070–1072
© 2015 British Association of Dermatologists
DOI: 10.1111/bjd.13866
1070
Research letter
1071
Fig 1. Ranking of oral, nonantibiotic treatments for hidradenitis suppurativa in a survey question that asked respondents to list their most frequently used treatments in order, commencing with their first-line therapy, from a list of 30 interventions. The four most frequently selected therapies are shown, with the mode for the distribution of their ranking on the x-axis and the percentage of total respondents (n = 117) who included the option in their 10 most-used interventions on the y-axis.
Fig 2. Recommended management of acute, painful hidradenitis suppurativa (HS) abscess (n = 114). Responses to a survey question asking respondents to select one of six options regarding their recommended management of an acute, painful HS abscess. Results are given as a percentage of the 114 respondents. The ‘opiate analgesia’ option was expanded to ‘analgesia including opiate analgesia (if needed)’ in the survey. In most cases, clinicians opting for ‘other’ management specified that this involved a combination of the options listed, while one respondent recommended oral corticosteroids and another used topical, very potent corticosteroids to treat acute abscesses.
case series evidence indicating a lack of efficacy for HS.8,9 There was no consensus regarding the timing of wide local excision surgery in the treatment pathway, and this treatment was included in the top 10 interventions by fewer than half of the respondents. Despite funding issues, biological therapies are being used for HS in the U.K., with infliximab offered most frequently and included in the top 10 list by about half of the survey respondents. Incision and drainage is most frequently recommended for management of an acute, painful HS abscess, with analgesia recommended by only a small minority. This may reflect the wording of the question that asked clinicians to select only © 2015 British Association of Dermatologists
one, most favoured option. However, it is also in agreement with the HS Priority Setting Partnership findings that pain management research should be prioritized because it is a neglected element of care for patients with HS.2 Although this survey has highlighted a number of areas of consensus regarding HS management, the multiple treatment options and lack of high-quality trial evidence for HS make a degree of variation inevitable, as confirmed by our results. Multicentre randomized controlled trials offer a potential solution, and 51 (47%) survey respondents indicated that they would be willing and able to recruit into HS trials, offering hope for the future. British Journal of Dermatology (2015) 173, pp1070–1072
1072 Research letter
Acknowledgments We thank the members of the U.K. Dermatology Clinical Trials Network and the British Association of Dermatologists who responded to the study survey. 1
Department of Dermatology and Wound Healing, Institute of Infection and Immunity, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, U.K. 2 Centre of Evidence-Based Dermatology, University of Nottingham, King’s Meadow Campus, Lenton Lane, Nottingham NG7 2NR, U.K. Correspondence: John R. Ingram. E-mail: [email protected]
J.R. INGRAM1 M. MCPHEE2
*Plain language summary available online
References 1 Zouboulis CC, Desai N, Emtestam L et al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol 2015; 29:619–44. 2 Ingram JR, Abbott R, Ghazavi M et al. The Hidradenitis Suppurativa Priority Setting Partnership. Br J Dermatol 2014; 171:1422–7.
British Journal of Dermatology (2015) 173, pp1070–1072
3 von der Werth JM, Williams HC. The natural history of hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2000; 14:389–92. 4 Mendoncßa CO, Griffiths CE. Clindamycin and rifampicin combination therapy for hidradenitis suppurativa. Br J Dermatol 2006; 154:977–8. 5 van der Zee HH, Boer J, Prens EP, Jemec GB. The effect of combined treatment with oral clindamycin and oral rifampicin in patients with hidradenitis suppurativa. Dermatology 2009; 219:143– 7. 6 Gener G, Canoui-Poitrine F, Revuz JE et al. Combination therapy with clindamycin and rifampicin for hidradenitis suppurativa: a series of 116 consecutive patients. Dermatology 2009; 219:148–54. 7 Bettoli V, Zauli S, Borghi A et al. Oral clindamycin and rifampicin in the treatment of hidradenitis suppurativa–acne inversa: a prospective study on 23 patients. J Eur Acad Dermatol Venereol 2014; 28:125–6. 8 Boer J, van Gemert MJ. Long-term results of isotretinoin in the treatment of 68 patients with hidradenitis suppurativa. J Am Acad Dermatol 1999; 40:73–6. 9 Soria A, Canoui-Poitrine F, Wolkenstein P et al. Absence of efficacy of oral isotretinoin in hidradenitis suppurativa: a retrospective study based on patients’ outcome assessment. Dermatology 2009; 218:134–5. Funding sources: none. Conflicts of interest: J.I. was a local principal investigator for an observational study of hidradenitis suppurativa, which was sponsored by AbbVie.
© 2015 British Association of Dermatologists
