Hidradenitis suppurativa (HS) is a debilitating disease that is associated with a high disease burden and multiple comorbidities.1 Achieving disease control and remission can be difficult and often involves both in-office procedures and medications with known effects on the immune system. Furthermore, the disease most commonly affects sensitive areas of the body, such as the genitalia, or areas that are hard to see completely using telemedicine or photographs, such as the underarms and body folds,. Due to the nature of the disease and potential suppression of the immune system through treatment, the management of HS during the COVID-19 pandemic has been challenging.
Few studies have assessed the impact of the pandemic on this patient population, which has an overall prevalence of 0.10% in the United States and disproportionately affects African Americans.2-4 In addition, there are many overlapping comorbidities between HS and severe COVID-19, which include obesity, cardiovascular conditions, diabetes, hypertension, and smoking history.5 These risk factors raise concerns about treating patients with HS in the office due to risk of exposure, especially in endemic areas. While many states are starting to reopen, the number of cases continues to rise, showing the need for continued social isolation and protection among at-risk patients.
“It is a complicated time to manage these patients because it is an extremely painful disease and is associated with drainage, odor, and difficulty with daily activity when active,” said Mital Patel-Cohen, MD, associate dermatologist with Summit Medical Group in Florham Park, NJ, in an interview with The Dermatologist. “We want to be able to treat HS effectively, but it is limiting when we are not able to see patients in the office, have to remove them from their immunosuppressant medications, or are unable to get laboratory work done as a part of routine monitoring of some of these therapies.”
Immunomodulating Agents During COVID-19
Overall guidance from various organizations do not recommend ceasing biologic or other immunosuppressive agents. A recent Letter to the Editor published in The Journal of American Academy of Dermatology extrapolated risk of respiratory tract infection rates from clinical trials that compared the efficacy and safety of adalimumab with placebo.6 They found a modest increased risk of total infections and nasopharyngitis by 2.5%, on average, with no difference in the risk of upper respiratory tract infections. Overall, there was minimal difference in respiratory tract infection rates between adalimumab- and placebo-treated participants.6
Decisions to discontinue treatment should be made between the physician and patient and take into account all of the patient’s risk factors, as well as risk of exposure. Certain fields may put patients at an increased risk for exposure, such as health care. “Some patients who cannot self‑isolate or have, unfortunately, been in a position where they could be exposed are opting to hold their immunosuppressant medicines,” said Dr Patel-Cohen. “If they cannot be on an immunosuppressive therapy, then we have to make sure we find an alternative because this disease can flare significantly,” she said.
For the few patients in her practice who have discontinued immunosuppressive therapies, Dr Patel-Cohen treats their HS flares with local injections or local incision and drainage. “We want to try our best to keep our patients out of urgent cares and out of emergency departments, and out of a situation where they need something urgent done physically,” she added.
The Telemedicine Visit
Telehealth platforms have allowed dermatologists to continue seeing their patients. In addition, the relaxation of regulations around telehealth visits has allowed some dermatologists to see patients who live far away from the clinic, sometimes even in another state. Shah et al7 noted in a Letter to the Editor published in The Journal of the American Academy of Dermatology that continued virtual outpatient care for patients with HS is important because it may reduce the number of emergency department visits associated with the disease but also allow dermatologists to continue caring for a patient population that has a high burden of mental health comorbidities including increased use of antidepressants and suicide completion. One study from Italy showed remote monitoring was effective for preventing worsening of disease in patients with chronic cutaneous autoimmune diseases, including HS.8
However, there are many limitations with using telehealth platforms and video calls for examining patients with HS. As previously mentioned, HS can affect areas, such as the breasts, underarms, genitals, and buttocks, that are both private and hard to visualize easily with a cell phone or computer. “This can make people uncomfortable because they basically have to expose themselves on a video call,” said Dr Patel-Cohen. One way to address patients’ discomfort is to make sure the appointment is set during a time when the patient can be in a place that is private, and they feel comfortable showing the affected areas. Dr Patel-Cohen explained that it is easier to make patients whom she has treated many times before feel less embarrassed about showing their HS, but it can be tricky to reassure new patients.
“It is a little bit harder when you are not face-to-face with someone to connect with them on an emotional level, which is really important for patients with HS,” she said. Her method for connecting with new patients and developing a relationship using telehealth is by starting to get the know the patient first by taking their history and asking them about their concerns, as well as sharing with them her experiences with treating HS. “I explain [to them] that I have seen [many patients with this disease], and I understand how difficult this disease can be through taking care of other patients like them so that they feel confident in me,” she said. She will review treatment options and discuss a treatment plan based on the severity of their disease before asking a new patient if they are comfortable showing her any active areas. “For patients who say they are not, I tell them: that is okay and is reasonable. We can start you on certain medications and when we are in a position to have people come into the clinic, we can always address it further,” she said.
“For telehealth, I find that, for newer patients, doing the whole visit and establishing the best rapport you can before asking to see any skin goes a long way,” Dr Patel-Cohen added.
Even with telehealth visits, the disruption to normal care can be anxiety-provoking among patients, especially those who choose to withhold their therapy. “While I have these patients on alternative non-immunosuppressive medications, with all the pressure and anxiety, and uncertainty of the pandemic coupled with the fear of having a bad flare-up of their disease, they are still feeling very stressed and I do get frequent calls from them,” said Dr Patel-Cohen. Her patients who are used to getting injections fairly frequently to treat their HS are also worried. While procedures to treat HS flares cannot be offered to everyone, patients who require urgent relief of their HS flares can still be treated with injections and incision and drainage.
Telehealth visits offer an opportunity for dermatologists to explain the importance of social distancing and isolation, as well as address any questions patients may have about it. Dr Patel-Cohen often explains what social isolation entails for each patient she sees to ensure they understand and are able to take necessary precautions to reduce their exposure at home. For example, if a patient’s significant other travels to and from work every day and they share the same bed, the patient is now potentially exposed even though they did not leave the house, Dr Patel-Cohen explained. Similarly, if the patient lives with roommates who leave the home for various reasons, they are still at risk of exposure despite remaining at home, she added. “This is a very important and detailed conversation that needs to happen if a patient is continuing or starting a biologic agent,” said Dr Patel-Cohen.
HS is a complicated and debilitating disease. “A severe HS flare can cause 10 out of 10 on the pain scale and be very limiting in terms of walking, moving, and sleeping,” said Dr Patel-Cohen. It is important that dermatologists optimize treatment of their patients with HS using all options available in their armamentarium to reduce the risk of relapse and the burden on emergency departments. Unlike psoriasis, HS is difficult to suppress or achieve remission.
“Losing treatment response and having to start this whole process all over is challenging, especially for our patients,” added Dr Patel-Cohen. “Using our prescription medications and optimizing medication management for these patients right now is even more important than it was in the past,” she reiterated.
Listen to Dr Patel-Cohen speak on hidradenitis suppurativa, synergetic approaches to care of patients with immune-mediated inflammatory diseases, and more at the virtual Interdisciplinary Autoimmune Summit from July 10 through July 12. Register Here.
1. Reddy S, Strunk A, Garg A. Comparative overall comorbidity burden among patients with hidradenitis suppurativa. JAMA Dermatol. 2019;155(7):797-802. doi:10.1001/jamadermatol.2019.0164
2. Garg A, Kirby JS, Lavian J, Lin G, Strunk A. Sex- and age-adjusted population analysis of prevalence estimates for hidradenitis suppurativa in the United States. JAMA Dermatol. 2017;153(8):760‐764. doi:10.1001/jamadermatol.2017.0201
3. Vlassova N, Kuhn D, Okoye GA. Hidradenitis suppurativa disproportionately affects
144 African Americans: a single-center retrospective analysis. Acta Derm Venereol.
5. Seltzer JA, Okeke CAV, Perry JD, Shipman WD, Okoye GA, Byrd AS. Exploring the risk of severe COVID-19 infection in hidradenitis suppurativa patients [published online ahead of print, 2020 May 7]. J Am Acad Dermatol. 2020;S0190-9622(20)30839-2. doi:10.1016/j.jaad.2020.05.012
6. Blaszczak A, Trinidad JCL, Cartron AM. Adalimumab for treatment of hidradenitis suppurativa during the COVID-19 pandemic: Safety considerations [published online ahead of print, April 10, 2020]. J Am Acad Dermatol. doi:10.1016/j.jaad.2020.04.030
7. Shah M, Naik HB, Alhusayen R. Hidradenitis suppurativa: the importance of virtual outpatient care during COVID-19 pandemic [published online ahead of print, 2020 Apr 30]. J Am Acad Dermatol. 2020;83(1):e81‐e82. doi:10.1016/j.jaad.2020.04.142
8. Huilaja L, Tiri H, Jokelainen J, Timonen M, Tasanen K. Patients with hidradenitis suppurativa have a high psychiatric disease burden: A Finnish nationwide registry study. J Invest Dermatol. 2018;138(1):46-51. doi:10.1016/j.jid.2017.06.020
9. Brunasso AMG, Massone C. Teledermatologic monitoring for chronic cutaneous autoimmune diseases with smartworking during Covid-19 emergency in a tertiary center in Italy [published online ahead of print, 2020 May 26]. Dermatol Ther. 2020;e13495. doi:10.1111/dth.13695