A Practical Guide to Comorbidity Screening in Hidradenitis Suppurativa

Dr. Haley Naik presented information about practical comorbidity screening approaches for patients with hidradenitis suppurativa (HS). HS has been considered a rare disease, but more recent data show it is as common as other dermatologic conditions, including psoriatic arthritis and lichen planus. HS significantly impairs quality of life, comparable to and sometimes exceeding that observed in other dermatologic diseases like psoriasis. It has a bimodal distribution of onset, usually beginning in late adolescence and affecting patients for most of their lives.

Haley Naik, MD, is a professor in the Department of Dermatology, UCSF School of Medicine.

First, Naik described comorbidities associated with HS, including metabolic syndrome, cardiovascular risk factors and disease, poor pregnancy outcomes, other immune-mediated conditions like inflammatory bowel disease (IBD) and spondyloarthritis, and mental health conditions. The comorbidity burden for HS patients exceeds that of patients with psoriasis and the general population. Naik emphasized that the potential outcomes for these patients are serious and the stakes are high. For many patients with HS, dermatologists are their one regular touch point with the healthcare system. Dermatologists are uniquely positioned to advocate for screening to prevent serious adverse health outcomes.

Second, Naik discussed practical tips for integrating comorbidity screening into clinical care for HS patients. These tips are also described in evidence-based recommendations for comorbidity screening in HS patients written by HS foundations in the United States and Canada and published in 2021 in the Journal of the American Academy of Dermatology.

Tip #1: Prioritize screening for life-threatening comorbidities

As HS is a systemic inflammatory disease, it is associated with many possible comorbidities. Naik recommends prioritizing life-threatening comorbidities including suicidality, severe depression, cardiovascular risk factors, and diabetes.

Naik highlighted the serious mental health burden experienced by HS patients. In a survey of >1,000 patients worldwide, more than one-third reported anxiety and depression, 8% reported suicidal ideation, and 4% reported attempted suicide. Electronic medical record data show that HS patients have an increased risk for completed suicide compared with the general population. Many patients with HS have chronic pain that is not well controlled, leading to an increased risk of substance use disorders (SUD). There is a simple, validated 2-question screening tool dermatologists can use for depression and suicidality and a validated 1-question tool for SUD.

Tip #2: Cluster comorbidity screening around treatment decisions

Patients respond better to screening questions about comorbidities when they are asked in context, such as when choosing the most appropriate treatment option:

• Patients with HS have increased risk for IBD; interleukin (IL)-17 inhibitors are contraindicated in patients with IBD. Dermatologists can ask about gastrointestinal symptoms or refer patients to colleagues.
• Patients with HS have joint pain and stiffness and increased prevalence of spondyloarthritis. Dermatologists should ask about these symptoms because tumor necrosis factor (TNF) inhibitors are a good choice for these patients.
• HS and psoriasis are highly comorbid. Dermatologists can identify psoriasis during a physical exam. Patients with both conditions may benefit from an IL-17 inhibitor over a TNF inhibitor.
• Dermatologists should screen for tobacco use before starting a Janus kinase inhibitor because it can reduce treatment efficacy.

Tip #3: Dermatologists do not need to lead every screening

Naik emphasized that taking care of HS patients is a team sport. Dermatologists can delegate comorbidity screening to primary care providers (PCPs) and other clinic staff. Naik encouraged dermatologists to develop a network of colleagues for referrals. For example, she regularly prescribes Nicorette gum or tobacco cessation services for patients who use tobacco and refers patients to their PCP or nutritionist for weight management.

Tip #4: Integrate comorbidity screening over time

After prioritizing life-threatening comorbidities, follow-up visits can include screening for 1–2 other comorbidities. This approach can be operationalized over the course of several years, making comorbidity screening practical even in busy clinics.

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