This week, Pediatrics published a State of the Art (SOTA) review by Dr Colleen Cotton and colleagues entitled, “Hidradenitis Suppurativa in Pediatric Patients.” Don’t feel daunted by the length of this article – it is completely down to earth and gives practitioners a well-organized ‘what you need to know’ based on current evidence (10.1542/peds.2022-061049).
Hidradenitis Suppurativa (HS) is a chronic inflammatory skin condition, affecting mainly the apocrine glands, so found in the groin, axillae, breast, and buttocks skinfold regions. The pathophysiology is complex and not fully understood. It presents with chronic recurring abscesses, nodules, fistulas, and sinuses: these can lead to scarring, if not promptly diagnosed and treated. Both adults and children with HS may have reduced quality of life, due to the illness itself, and co-morbidities including mood disturbances, such as depression, following diagnosis. The point prevalence of HS in the pediatric population ranges from 0.002% in those under 9 years of age to 0.11% in those 14-17 years of age. While not common, pediatric HS is underdiagnosed and undertreated, and these prevalence estimates may represent an underestimate.
My own learning from this SOTA focused on 3 main points:
- HS is underdiagnosed, and delays in diagnosis, from 0.7-2 years, are common. Diagnosis is predominantly clinical, so what clues can one use? Tender or painful cysts and abscesses in characteristic locations (axillae, groin, buttocks) were the most common signs at disease onset, while early misdiagnoses were most commonly folliculitis or comedones. Being mindful of early signs and symptoms may help avoid late diagnosis, which is associated with greater disease severity, and complications such as scarring, in this waxing and waning chronic condition.
- Good treatments are available and within reach of primary practitioners. Treatment rests on appropriate diagnosis (see #1!) but specific topical antibiotics (first line is 1% clindamycin solution), systemic antibiotics (starting with doxycycline), and good wound care are evidence-based treatments. For patients with moderate to severe illness, referral to a dermatologist seems the best course, since biologics and intralesional corticosteroids are not within most of our daily arsenals.
- Since estimated rates of co-morbidities in HS range from 34-93%, screening for co-morbidities is important, and gives an opportunity for holistic primary care and early treatment. Rates of obesity range from 32.5% and 68.7% in HS, with increased rates of hyperinsulinemia, polycystic ovary syndrome, and hyperlipidemia noted. Rates of anxiety, depression, and other mental health disorders appear to be elevated in youth with HS, with rates increasing after diagnosis. Other associated conditions include diabetes, inflammatory bowel disease, and Down syndrome.
Regardless of the learning points you take away from this article, there is so much to learn in this SOTA, from pathophysiology to current evidence-based treatment. I feel more prepared to consider the diagnosis of HS in children and teens, and hope to avoid diagnostic delay and improve quality of life with prompt care and attention to this condition!
