Expert Practices in Hidradenitis Suppurativa Flare Management: A Cross-Sectional Survey Study

Abstract Introduction: Hidradenitis suppurativa (HS) is a chronic skin condition with recurrent, debilitating flares. Although the majority of patients with HS endorse flares, there is a lack of research regarding HS experts’ flare management practices and perspectives. Methods: An anonymous online survey was distributed through an HS expert listserv. Board-certified dermatologists who saw 1 or more HS patient(s) per month were eligible for participation. Results: A total of 35 responses were collected; 97.1% self-identified as HS experts. Therapies used for HS flares by more than two-thirds of the respondents included systemic antibiotics (100%), nonprescription pain relievers (91.4%), intralesional triamcinolone injections (91.4%), prescription pain relievers (71.4%), oral corticosteroids (68.6%), and warm compresses (68.6%). The top 3 dermatologist-reported barriers that patients face in accessing care during flares include lack of clinic appointment availability (88.6%), distance that patients have to travel to reach clinic (85.7%), and lack of transportation for patients (62.9%). Conclusions: Overall, this study highlights variations in the ways that HS experts manage flares. Many of the treatment modalities used by the majority of respondents are not part of the official North American guidelines. Further prospective studies and expert consensus guidelines are needed to standardize the approach to flare management.


Introduction
Hidradenitis suppurativa (HS) is a chronic skin condition characterized by recurrent nodules, abscesses, and sinus tracts, typically in intertriginous areas [1].Current therapeutic modalities for HS include biologic agents such as adalimumab and secukinumab, systemic antibiotics, and hormonal treatments [1,2].During HS flares, patients may experience new or worsening physical and emotional symptoms such as pain, drainage, swelling, depression, and anxiety [3], necessitating additional treatment.Given the lack of standardized guidelines for the treatment of HS flares, the aim of our study was to gain insights into HS specialists' flare management practices.

Materials and Methods
An anonymous online survey was distributed between March and April 2023 through an HS expert listserv (HS Place).Per the recent international consensus of disease flare in HS, for the purposes of this survey, an HS flare was defined as "new or substantial worsening of clinical signs or symptoms" [3].Board-certified dermatologists who saw 1 or more patient(s) with HS per month were eligible for participation.This study was deemed exempt by the institutional review board of the University of Southern California.

Results
Of 166 listserv members, 35 responses were collected (response rate: 21.1%).Demographics and HS flare management practices of the respondents are summa-rized in Table 1.There were 21 (60%) females, and the mean number of HS patients seen in a month was 38.4 (standard deviation: 19.6, range: 12-100).The majority practiced in academic settings (88.6%) and urban locations (82.9%).Overall, 34 (97.1%)self-identified as HS experts, 31 (88.6%)directed HS specialty clinics, and 15 (42.9%) were current or former board members of a national or international HS foundation.The majority (82.9%) mainly saw patients with Hurley stage II-III.Figure 1 provides the variety and frequency of treatments recommended for HS flares by respondents.

Discussion
Currently, the North American treatment guidelines recommend antiseptic washes, warm compresses, shortterm oral steroids, ILTAC, incision and drainage (I&D), deroofing, and topical resorcinol for acute HS lesions [4].In contrast, all respondents in our study reported using systemic antibiotics for flares, most commonly for 2-3 week courses, which is not discussed in the guidelines.
Many clinicians endorsed using higher doses of ILTAC (20 mg/cc or 40 mg/cc) for flares, compared to 10 mg/cc recommended by the North American treatment guidelines [4].This is in line with the findings of Garelik and colleagues, who described benefit with the use of higher doses of ILTAC (20 mg/cc and 40 mg/cc) in patients with HS [5].Furthermore, 75% had used a punch tool to perform an I&D, which may facilitate continued drainage of abscesses [6].
Our findings highlight the importance of providing patients with a practical at-home action plan for flare management, especially since nearly one-half of respondents endorsed that patients have too much pain to travel to clinic during a flare.A cross-over randomized controlled trial demonstrated that written action plans for HS increased patients' confidence in recognizing and treating disease flares [7].Additionally, it is essential to mitigate other barriers to care, such as limited clinic appointments and long travel distances, by helping patients find local dermatologists who are comfortable managing flares and increasing awareness of HS flare management techniques among emergency room providers.Providing more avenues for patients to receive care for disease exacerbations may also reduce no-shows to HS clinic visits since a recent survey study demonstrated that an HS flare was the top reason for missed appointments [8].
To our knowledge, this study describes novel findings regarding flare management practices among HS experts.Study limitations include a small sample size, limited response rate, and most respondents practiced in urban, academic locations.Frequency of treatments prescribed or recommended for HS flares by respondents.*Other: "topical steroids" (n = 2), "dose escalation," "excision," "dapsone," "IV ertapenem, 10 mg/kg infliximab infusion," "depends" (n = 1 each).

Conclusion
This study highlights that HS experts have varied practices for HS flare management that are not necessarily in the current HS treatment guidelines.Increased recognition and timely management of HS are needed to reduce the frequency and intensity of flares.Larger prospective investigations evaluating the efficacy of various treatments for HS flares, relationships between Hurley stage, and corresponding management strategies, as well as structured expert consensus guidelines are needed to establish a standardized approach to treating HS flares.

Table 1 .
Respondents' demographics and perspectives on HS flare management practices