Clinical Challenge: Managing Pain in Hidradenitis Suppurativa

Aside from causing potentially disfiguring skin lesions, hidradenitis suppurativa (HS) has a devastating impact on patients’ quality of life (QoL). The condition has a strong association with poor mental health, unemployment, intimacy problems, and substance use disorders. However, chronic pain heads the list of adverse effects for most patients. Pain in HS has a stronger association with impaired QoL than disease severity.

A recent study of 383,000 HS-related emergency department (ED) visits from 2006 to 2017 showed that 70% of patients reported severe pain, and 40.1% rated their pain as 10 on a 10-point scale. About 4% of ED visits led to inpatient admissions. A study from Germany showed that 83.6% of 1,795 patients with HS reported pain during visits to dermatology outpatient clinics. In contrast to the study of ED visits, most patients rated their pain as mild.

For Alok Vij, MD, of the Cleveland Clinic, pain has a major influence on his approach to treating HS. When evaluating a patient’s response to treatment, Vik said he often begins considering a different option within a month if the HS has shown little improvement.

“I don’t like to push through it, because I try to put myself in the patient’s position,” Vij told MedPage Today. “This is a very painful issue. It’s affecting their quality of life significantly. Depression is very commonly associated. If someone is not getting relief from a treatment, we could be doing more harm by not trying a different approach in some cases.”

Even mild forms of the disease can cause disruptive pain, said Danny Del Campo, MD, of the Chicago Skin Clinic. Sticking with a therapy that produces limited improvement can exacerbate the disease’s overall adverse impact on health-related QoL.

“If people are not getting relief should they be continuing the same process?” he asked. “Sometimes that can lead to more frustration and lead to a longer-lasting disease process. If someone is not getting enough improvement within a short period of time — on the order of weeks, not months — they should be kicking it up to the next level.”

Start Simple

Multiple medical professional organizations have guidelines for pain management in HS, although specific treatment recommendations vary, according to a recent review. Emphasis on simple analgesics and nonsteroidal anti-inflammatory agents (NSAIDs) and limited use of opioids are common characteristics of clinical guidance.

Patients with HS often have comorbid substance use disorders, and HS increases the risk of long-term opioid use. Nevertheless, the study of HS-associated ED visits showed that almost 60% of patients went home with opioid prescriptions.

For patients with early-stage disease, simple nonpharmacologic treatment can help reduce HS-related pain, said Del Campo. Warm compresses applied directly to lesions, warm sitz baths, and dilute-vinegar baths all have a role in pain management in his practice. Occasionally, he recommends acetaminophen in addition to the nonprescription interventions, but he typically avoids the drug because it is strictly an analgesic and does not address the underlying inflammation at the root of HS.

If a patient does not obtain adequate pain relief with simple approaches, Del Campo said he may consider consultation with a pain management specialist.

“We don’t want to create a new problem by introducing the potential for opioid dependence in a patient who has a chronic condition,” said Del Campo.

Vij also recommends acetaminophen infrequently, not only because of therapeutic limitations but also because of a risk of exacerbating fatty liver disease — another common comorbidity in patients with HS. Instead, he prefers NSAIDs, which work on the underlying inflammation and do not pose a risk to the liver.

Comorbid depression, another common finding among patients with HS, strongly affects pain perception, and some patients may benefit from consultation with a mental health specialist, said Vij. Both cognitive behavioral therapy and acceptance and commitment therapy have been shown to be helpful in relieving acute and chronic pain. Mental health specialists also can evaluate patients’ need for pharmacologic therapy.

Potential Algorithm

Appropriately addressing pain is essential for improving QoL and reducing the risk of substance use and opioid dependence in patients with HS, but multiple factors interfere with that goal, according to a recent article in the Journal of the American Academy of Dermatology.

“Unfortunately, current HS therapies often provide inadequate pain relief, and studies of HS pain-directed therapies are sparse,” stated Lauren A.V. Orenstein, MD, of Emory University in Atlanta, and co-authors. “This, coupled with limited clinical training in pain management among dermatologists, creates an environment where patients’ pain often goes medically untreated and patients may resort to self-management.”

In addition to reviewing evidence-based treatment options for HS-related pain, the authors offered an algorithm for pain management. For acute pain, they suggested acetaminophen and a topical NSAID. Depending on pain severity or refractoriness, they recommended potential add-on options: systemic NSAIDs, intralesional triamcinolone, and incision and drainage of abscesses. If pain persists, the next step is to offer patients tramadol (first-line opioid) or another short-acting opioid (maximum of 20 pills for either type of drug).

Orenstein and co-authors recommended a similar stepped-care approach for chronic HS-related pain. Guided by the pain’s level of refractoriness, they recommend, in the following order:

• HS disease-directed therapy and screening for pain severity and psychological comorbidities

• Nonpharmacologic interventions (physical therapy, wound care, and behavioral health)

• Pharmacologic analgesia (nociceptive pain: NSAIDs, duloxetine, and nortriptyline; neuropathic pain: gabapentin, duloxetine, pregabalin, venlafaxine, and nortriptyline for neuropathic pain), and adjunctive therapies (topical NSAIDs, topical lidocaine)

• Referral to a pain specialist

Multimodal, Multidisciplinary

The algorithm emphasizes multimodal pain management. That often involves a multidisciplinary approach, not only for pain management but also for other comorbid conditions commonly seen in patients with HS: mental health problems, obesity, and risk factors for diabetes and cardiovascular disease.

“As dermatologists, it’s important for us to let patients and their primary care doctors know about comorbid conditions and make sure patients are getting their whole health addressed,” said Joslyn Kirby, MD, of Beth Israel Deaconess Medical Center in Boston.

“I will often tell patients, ‘I’m the person you want managing your HS, but I’m going to admit that I am not the person you want managing your arthritis or high blood pressure.’ I need the help of a primary care doctor to do that,” Kirby said. “It’s an opportunity for me to ask whether the patient has a primary care provider. If not, I can help connect them with one.”

To win a patient’s buy-in for treatment of HS, associated pain, or other comorbid conditions, clinicians have to earn the patient’s trust, said Vij.

“I see so many patients who feel like they haven’t been heard, that they haven’t gotten the chance to get a good diagnosis, develop a good treatment plan, and develop a relationship with a provider,” he said. “They’ve kind of bounced around from the ED to a primary care physician or to a general surgeon and back and forth, without finding a real home.”

“One of the biggest problems I face [in treating HS] is building trust in patients who might feel like they’ve been burned or cast aside by the house of medicine,” Vij said. “Once we’ve done that, it makes the whole process a lot easier. They really engage with the treatment plan.”