Compiled by our Editorial Team of Louise Todd, Tom Chown, Jacob Baker, Penny Staton, Georgina Mason, Allen Wellings, Abhi Chakravorty and Adam Jeffery.
The 27th European Academy of Dermatology and Venereology (EADV) meeting opened in style, with a wide array of high-science sessions covering the management of a range of conditions including leprosy, eczema, dermato-oncology and dermatitis to name but a few. In this series of EADV 2018 daily highlights, we will be taking a closer look at the scientific content being presented around a debilitating condition, hidradenitis suppurativa (HS).
Professor Gregor Jemec from Roskilde Hospital, Denmark and Dr Lukasz Matusiak from Wroclaw Medical University, Poland chaired a fascinating session organised by the European Hidradenitis Suppurativa Foundation, exploring current research and challenges in the management of HS. This inflammatory cutaneous disease of the hair follicles results in deep, painful lesions, most frequently in the axilla. HS is a chronic condition, staged according to the Hurley staging system, with Hurley I being the mildest form, and Hurley III being the most severe. It has proven to be difficult to manage in current clinical practice. This session covered insights including the pathogenesis of disease, the role of biomarkers and the development and use of new imaging techniques for the differential diagnosis and management of HS.
Dr Giovanni Damiani of the Ospedale Maggiore Policlinico, Milano, Italy discussed the impact of comorbidities on the treatment choices of patients with HS, reviewing how patients with severe HS are more likely to suffer from associated comorbidities than the general population. Of those HS patients with Hurley II stage disease, 55% have one or more comorbidities, compared to 81% of those with Hurley stage III disease.
Treatment of these patients remains a therapeutic challenge, with complicated treatment management challenges due to the presence of comorbidities. In some patients, treatment with adalimumab or metronidazole/colchicine may be a useful alternative. Outcomes in these patients as assessed by patient-reported outcomes tools (including the Patient Global Assessment tool [PGA], visual analogue scales [VAS], and the Dermatology Life Quality Index [DLQI]) revealed significant improvements in HS, along with clinically important changes in DLQI score.
Dr Damiani went on to discuss the use of new technologies in the treatment of HS, including thermography, a painless imaging tool for use alongside MRI in the surgical excision of HS lesions. He explained the potential benefits and pitfalls of this methodology, including the need for clearer measures of lesion differentiation, currently being explored with the use of mathematic modelling tools.
Other sessions and presentations further explored this theme. A poster presented by Dr Juan José Andrés-Lencina, from Madrid, Spain, reported details of a 19-year old patient with axillary Hurley III HS, admitted at the Hospital Universitario 12 De Octubre, Madrid, Spain for antibiotic treatment.
The lesions did not respond to 3 weeks of treatment, with chronic fistulas and cutaneous abscesses still present and actively draining. Manual cures were unsuitable due to the patient’s pain levels, and so surgical treatment was instead commenced.
Whilst undergoing preparation for surgery, cutaneous ultrasound was used to identify lesions invisible during clinical evaluation enabling the identification of 3 new fluid collections, and 1 fistulous tract in the left axilla, and 2 fluid collections in the right axilla. The main margins of the left axilla were also increased.
This single-patient case study demonstrates the potential usefulness of ultrasound. Dr Andrés-Lencina’s report went on to explain that the intraoperative ultrasound allows better review and evaluation of affected areas, as the patient is then under anaesthetic. This can lead to more accurate surgical excision and thereby improve patient outcomes.
With Dr Graziana Amendolagine of the University of Ferrara, Italy, sadly unable to attend, her presentation was ably delivered by her colleague who reviewed the role of bacteria in the pathogenesis of HS, and the role this has on triggering an immune response. The presence of high-levels of some bacteria in HS is widely-reported, however the levels of infection are inconsistent due to differences in sample collection and processing techniques.
A 2014 study lead by Hélène Guet-Revillet, Université Paris Descartes, France reported results of bacterial analysis of 102 HS lesions, from 82 patients (Gaut-Revillet H et al. Emerg Infect Dis. 2014;20:1990–8). They found the bacteria Staphylococcus lugdunensis present as a unique or predominant isolate in 58% of HS nodules analysed, and high levels of anaerobe activity in 83% of lesions.
As Dr Amendolagine went on to explain, a range of antibiotics are used to treat HS including clindamycin, rifampicin and tetracycline. These are broad spectrum antibiotics, resulting in good anti-inflammatory responses, but can lead to treatment resistance, particularly over long-term use. A study published this year (Ardon CB et al. J Eur Acad Dermatol Venereol. 2018. [Epub ahead of print]) reported 89% of lesions having developed resistance to clindamycin, a rate sure to cause alarm to the dermatological community. Dr Amendolagine’s group also reported significant rates of resistance, providing a warning to those involved in the treatment and management of HS to be cognisant of this and prescribe based on the results of microbial tests when possible.
Day 2 will continue to bring further insight into the management of dermatological conditions, and we will provide you with daily overviews to highlight just some of the exciting new developments in this field.
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