Pearls for treating hidradenitis suppurative in kids

Dr. SayedWhile hidradenitis suppurativa (HS) is similar in teenagers and adults, an HS diagnosis in children younger than 11 should prompt dermatologists to look further at the potential cause, according to Christopher J. Sayed, M.D., assistant professor of dermatology at University of North Carolina at Chapel Hill.

Dr. Sayed presented on HS in pediatric patients during the Hidradenitis Suppurativa/Acne Inversa: Current Medical and Surgical Management scientific session March 5 at the American Academy of Dermatology annual meeting in Orlando, Fla.

“The teenage population is very similar to adults with hidradenitis suppurativa in a lot of ways. It’s going to skew to female patients, and patients who have issues with being overweight or have a tendency toward metabolic syndrome as they get older,” Dr. Sayed says. “For the patients that are under age 11, you should start to worry that there could be and underlying hormonal issue, like precocious puberty, which can be caused by a number of factors.”

Another thing dermatologists should keep in mind during this history taking and exam is how the HS might be impacting the patient socially.

“One thing to be particularly aware of in the pediatric population is the impact it has on their ability to attend school and their ability to be socially interactive,” Dr. Sayed says. “Many patients end up home schooling or missing a lot of school or isolating themselves socially because of their HS.”

Dermatologists should keep tabs on pediatric HS patients, looking for signs of depression and social isolation, so they can refer them to other specialists, if necessary, according to Dr. Sayed.

“If they’re having issues with depression and chronic pain, make sure that those are addressed appropriately. That can mean finding psychologists or chronic pain specialists to help focus on these issues,” he says.

Next: For optimal treatment, the key is to catch the disease early on

15-year-old African-American female with Hurley stage II disease in the axillaeFor optimal treatment, the key is to catch the disease early on, according to Dr. Sayed. Patients with early stage disease benefit from Nd: YAG or other types of lasers that destroy the follicular unit. Dermatologists might also try antibiotics, birth control pills, spironolactone-things they’d frequently use in young, female acne patients, he says.

“There are no approved biologics for HS in pediatric patients, but, in many cases, [biologic treatments] can be useful in the pediatric population, just as they are in adults,” Dr. Sayed says. “Adalimumab is the only biologic that’s approved for HS in adults. And there’s plenty of data on infliximab on adults, but they’re not specifically approved for pediatric HS.  Both are approved for other conditions in pediatric populations so we should feel safe using them in the HS population when the benefits outweigh the risks”

The fact that the biologics aren’t approved for pediatric HS patients can lead to problems with insurance carriers’ covering the medications. These insurance approval problems often can be overcome, however, if dermatologists are willing to fight for the treatment, Dr. Sayed says.

HS treatment success with first-line therapies is hit and miss, according to the dermatologist. When the disease is diagnosed early on, laser treatment can control it well.

“But it’s not uncommon when the disease is very aggressive to have to go to second- and third-line treatments,” he says. “With young patients, they have such a long course of disease. If you have a 40-year-old patient or even a 25-year-old patient, they may be more likely to outgrow their disease in 5 to 10 years of their diagnosis. A lot of teenagers are going to have their disease for decades. Younger age of onset is also correlated with a more severe disease course.”

Next: Lifestyle modifications as treatment

23-year-old African-American patient with severe Hurley stage III disease in the axillae that started at age 14Lifestyle modifications can help. It’s always good to remind patients when they’re younger that smoking might make HS worse and more difficult to control.

“So trying to break those habits at an early age, or counseling them to avoid those habits in the future, is always part of what I do for young patients,” Dr. Sayed says.

Weight often is an ongoing issue for these patients. Many HS teenagers are overweight and, ironically, having HS can make it harder for them to lose weight by being physically active.

“They tend to gain weight over time,” Dr. Sayed says. “So, to be able to counsel them early on that trying to keep their weight as under control as possible and not gaining weight may help keep the disease from being as bad as it can be.”

While by some estimates HS is an uncommon disease, it is often underreported and misdiagnosed so it may effect up to 2% of the population, according to the dermatologist.

“About a third of patients will have their first symptoms of HS before age 18. That may be an underestimate,” Dr. Sayed says. “Patients often go for years without being diagnosed even though they’ve had symptoms for a long time.”

Dermatologists who recognize HS in the pediatric population early and treat it aggressively before things get worse, could help patients avoid the need for surgery later on and could impact disease progression, he says.

Disclosure: Dr. Sayed is a speaker and is on the advisory board for AbbVie, which manufactures adalimumab (Humira).