What strategies can help manage pain in HS patients?
Clinical Applications
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, FAAD, November 1, 2021
In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, FAAD, talks with Lauren A. V. Orenstein, MD, MSc, FAAD, about her JAAD paper "Pain management in hidradenitis suppurativa and a proposed treatment algorithm."
DermWorld: You and your colleagues recently published recommendations for managing pain associated with hidradenitis suppurativa (HS). Thank you for addressing this very important topic. I feel this has been a very underappreciated aspect of this disease; in fact, several of the international guidelines you mentioned failed to address this. Do you think this is unique to this condition and, if so, why might we have been slow to address it?
Dr. Orenstein: Although pain is one of the most important symptoms for individuals living with HS and a major contributor to impaired quality of life in this disease, very little is known about effective therapies. The importance of addressing our patients’ skin symptoms in addition to treating the inflammatory skin disease is not unique to HS; addressing symptoms is important for any patient whose skin disease fails to respond or responds only partially to disease-modifying therapies. Recent data suggest that HS pain is complex, likely linked both to chronic underlying inflammation, structural tissue damage, and intermittent acute flares. As we learn more about the mechanisms of HS pain and the types of pain that are most disruptive to patients’ daily lives, we may be able to offer pain management strategies that are tailored more specifically to HS pain.
DermWorld: You indicated that HS pain can be either predominantly nociceptive or neuropathic. Can you tell us more about this? Do you feel these types of pain are easily distinguished and if so, is it critical from a patient management perspective to do so?
Dr. Orenstein: In HS, nociceptive pain is thought to result from a direct inflammatory insult to the HS affected tissue. Individuals with nociceptive pain often experience a throbbing, pressure-like pain within and around HS lesions. Neuropathic pain, on the other hand, may travel beyond the HS affected tissue causing hot, burning, tingling pain. Clinically, I think that it is helpful to distinguish between nociceptive pain and neuropathic pain because it affects how I think about treatment selection. Although nociceptive and neuropathic pain are treated differently in other painful disease states, more evidence is needed to determine whether different therapeutic approaches are critical within HS.
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DermWorld: Do we know if treating pain in our patients with HS is associated with better disease outcomes?
Dr. Orenstein: HS pain is associated with poor mental health, work loss, and impaired quality of life. While I anticipate that effective management of HS pain would improve these outcomes, there have been no formal studies of pain therapies in HS.
DermWorld: Do you have any advice on how to find mental health care providers who can help address the psychosocial aspects of this disease? Do you have any suggestions as to how we might recommend this care to our patients without potentially offending them?
Dr. Orenstein: Addressing mental health comorbidities is critical in this patient population yet requires sensitivity to help patients feel comfortable and improve the likelihood that they will be receptive to getting help. The U.S. and Canadian HS Foundations recommend screening HS patients for anxiety and depression using the GAD-7 and PHQ-2 or PHQ-9 surveys (doi: 10.1016/j.jaad.2021.01.059. Epub ahead of print), and I administer these surveys routinely in HS clinic. For those with positive screens, I open with: “Individuals living with HS often suffer from anxiety, depression, or feelings of decreased wellbeing. Your surveys today suggest some distress. How do you feel that you’re doing?” After listening to the patient’s perspective, I will often follow up with: “Thank you for sharing. Many of my patients find it helpful to see a mental health professional as they learn to navigate and cope with these difficult issues. Would you be interested in a referral?”
If the patient agrees, it is helpful to find a mental health professional with expertise in chronic medical diseases and/or sexual health. If you have many HS patients in need of mental health services, it may also be helpful to develop relationships with local psychologists or psychiatrists and to help educate them about HS prior to the first HS patient consultation.
DermWorld: Not all dermatologists are comfortable prescribing many of the drugs you listed. Do you have any reassuring words for our potentially reticent colleagues?
Dr. Orenstein: Physicians should prescribe within the limits of what they feel is safe and within the scope of their training. However, we as dermatologists have an in-depth understanding of the HS disease process which positions us to advocate on behalf of our patients and to develop appropriate pain-management strategies. To gain the skills and confidence to manage HS pain, I suggest attending relevant continuing medical education programs, working closely with a pain or palliative care specialist, and gradually expanding your treatment armamentarium for HS pain.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DW.
