Managing Pain in Patients With HS: Interview With Lauren Orenstein, MD

A recent study reviewed treatment options and tools available for addressing pain in patients with hidradenitis suppurativa. In this podcast, Lauren Orenstein, MD, discussed pharmacological and nonpharmacological options for patients with HS-related pain, as well as areas of future research needed to improve pain management for these patients.

Dr Orenstein is an assistant professor of dermatology at Emory University.

Transcript

Melissa: Hello, welcome to another podcast with The Dermatologist. I’m Melissa, the associate editor. Today, I have the pleasure of speaking with Dr Lauren Orenstein. She is an assistant professor of dermatology at Emory University.

Dr Orenstein is a coauthor of the recent review titled “Pain Management in Hidradenitis Suppurativa and a Proposed Treatment Algorithm,” which was just published in the Journal of the American Academy of Dermatology.

In this podcast, we will be discussing her recent review and proposed treatment algorithm, which you can access using the link below. Thank you for joining us today, Dr Orenstein. Why did you and your team decide to research pain management for HS and develop an algorithm specifically for dermatologists?

Dr Lauren Orenstein: Pain is considered by patients, it’s considered to be the most important symptom of HS, and it’s been shown that pain is even more strongly linked with quality of life in HS than disease severity. This is a really important problem for patients.

It affects not only their quality of life but ability to work, ability to have intimate relationships. Patients with HS have been shown to have higher rates of opioid use compared to other patient populations. It’s a really important problem, but despite the scope of this problem for HS patients, our guidelines on pain management are really sparse.

A lot of patients report that their pain is not being adequately treated. Our goal with this paper was, one, to help familiarize dermatologists with some of the agents that are most likely to be helpful in pain management in hidradenitis.

Also, to serve as a starting point for further research into the mechanisms and effective treatments for HS pain. Unfortunately, at this point, there’s really not a whole lot known about which treatments are most effective, and so this is a starting point of collecting expert opinions and something that needs to be tested out and studied further.

Melissa: What were some of the challenges for developing your review?

Dr Orenstein: I think one of the biggest challenges was figuring out what we were going to include versus not include, because the truth of it is that there have been very few of these treatments that have been studied in hidradenitis specifically.

What we ended up doing was choosing to include some of the therapies and treatments that are most frequently, at least in my experience, have been reported to be used by dermatologists for HS pain. Then for each of those, we tried to delve into what’s the evidence for each of them.

Melissa: Why was it important to distinguish between nociceptive and neuropathic pain?

Dr Orenstein: Nociceptive pain is pain that is caused by pain signals that are released at the site of tissue damage, whereas neuropathic pain is pain that is caused by nerve dysfunction. In hidradenitis, we have had a few different studies looking at neuropathic pain in HS and showing, oh, there may actually be a neuropathic component.

It makes sense that there is nociceptive pain, because that’s likely caused by inflammation at the sites of the HS. It’s only recently been recognized that neuropathic pain also exists in hidradenitis. We know from other diseases in the literature that neuropathic pain and nociceptive pain respond differently to different therapies.

So, it’s really important that we start to tease that out to figure out which therapies may be the best fit for individual patients.

Melissa: What are some of the challenges of treating pain in HS?

Dr Orenstein: It’s very challenging to manage pain in HS, because we just don’t know which analgesics or which types of therapies are likely to be the most effective for patients in general or for an individual patient.

I think some of the other challenges are that a lot of our patients with HS are living in severe pain, and that the degree of pain that they’re experiencing may be more than we as dermatologists are trained to manage on our own.

It’s really important to have backup and be able to engage a multidisciplinary team to be able to help with management of patients with severe, chronic pain. Also, there’s a lot of overlap between pain severity impact on quality of life and psychiatric disorders, like anxiety and depression.

It’s important, as we’re trying to treat our patients with pain, if there are also mental health disorders, to make sure that our patients are getting appropriate care for that.

Melissa: What pharmacological options appear to be effective for managing pain or show promise for managing pain in HS?

Dr Orenstein: That’s a great question. In terms of things that have been used to treat HS pain, the only things that we really have good evidence for, we have evidence for some HS disease-directed therapies, so meaning adalimumab was shown in clinical trials to reduce HS pain.

Spironolactone, I believe, in some observational studies has been shown to reduce HS pain. We’re hoping that, in the future, that clinical trials will continue to incorporate measures of pain into their trial so that we can know better which disease-directed therapies help with pain.

That’s probably the first step, is just making sure that the HS is being treated well and appropriately. In terms of other medications and impact on pain, there’s been some mixed evidence about intralesional triamcinolone being injected for acutely flared or painful HS lesions.

I say mixed in that I think were two observational studies to date that suggested that it is helpful and one randomized control trial that suggested that maybe it wasn’t. But that’s actually some of the best quality or best level evidence we have.

Other things that I think I have promise are, particularly for chronic neuropathic pain, I tend to use the antiepileptics, such as gabapentin and pregabalin, as well some of the serotonin/norepinephrine inhibitors, such as duloxetine.

Lastly, something that I’m really interested in studying, but it hasn’t been done yet, something that’s recommended by a pain colleague who I work with, is low-dose naltrexone, which has some anti-inflammatory activity, but also has been shown in other diseases to help with nociceptive and neuropathic pain.

I would be excited to study any of those last few options to learn more about their efficacy in HS.

Melissa: Particularly for those with chronic pain, what non-pharmacological options are helpful for patients to either reduce or help them cope with their pain?

Dr Orenstein: Mm-hmm, absolutely, that’s another great question. I think that some of the strongest evidence outside of HS is for psychological treatments in the management of chronic pain. Specifically, cognitive behavioral therapy, CBT, and acceptance commitment therapy, ACT.

Really, a lot of robust data that that can really help patients with the way that they experience their chronic pain. In hidradenitis, there’s also probably some role for things like specialized wound care therapy, because inappropriate bandages can contribute to a lot of irritation and unnecessary pain at sites of inflammation.

Then things like physical therapy may be helpful as well, although I think the role for that is a little bit more limited, just in that a lot of patients are so uncomfortable that they’re not able to complete physical therapy exercises. But I think, particularly for areas of scarring, or places where there’s reduced range of motion, physical therapy may help with some of that.

Melissa: When should a dermatologist consider referring a patient or collaborating with a pain management physician?

Dr Orenstein: I think that there’s almost always some role. At least in patients with chronic HS pain, I think that there’s almost always some role for other specialists and coordination of multidisciplinary care. Sometimes, that’s a pain specialist, but sometimes, that’s also a primary care physician and/or a psychologist, or a psychiatrist, or a wound care specialist.

I think that there are a lot of different ways to link into multidisciplinary care, and the individual needs of the patient should drive that. In terms of when I personally engage pain management specialists, it depends.

Well, one is my level of comfort, and at any time, when I feel that my training is not adequate, or for a patient’s needs, then I will refer a patient. My rule of thumb generally, though, about how I refer patients to pain management is that, if a patient has failed at least two pharmacologic therapies for their pain.

If a patient has medically refractory HS, meaning they just have such severe HS, and they’re not responding to their HS disease-directed therapies, and then also patients who come into me for consultation and are already using opioids on a chronic basis.

That’s not something that I’m trained to do, and also, I set it for those patients as goals to try to be able to reduce their opioid use, or even get off of them entirely. But I think that having a pain specialist involved really augments our ability to be able to get patients off of those medications.

Melissa: Obviously, there’s a lot, but what areas of future research are needed to improve pain management in patients with HS?

Dr Orenstein: I think that a lot of research is needed in pain and HS. This is one of the biggest problems for patients with HS, and we really know very little about what causes their pain and what kinds of therapies are effective.

So I think probably first and foremost would be research into the underlying mechanisms of pain and hidradenitis. For a long time, it’s been assumed to be only inflammation of the skin. But I think some of our more recent evidence, especially of having neuropathic pain, suggests that there may be other factors at play.

There has recently been some interest – there was an opinion article in JAMA Dermatology published – about using quantitative sensory testing in hidradenitis suppurativa to help locate where in the pain pathway the pain may be originating.

So this is one of my areas of interest in terms of HS pain research. I think eventually we’re going to need also studies about which therapies are most effective for HS pain. So that probably starts with observational studies and case series, and probably eventually involves randomized control trials.

As we move to an era of doing trials for HS pain, whether that’s for disease-directed therapies or analgesics, we also need better measures of HS pain severity. So there’s been some effort, and there are ongoing efforts by HISTORIC, which is the HIdradenitis SuppuraTiva cORe outcome set International Collaboration, to establish what those measures should be for clinical trials.

Melissa: What key takeaways would you like to leave with our audience?

Dr Orenstein: One of the key takeaways from this is that I’d like for people to recognize that pain is such a critical problem for individuals living with hidradenitis suppurativa. Pain has a huge impact on quality of life and has implications in terms of chronic opioid use in this patient population.

Research into the underlying mechanisms as well as effective therapies is a critical need to help serve our HS patients.

Melissa: Thank you again for joining us today, Dr Orenstein, and for talking about your work. If you have any questions or comments, please submit them in the feedback box below, and thank you for listening.