Amit Garg, MD, is a Professor and the Founding Chair for the Department of Dermatology at the Donald and Barbara Zucker School of Medicine at Hofstra / Northwell. Dr. Garg is a skilled medical dermatologist and a medical educator. He’s known for his outstanding expertise in autoimmune and inflammatory skin diseases including psoriasis and hidradenitis suppurativa. He joined The Dermatologist to share insights into Hidradenitis Suppurativa and to discuss his latest study, “Comorbidity screening in hidradenitis suppurativa: Evidence-based recommendations from the US and Canadian Hidradenitis Suppurativa Foundations”.1
What were the reasons you and your team conducted this study?
Over the past five years, there's been an abundance of original studies describing a myriad of comorbid conditions linked to Hidradenitis Suppurativa involving a number of different organ systems.
There was a need to systematically evaluate the data on this topic and to summarize the level of evidence on comorbidity screening in HS, so that dermatologists and other physicians that are part of the care team have an evidence-based framework to comprehensively care for the HS patient.
Your study recommends screening for a least 19 different comorbidities, but states, “The role of the dermatologist in screening varies according to comorbidity.” How was this the case?
The evidence indicates that screenings for comorbidities in HS is much broader than the scope of practice for most dermatologists—even for those who have a specific expertise in caring for HS patients. We recommended that dermatologist pursue screening measures which are within their scope or otherwise can be achieved through a simple review of systems' assessment. Then the remaining comorbidities should be pursued by other types of physicians including primary care physicians and specialists who are expert in those other screening measures. It requires a multidisciplinary team to be able to comprehensively care for the HS patient based on the data we now know about their comorbidities.
How should dermatologists support screening efforts to identify comorbid conditions in HS?
The evidence suggests that HS patients should be screened for acne, dissecting cellulitis of the scalp, pilonidal disease, pyoderma gangrenosum, all of which can be achieved through physical examination of the skin by a dermatologist.
We also felt that dermatologists should be able to offer simple review of systems' assessments to screen for tobacco smoking, inflammatory bowel disease, inflammatory arthritis, even something like sexual dysfunction. The article has simple and specific questions the dermatologist can use to screen for these conditions. The remaining screenings involving a number of other organ systems should be undertaken, again, by primary care doctor, or other specialists.
However, we also felt that the dermatologist was in the best position to advocate for those comprehensive screening measures to physicians who are less familiar with HS and its comorbidities. In addition to the skin exams and simple review of systems, dermatologists should advocate in making sure that other physicians get involved in the care of HS patients.
What further research is needed to enhance proper comprehensive care strategies for comorbidities associated with HS?
We still have a long ways to go, and there's a lot to learn in HS. Now that we are aware that these comorbidities exist, we need to develop strategies to implement these screenings into practice for HS patients. Then we need to evaluate whether those strategies have improved the overall health of HS patients.
We need to better understand how comorbid diseases afflict special populations with HS including women and skin of color patients. These are subgroups who are disproportionately afflicted with the disease. Similarly, we want to understand the burden of comorbid disease among children and adolescents with HS. I think that understanding the mechanisms linking HS to all these comorbid diseases is also of fundamental importance.
Finally, with the development of novel therapeutic immune targets, which effectively can address inflammation in HS, there's an opportunity to understand whether treatment of HS allows for control of comorbidities or a reduction in the risk of developing comorbid diseases.
The most important take-home point for dermatologists is to understand that while our focus should be on evaluating and treating HS, it's also important to have the broader care needs of the HS patient in mind, and to advocate for a multidisciplinary comprehensive care strategy for HS patients.
Any pearls of wisdom you’d like to share with your colleagues regarding HS?
I don't think I'd be saying anything my colleagues haven't already appreciated when I say that HS patients truly do suffer. Perhaps more so than any other patients with diseases of the integument. Please give these patients your time, your expertise, and your compassion when caring for them.
Reference:
1. Garg A, Malviya N, Strunk A, et al. Comorbidity screening in hidradenitis suppurativa: Evidence-based recommendations from the US and Canadian Hidradenitis Suppurativa Foundations. J Am Acad Dermatol. Published online January 23, 2021;S0190-9622(21)00213-9. doi:10.1016/j.jaad.2021.01.059
