Delays in HS Diagnosis, Treatment Shed Light on Provider Education Gaps

Patients with hidradenitis suppurativa (HS) have to wait over 2 months on average from receiving a referral to a diagnosis and experience low implementation rates for treatment, highlighting the need for greater HS awareness and education for providers, according to a retrospective study from Canada.

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Patients with acute HS flare-ups often seek care at urgent care clinics and emergency departments. It's crucial for health care providers to understand that HS is a chronic condition and that they need to provide follow-up care beyond managing acute lesions. Specialist physicians, including gastroenterologists, rheumatologists, infectious disease specialists, gynecologists, general surgeons, plastic surgeons, and urologists, may be involved in HS care to address comorbid conditions, consult on antibiotic use, manage misdiagnoses, and provide surgical interventions. Awareness of HS among specialists is key to avoiding misdiagnoses and ensuring effective treatment.

Although past studies have analyzed diagnostic accuracy and management of HS in emergency department settings, this has not been studied in other health care settings. “Given the prolonged wait times to see a dermatologist in many areas of Canada, it is important that referring providers are knowledgeable in HS and are comfortable initiating preliminary management to help ameliorate patients’ symptoms while they are waiting to see a dermatologist,” the authors wrote.

This study included patients who were referred to Beacon Dermatology in Calgary, Alberta, between May 2020 and May 2023, either due to suspicion of HS or for a first time diagnosis of HS by one of the dermatologists there. Patients who had already been diagnosed with HS by a dermatologist from another clinic and were referred for ongoing care were excluded. Additionally, patients who received their first HS diagnosis at Beacon Dermatology before 2020 were excluded from the study.

Overall, 825 patient records were collected during the initial search, 374 of which were excluded (n = 111 duplicates; n = 151 referrals or transfers after HS diagnosis; n = 80 prior to 2020; n = 28 missing diagnostic consideration in referral letter or clinic notes; n = 4 missing referral letters). Among the 451 remaining charts, the mean age of the patients was 35.5 years (range, 11-87), and 83% (n = 373) were women.

The median duration from when the referring provider initiated the electronic referral to patients' initial appointments with a dermatologist was 9.1 weeks. During their first dermatology visit, patients reported experiencing HS symptoms for an average of 7.3 years (n = 389). Diagnosis revealed that 55% of patients (n = 246) had mild (Hurley stage I) or mild to moderate (Hurley stage I-II) HS, while 45% (n = 200) had moderate (Hurley stage II), moderate to severe (Hurley stage II-III), or severe (Hurley stage III) HS.

Most patients (91.8%) were referred by primary care providers, with some referrals from specialties like emergency medicine, gynecology, and others. Out of 451 patients, 449 were diagnosed with HS by Beacon Dermatology, while 2 patients referred by family physicians received different diagnoses.

Dermatologists confirmed HS in 63.4% (n = 286) of cases, with 4.9% of referral letters lacking a specific diagnosis but indicating HS symptoms. Misdiagnoses were common, including abscesses and acne. Initial management was initiated in 63% of cases. Diagnostic concordance rates were 62% for mild HS and 80% for moderate-to-severe HS. Treatment included topical antibiotics, oral medications, and procedures like incision and drainage.

The researchers identified 2 main limitations of this study, including the reliance on retrospective data and a potential sampling bias due to providers referring patients to dermatologists possibly having higher awareness and knowledge of HS.

The study findings suggested a need for increased teaching about HS in medical schools, as well as the development of continuing medical education courses on HS management for practicing providers, to help optimize interdisciplinary care for HS patients.

“This study highlights some of the current gaps in care for HS patients in Canada," the authors concluded. "Given the prolonged time to diagnosis, increasing awareness of HS among healthcare providers is an important goal. Recognizing potential signs of HS and understanding how HS can be differentiated from other conditions with overlapping symptoms is a particularly important skill to focus on for primary care providers and specialists who routinely treat HS patients.”

Reference

Johnston LA, Poelman SM. Hidradenitis suppurativa patient referrals to a Canadian community dermatology practice: A retrospective chart review. J Cutan Med Surg. Published January 19, 2024. doi:10.1177/12034754231223451