Key clinical point: Severe pain is common among patients with hidradenitis suppurativa (HS) presenting to the emergency department (ED) and opioids are frequently prescribed.

Major finding: An estimated 383000 ED visits for HS were recorded during the study period (2006-2017); such visits increased from 25260 in 2006 to 131430 in 2017. Severe pain was reported at 69.9% of visits, with 40.1% of patients rating pain as 10 on a 10-point pain scale. At discharge, 58.3% (95% confidence interval, 41.0%-73.8%) of patients were prescribed opioids. Hydrocodone was prescribed most commonly (80.3%), followed by oxycodone (11.3%).

Study details: This study analyzed pain severity and management of HS in the ED setting using data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of visits to EDs in the United States.

Disclosures: No study sponsor was identified. Dr. Orenstein reported serving as a paid trial investigator for ChemoCentryx Inc and receiving personal fees from ChemoCentryx Inc, Frontline Medical Communications, Huron Consulting Group, and Medical Education Solutions, LLC outside the submitted work. No other disclosures were reported.

Commentary

“This repeated cross-sectional study, which utilized data from a nationally representative sample of visits to emergency departments in the United States, found that pain is a significant problem among HS patients seeking care in the ED. The high rates of “severe pain” (70%) and “10-out-of-10” pain (40%) were particularly notable, as was the frequency with which opioids were prescribed (58%). These numbers were far in excess of those experienced by patients seeking ED care for atopic dermatitis or psoriasis. Patients with HS received prescriptions for opioids more frequently even than those presenting with low back pain.

These data suggest many patients with HS are not receiving effective medical therapies for prevention of disease flare. Prior work has shown that the large majority of outpatient encounters for HS are not with dermatologists and that, consequently, patients are less likely to receive appropriate antibiotic and non-antibiotic systemic therapies. Inadequately managed disease activity predictably leads to flaring symptoms and the need to seek care urgently. Unfortunately, as this study clearly demonstrates, the emergency department—where incision and drainage, opioids, and antibiotics lacking efficacy data for HS are most commonly dispensed—is a suboptimal setting for the care of patients with hidradenitis.

Earlier referral to dermatology and improved management of HS are critical to reducing ED visits, pain, and opioid prescribing among those suffering with HS.”

Robert G. Micheletti, MD

Assistant Professor of Dermatology and Medicine

Perelman School of Medicine, University of Pennsylvania

References:

Wehner MR, Micheletti R, Noe MH, Linos E, Margolis DJ, Naik HB. Hidradenitis suppurativa encounters in a national electronic health record database notable for low dermatology utilization, infrequent biologic prescriptions, and frequent opiate prescriptions. J Am Acad Dermatol. 2020;82(5):1239-1241.

Reddy S, Orenstein LAV, Strunk A, Garg A. Incidence of long-term opioid use among opioid-naive patients with hidradenitis suppurativa in the United States. JAMA Dermatol. 2019;155(11):1284-1290.