STUDY 1

Patel, K. R., Lee, H. H., Rastogi, S., Vakharia, P. P., Hua, T., Chhiba, K., Singam, V., & Silverberg, J. I. (2020). Association between hidradenitis suppurativa, depression, anxiety, and suicidality: A systematic review and meta-analysis. Journal of the American Academy of Dermatology, 83(3), 737-744.

Summary

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that affects 0.03%-4% of the population across the world (Calao et al., 2018). It is associated with multiple comorbidities, such as obesity, metabolic syndrome, smoking, depression, arthritis, autoinflammatory syndromes, and inflammatory bowel disease, and can have a debilitating effect on a person's well-being (Porter & Kimball, 2017). The condition is also highly symptomatic, as it is often associated with skin pain, pruritus, disfiguring lesions, scarring, sexual disturbances, psychological distress, and impaired quality of life (Alikhan et al., 2009; Kurek et al., 2012; Vekic & Cains, 2017). Given the many known comorbidities of HS, the researchers in this study looked to determine if there is an association between HS and increased depression, anxiety, and suicidality because previous studies have shown conflicting results (Patel et al., 2017; Thorlacius et al., 2018).

This study was exempt from institutional review board approval because data were gathered from published literature. Ultimately, 38 observational studies were included in the systematic review after meeting inclusion/exclusion criteria, and 27 articles were included in the quantitative meta-analysis. All studies included were published from 1963 through 2018 and investigated the association between HS and depression (n = 37), anxiety (n = 14), antidepressant use (n = 2), anxiolytic use (n = 1), and suicidality (n = 2).

This meta-analysis found that, in the studies reviewed, about 25% of adults with HS had depression and about 20% had anxiety. Regardless of the study design, control population, and disease clarification, adults with HS were found to have significantly higher odds of depression and anxiety. Furthermore, patients with HS had higher rates of antidepressant and anxiolytic medication use, and HS was also associated with a higher rate of suicidality.

Commentary

The findings of this systematic and meta-analysis study underscore the importance of increasing screening for mental health comorbidities such as depression, anxiety, and suicidality in those with HS. Patients with HS who show signs of depression, anxiety, and suicidality may have a higher disease burden of HS and subsequently should be more closely monitored. Furthermore, a more holistic treatment approach that encompasses referral and treatment for coexisting mental health comorbidities would likely benefit patients with HS in the long term.

A prior systematic review by Halaris (2017) and meta-analysis by Bjelland et al. (2002) showed that patients tend to report that their chronic diseases, such as diabetes, chronic obstructive pulmonary disease, and heart disease, are directly intertwined with their mental health symptoms. In particular, chronic pain that is associated with chronic disease has been associated with depression in adult patients. Although the exact mechanism of the association between HS, depression, and anxiety is unknown, what we do know is that pain is a commonly reported symptom in HS and can play an important role in the development of mental health symptoms in those with HS. Therefore, medical and surgical treatments that focus on diminishing pain could potentially reduce mental health symptoms in patients with HS. New promising medical treatments, such as anakinra, canakinumab, and adalimumab, have shown to reduce pain and inflammatory symptoms by targeting different proinflammatory mediators associated with HS (Elston, 2020; Lyons et al., 2020). Other physical interventions such as flushing of sinus tracts with normal saline or triamcinolone suspension can also reduce pain, although surgical intervention involving unroofing of sinus tracts continues to be the definitive treatment for persistent and severe disease (Elston, 2020). Regardless of the mechanism, future longitudinal studies are needed to determine the relationship between HS and mental health symptoms and develop strategies that integrate multiple modalities of therapy to treat and prevent worsening of HS symptoms.

REFERENCES

Alikhan A., Lynch P. J., & Eisen D. B. (2009). Hidradenitis suppurativa: A comprehensive review. Journal of the American Academy of Dermatology., 60(4), 539-561.

Bjelland I., Dahl A. A., Haug T. T., & Neckelmann D. (2002). The validity of the Hospital Anxiety and Depression Scale. An updated literature review. Journal of Psychosomatic Research, 52(2), 69-77. 10.1016/s0022-3999(01)00296-3

Calao M., Wilson J. L., Spelman L., Billot L., Rubel D., Watts A. D., & Jemec G. (2018). Hidradenitis suppurativa (HS) prevalence, demographics and management pathways in Australia: A population-based cross-sectional study. PLoS One, 13(7), e0200683. 10.1371/journal.pone.0200683

Elston D. M. (2020). Hidradenitis suppurativa: New drugs, old challenges. Journal of the American Academy of Dermatology, 83(3), 733-734. 10.1016/j.jaad.2020.05.031

Halaris A. (2017). Inflammation-associated co-morbidity between depression and cardiovascular disease. Current Topics in Behavioral Neurosciences, 31, 45-70. 10.1007/7854_2016_28

Kurek A., Peters E. M., Chanwangpong A., Sabat R., Sterry W., & Schneider-Burrus S. (2012). Profound disturbances of sexual health in patients with acne inversa. Journal of the American Academy of Dermatology, 67(3), 422-428.e1. 10.1016/j.jaad.2011.10.024

Lyons A. B., Shabeeb N., Nicholson C. L., Braunberger T. L., Peacock A., & Hamzavi I. H. (2020). Emerging medical treatments for hidradenitis suppurativa. Journal of the American Academy of Dermatology, 83(2), 554-562. 10.1016/j.jaad.2020.04.009

Patel Z. S., Hoffman L. K., Buse D. C., Grinberg A. S., Afifi L., Cohen S. R., Lowes M. A., & Seng E. K. (2017). Pain, psychological comorbidities, disability, and impaired quality of life in hidradenitis suppurativa [corrected]. Current Pain and Headache Reports, 21(12), 49. 10.1007/s11916-017-0647-3

Porter M. L., & Kimball A. B. (2017). Comorbidities of hidradenitis suppurativa. Seminars in Cutaneous Medicine and Surgery, 36(2), 55-57. 10.12788/j.sder.2017.018

Thorlacius L., Cohen A. D., Gislason G. H., Jemec G., & Egeberg A. (2018). Increased suicide risk in patients with hidradenitis suppurativa. The Journal of Investigative Dermatology, 138(1), 52-57. 10.1016/j.jid.2017.09.008

Vekic D. A., & Cains G. D. (2017). Hidradenitis suppurativa-Management, comorbidities and monitoring. Australian Family Physician, 46(8), 584-588.

STUDY 2

McGee, J. S., Reynolds, R. V., & Olbricht, S. M. (2020). Fighting COVID-19: Early teledermatology lessons learned. Journal of the American Academy of Dermatology, 83(4), 1224-1225. https://doi.org/10.1016/j.jaad.2020.06.027

Summary

Teledermatology has grown steadily over the past decade, with the number of active programs increasing from 37 to 102 between the years 2011 and 2016 (Yim et al., 2018). This growth accelerated dramatically during the COVID-19 pandemic, as practices across the country shuttered their doors and insurers expanded coverage for telehealth. This retrospective analysis of medical records investigated whether the transition to telehealth led to changes in practice patterns.

Investigators reviewed records at the Beth Israel Deaconess Medical Center Department of Dermatology in Boston, Massachusetts. The study sample included 250 in-person visits conducted in February 2020, prior to the pandemic, and 274 teledermatology visits conducted in April 2020, during the pandemic. The following data were collected: patient age, preferred language, diagnoses, disposition, visit type, and visit duration.

Prior to the pandemic, individuals older than 65 years and non-English-speaking patients comprised 32% and 7% of in-person visits, respectively. During the pandemic, they comprised only 23% and 3% of teledermatology visits, respectively. The most common diagnoses for telehealth visits were a lesion of concern (24%), acne (19%), and dermatitis (18%). Approximately 60% of visits for a lesion of concern required in-person follow-up, whereas close to none of the visits for acne or dermatitis required office follow-up.

Commentary

Although this is a single-center study of records, it highlights several challenges in telemedicine. Although telemedicine undoubtedly has numerous benefits, it may also create disparities based on an individual's access to technology, digital literacy, and ability to engage in care virtually. This is particularly concerning for older adults and non-English-speaking patients. A survey by the American Association of Retired Persons found that 34% of individuals older than 65 years did not have access to high-speed Internet (Keenan, 2020). In addition, 42% of Hispanic/Latino respondents did not have Internet access, compared to 19% of white individuals. Even those who had Internet were not entirely comfortable with telehealth services, with 17% of 50- to 80-year-olds having never used videoconferencing technology previously (Buis et al., 2020).

This study also demonstrates that not all conditions are appropriate to evaluate through telehealth. More than half of patients who were seen for lesions of concern required in-office follow-up, likely leading to additional costs for the patient and additional time and resources spent on the part of the provider. This finding reaffirms prior studies. A randomized clinical trial found that patients with physician-diagnosed psoriasis had similar disease outcomes with telemedicine and in-office care; however, studies on patients with skin cancer found that telemedicine was associated with poorer diagnostic accuracy (Armstrong et al., 2018; Finnane et al., 2017).

With telehealth poised to become a permanent fixture in clinical practice, it is important to recognize that it may not be suitable for all patients or conditions. In-person visits should be considered for patients lacking Internet access or those who will likely require a biopsy, full-body examination, or evaluation of subtle skin findings that may not be clearly visible on camera. For patients who face language barriers or have limited familiarity with telemedicine, education and support should be provided so that they can feel engaged in their visit, be it in person or through a screen. Future studies on telehealth adoption and utilization should include vulnerable populations to identify potential barriers and facilitators of telehealth use.

REFERENCES

Armstrong A. W., Chambers C. J., Maverakis E., Cheng M. Y., Dunnick C. A., Chren M. M., Gelfand J. M., Wong D. J., Gibbons B. M., Gibbons C. M., Torres J., Steel A. C., Wang E. A., Clark C. M., Singh S., Kornmehl H. A., Wilken R., Florek A. G., Ford A. R., [horizontal ellipsis] Lane C. J. (2018). Effectiveness of online vs in-person care for adults with psoriasis: A randomized clinical trial. JAMA Network Open, 1(6), e183062. https://doi.org/10.1001/jamanetworkopen.2018.3062

Buis L., Singer D., Solway E., Kirch M., Kullgren J., & Maleni P. (2020, August 17). Telehealth use among older adults before and during COVID-19. University of Michigan National Poll on Healthy Aging. https://hdl.handle.net/2027.42/156253

Finnane A., Dallest K., Janda M., & Soyer H. P. (2017). Teledermatology for the diagnosis and management of skin cancer: A systematic review. JAMA Dermatology, 153(3), 319-327. https://doi.org/10.1001/jamadermatol.2016.4361

Keenan T. A. (2020, June). Views on telehealth. AARP Research. https://doi.org/10.26419/res.00388.001

Yim K. M., Florek A. G., Oh D. H., McKoy K., & Armstrong A. W. (2018). Teledermatology in the United States: An update in a dynamic era. Telemedicine Journal and E-Health, 24(9), 691-697. https://doi.org/10.1089/tmj.2017.0253

STUDY 3

He, Z., Marrone, G., Ou, A., Liu, H., Ma, L., Huang, Y., Li, Y., Sun, L., Bai, Y., Liu, W., Zha, X., & Lu, C. (2020). Factors affecting health-related quality of life in patients with skin disease: Cross-sectional results from 8,789 patients with 16 skin diseases. Health and Quality of Life Outcomes, 18(1), 298. 10.1186/s12955-020-01542-6

Summary

Little is known about generalized factors that are associated with health-related quality of life (HRQoL) across skin diseases. This cross-sectional study of 9,845 patients with skin disease across nine hospitals in China sought to investigate overall HRQoL associated with 16 common skin diseases (He et al., 2020).

The investigators used the Chinese version of the Skindex-29, which measures dermatology-specific health concerns across the domains of symptoms, emotions, and functioning (He et al., 2020). Demographic information and clinical factors were collected. Each disease diagnosis was confirmed by at least two dermatologists who had been trained prior to ensure that the same diagnostic criteria were followed.

Statistical analysis was conducted in SPSS. Logistic regression models were used to assess the relationship between severely impaired HRQoL and demographic/clinical characteristics, and adjustments were made for different skin diseases. Among the 10,024 patients enrolled, 179 patients under 16 years old were excluded from the analysis, which left 9,845 patients (98.2%) for descriptive analysis (He et al., 2020). Among the subjects, 43.4% experienced other chronic diseases. The mean duration of their skin disease was 4.0 years (SD = 6.0), half had moderate disease (50.6%), 31.8% had mild disease, and 13.0% had severe disease. Overall, 223 skin diseases were collected and classified into 21 disease categories. The investigators chose skin diseases with frequencies greater or equal to 100 for statistical analysis. The 16 diagnoses with frequencies exceeding 100 were acne (29.9%), psoriasis (13.6%), eczema (13.0%), urticaria (7.3%), nonspecific dermatitis (5.3%), seborrheic dermatitis (3.2%), alopecia (2.6%), herpes (2.6%), contact dermatitis (2.0%), chloasma/melasma (1.9%), warts (1.5%), folliculitis (1.4%), neurodermatitis (1.3%), alopecia areata (1.3%), tinea (1.2%), and vitiligo (1.1%).

The investigators reported that emotion was the most negatively impacted aspect of HRQoL associated with skin disease (He et al., 2020). Acne, psoriasis, and eczema were also associated with severely impacted emotional HRQoL. Functioning and aggregate HRQoL score was severely impaired for patients with psoriasis. In addition, being female, under 45 years old, consuming alcohol, coexisting diseases of 3 years or longer in duration, and higher disease severity were associated as factors for severely impaired HRQoL for each Skindex-29 domain and for the aggregate. Severe symptoms were associated with lack of exercise, and smoking was associated with impaired function.

Commentary

This study emphasizes the importance of addressing the emotional needs of patients with severe skin disease. Quality of life outcomes are important to dermatology because many diseases carry significant morbidity because of their visibility and significant psychosocial burdens (DeLong & Chen, 2012). Skindex-29 is a validated, Likert-scale questionnaire that poses questions in the domains of physical symptoms, emotions, and functioning (Chren, 2012). When compared with Skindex-29, the Skindex-16 has fewer items to which most of the patients choose the same response and is a better measure of bother rather than frequency of patient experiences (Chren et al., 2001). Skindex-29 is generally preferred for use in research studies, and Skindex-16 may be considered for application in settings where patient response is a concern.

Several skin-specific HRQoL instruments have been developed, chief among them are the Dermatology Life Quality Index (DLQI) and the Skindex. The DLQI was the first skin-specific quality-of-life assessment tool and was developed by Finlay and Kahn in 1994. The DLQI is a 10-question survey that focuses on disability symptoms over the past 1 week in the following domains: symptoms and feeling, daily activities, leisure, work and school, personal relationships, and effects of treatment on daily life (Finlay & Kahn, 1994). Both et al. (2007) published a critical review of generic and dermatology HRQoL instruments and recommended Skindex-29 over the DLQI as an instrument of choice in dermatology. Of note, this was prior to the widespread use of Skindex-16, which has not been compared directly with DLQI. Limitations to the DLQI include dimensionality and focus on disability rather than emotional impact (Rogers et al., 2012). The DLQI is more occupied with daily activities, whereas the Skindex is more focused on measuring emotional impact (Kjeldstrup Kristensen et al. 2020).

Nurses may consider utilizing HRQoL questionnaires in clinical practice. HRQoL tools have important applications in dermatology, as physician-reported judgment of disease has been reported to not consistently correlate with patient-reported scores (Chren et al., 1996). HRQoL scores may be utilized to screen for disability related to disease, develop and modify treatment plans, improve patient-nurse communication, and justify the use of drugs with associated risk or expense (Rogers et al., 2012). Barriers to implementation of HRQoL tools include length of surveys and time needed to complete and score them. To overcome these barriers, nurses may consider using a shorter scale such as the Skindex-16, which is a single-page instrument (Chren et al., 2001).

REFERENCES

Both H., Essink-Bot M. L., Busschbach J., & Nijsten T. (2007). Critical review of generic and dermatology-specific health-related quality of life instruments. Journal of Investigative Dermatology, 127(12), 1276-2739. 10.1038/sj/jid/5701142

Chren M. M. (2012). The Skindex instruments to measure the effects of skin disease on quality of life. Dermatologic Clinics, 30(2), 231-236, xiii. 10.1016/j.det.2011.11.003

Chren M. M., Lasek R. J., Quinn L. M., Mostow E. N., & Zyzanski S. J. (1996). Skindex, a quality-of-life measure for patients with skin disease: Reliability, validity, and responsiveness. The Journal of Investigative Dermatology, 107(5), 707-713. 10.1111/1523-1747.ep12365600

Chren M. M., Lasek R. J., Sahay A. P., & Sands L. P. (2001). Measurement properties of Skindex-16: A brief quality-of-life measure for patients with skin diseases. Journal of Cutaneous Medicine and Surgery, 5(2), 105-110. 10.1007/BF02737863

DeLong L. K., & Chen S. C. (2012). Future directions in dermatology quality of life measures. Dermatologic Clinics, 30(2), 343-347, x. 10.1016/j.det.2011.11.005

Finlay A. Y., & Khan G. K. (1994). Dermatology Life Quality Index (DLQI)-A simple practical measure for routine clinical use. Clinical and Experimental Dermatology, 19(3), 210-216. 10.1111/j.1365-2230.1994.tb01167.x

He Z., Marrone G., Ou A., Liu H., Ma L., Huang Y., Li Y., Sun L., Bai Y., Liu W., Zha X., & Lu C. (2020). Factors affecting health-related quality of life in patients with skin disease: Cross-sectional results from 8,789 patients with 16 skin diseases. Health and Quality of Life Outcomes, 18(1), 298. 10.1186/s12955-020-01542-6

Kjeldstrup Kristensen J., Grejsen D., Swartling C., & Bygum A. (2020). In hyperhidrosis quality of life is even worse than in acne, eczema, or psoriasis. A comparison of Skindex-16 and Dermatology Life Quality Index (DLQI). International Journal of Dermatology, 59, e392-e393. 10.1111/ijd.15164

Rogers A., DeLong L. K., & Chen S. C. (2012). Clinical meaning in skin-specific quality of life instruments: A comparison of the Dermatology Life Quality Index and Skindex banding systems. Dermatologic Clinics, 30(2), 333-342, xiii 10.1016/j.det.2011.11.010