A Dermatological Questionnaire for General Practitioners with a Focus on Hidradenitis Suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a skin chronic inflammatory disease typically located in several areas such as perianal, inguinal and axillary regions. In 40% to 70% of cases, general practitioners (GPs) are the first health care professionals consulted by patients suffering from HS. The role of GPs in HS management could be more substantial than it has been in the past. AIM: We developed a questionnaire to assess the knowledge of HS by GPs and to evaluate if in their perception the dermatologist is the reference medical doctor for pathology above.
METHODS: The data were processed by a univariate descriptive statistical analysis.
RESULTS: Our study showed GPs could recognise patients affected by HS. They have proven to know the main features of HS. Nevertheless, the second part of the questionnaire has highlighted the considerable confusion of GPs about who the reference figure is.
CONCLUSION: The data registered regarding therapy and follow up too, only show a mild preponderance of dermatologist compared to other professional figures, such as a surgeon, GPs and plastic surgeon.

Introduction

Hidradenitis suppurativa (HS) is a chronic inflammatory disease, commonly characterised by painful, deep dermal abscesses and chronic, draining sinus tracts. Lesions are typically located in several skin areas such as perianal, inguinal and axillary regions [1] [2]. The prevalence rate is not finally defined yet: it varies between 0.0003% and 4% depending on the study population [3] [4]. Estimates from insurance databases suggest a prevalence of < 0.1% [5] [6].

This variation strongly suggests a significant selection bias or misclassification, and it may be speculated that not all patients ask any healthcare consultation. Also, diagnosis of HS may usually be delayed for years, and even when diagnosed, is challenging to treat [7].

The healthcare system identifies the general practitioners (GPs) as the first reference figures for the citizen in the health care. The situation does not change for HS.

In 40% to 70% of cases, GPs are the first health care professionals consulted by patients suffering from HS [8]. The role of GPs in HS management could be more substantial than it has been in the past. Moreover, GPs are still the primary caregivers for 15% of patients after an HS diagnosis is received [7].

The main goal of the study is to assess the knowledge of HS by GPs and to evaluate if in their perception the dermatologist is the reference medical doctor for pathology above.

Methods

At the Department of Clinical Medicine and Surgery, Section of Dermatology of University Hospital Federico II of Naples, we developed a questionnaire (Table 1) on HS, structured as follows:

Table 1

Six knowledge questions about HS (first part of the questionnaire) and five questions about HS diagnosis, therapies and follow up (second part of the questionnaire)

QUESTIONNAIRE (first part)

HS manifest with painful skin lesions

HS manifest with inflammatory nodules

HS manifests with abscesses

HS manifests with draining fistulas

HS manifests with scars

HS occurs with lesions typically localised in the following regions: axillary, inter-inframammary, inguinal, perineal, gluteus

Options: I do not agree – I do not know – I partially agree - I fully agree

QUESTIONNAIRE (second part)

The diagnostic suspicion is supported by

In the diagnosis of HS, the reference figure is

In the HS therapy setting, the reference figure is

In the management of drug therapy (topical/systemic), the reference figure is

In the follow up of HS patients, the reference figure is

Options: Dermatologist – Surgeon – General Practitioner – Plastic surgeon

-6 knowledge questions about the pathology;

-5 related questions to HS diagnosis, therapies and follow up.

The paper mentioned above questionnaire was filled by 150 GPs from Campania, Italy.

The results were expressed as a percentage.

Results

The first part of the questionnaire consists of 6 general questions about HS. The collected responses showed a good knowledge of the disease by GPs. More than 80% (partially agree + fully agree) showed to know that HS manifests with painful skin lesions, with inflammatory nodules, abscesses and draining fistulas.

A smaller percentage of respondents (75% = partially + fully agree) proved to be aware of the anatomic sites involved by the disease and that HS is also characterised by scarring (Figure 1).

Figure 1

Results of 6 knowledge questions about HS (first part of the questionnaire). The collected responses showed a good knowledge of the disease by GPs. More than 80% showed to know that HS manifests with painful skin lesions, with inflammatory nodules, abscesses and draining fistulas even though GPs were not aware that HS is also characterised by scarring

In the second part of the survey, according to GPs involved in the study, diagnostic suspicion is supported by a dermatologist (24%), surgeon (26%), GP (38%), plastic surgeon (12%).

In the diagnosis of HS, dermatologists are slightly most involved (33%) compare to the surgeon (24%), GP (26%) and plastic surgeon (17%).

In the HS therapy setting the reference figure is dermatologist (39%), surgeon (20%), GP (26%), plastic surgeon (15%).

In the management of drug therapy (topical / systemic) the reference figures are as follow: dermatologist (44%), surgeon (16%), GP (24%), plastic surgeon (16%).

In the follow up of the HS the reference figures are as follow dermatologist (30%), surgeon (24%), GP (31%), plastic surgeon (15%) (Figure 2).

Figure 2

Results of 5 questions about HS diagnosis, therapies and follow up (second part of the questionnaire). This part of the questionnaire has highlighted the considerable confusion of GPs about who the reference figure is for HS

Discussion

The diagnosis of HS is based on the presence of recurrent painful or suppurating lesions more than twice in 6 months in the considered ‘typical’ areas of the body, including axilla, genital area, perineum, gluteal area and, in women, infra-mammary area. Long delays in diagnosis are common since HS is frequently misdiagnosed as a simple infection [9].

Our study showed that GPs could recognise patients affected by HS. They have proven to know the main features of HS. However, initial or mildly severe clinical frameworks can easily be confused with other pathologies whose overall management is different. This data affects the problem of delayed diagnosis and contributes to determining worsening conditions [10].

The second part of the questionnaire has highlighted the considerable confusion of GPs about who the reference figure is.

The data registered regarding therapy and follow up too, only show a mild preponderance of dermatologist compared to other professional figures, such as a surgeon, GP and plastic surgeon. Inadequate management is more frequently associated with a wrong diagnosis. The consequence is the worsening of clinical manifestations with an increase of severity degree.

It is well known that it is easier to treat mild forms of HS, compared to severe forms that are less responsive to therapies. Also, the disease progression has a significant impact on the quality of life of patients. Furthermore, the literature shows that inadequate management of HS patients causes worsening not only of skin but also of systemic clinical conditions [11] [12].

Indeed, HS has been considered a systemic disease because of the possible association with several comorbidities like endocrine disorders, such as diabetes and hyperinsulinemia, acromegaly and Cushing disease, cardio-metabolic comorbidities, metabolic syndrome, obesity and other conditions like inflammatory bowel diseases (especially Crohn disease), spondyloarthropathy, genetic keratin disorders associated with follicular occlusion and squamous cell carcinoma [13] [14] [15] [16] [17] [18] [19] [20]. Early recognition of the HS associated diseases and a timely therapy improve disease outcome and can prevent long-term complications.

The worsening natural history of the disease, together with co-morbidities, makes necessary a multidisciplinary approach to HS. The multidisciplinary assessment of patients allows a complete evaluation of the disease and a more comprehensive treatment approach compared with traditional consultation.

In a shared and multidisciplinary approach, the GP plays a key role, as the first physician interfaces with patients suffering from HS.

The GP should be able to recognise the dermatologist as the reference figure in the treatment of HS patients, notwithstanding the contribution of the other medical figures indispensable for the proper management of a multidisciplinary pathology, such as HS.

In conclusion, this study emphasises the need for education of GPs to make an accurate and early diagnosis, to initiate treatment and obtain the best management of HS patients.

Future objectives include submitting the same web-based questionnaire to the largest number of general practitioners on a national scale.