Hidradenitis suppurativa: The importance of virtual outpatient care during COVID-19 pandemic.

To the Editor: We read with interest “Strategic dermatology clinical operations during COVID-19 pandemic” by Price et al and greatly appreciate their approach to maintaining successful patient care while limiting risks. In addition to preventing the spread of infection, the role of the dermatologist is also to provide appropriate care to patients with skin disease to prevent complications and to lower the burden on the health care system through emergency department (ED) visits and admissions.

Reducing the burden on urgent care and emergency departments

Hidradenitis suppurativa (HS) is an extremely painful, debilitating disease that significantly impairs quality of life. Because HS symptom control and lesion resolution are often inconsistent and inadequate, HS patients exhibit greater use of emergency department (ED) and inpatient care than patients with other chronic inflammatory skin conditions. Kirby et al reported a mean 3-year ED cost of $2002 for HS patients and a higher proportion of ED visits relative to psoriasis (P = .02) and control groups (P < .001) after adjusting for age, sex, and comorbidities.

In addition, of 47 respondents who completed the Canadian Skin Patient Alliance Hidradenitis Suppurativa Patient Experience survey, half consulted with ED physicians for HS symptoms (of which, 36% consulted with more than 10 ED physicians), and 30% made 10 or more trips to the ED in the prediagnosis stage. We therefore strongly disagree with categorizing HS follow-up as “nonurgent/reschedule,” as outlined by Price et al, because this approach would likely contribute to increased ED visits.

Furthermore, continued virtual outpatient care for HS patients may reduce ED exposure and minimize risk of infection, which is important for HS patients with significant concomitant comorbidities and those on immunomodulatory therapies. In addition, it would provide dermatologists a platform to explain and emphasize to patients the importance of social distancing while on immunosuppressants, crucial since research after the 2003 severe acute respiratory syndrome outbreak demonstrated higher self-reported compliance with quarantine measures when the rationale was understood (P = .018).

Minimizing psychiatric comorbidities and behaviors

Studies have also demonstrated increased risk of antidepressant drug use (P < .0001) and completed suicide (P = .0334) in the HS population after adjusting for confounding factors. We caution against interruption in care for HS patients due to the potential for increased severity or frequency of suicidal behaviors, or depression and anxiety, or both, especially considering the additive stress and anxiety resulting from the current socially isolating quarantine climate.

Optimizing HS virtual outpatient care

In our complex medical dermatology practices, we have implemented a triage system similar to Price et al with 3 categories: (1) in person, (2) virtual/phone, (3) cancel/reschedule. We find that the follow-up of both HS and autoimmune bullous diseases through virtual visits is quite effective in a large proportion of patients, during which we use patient-reported outcomes such as pain scores, treatment satisfaction scores, and patient global assessments. Virtual visits also allow us to counsel patients regarding maintenance regimens for the prevention of disease flares, HS action plans informing steps to take during HS exacerbations and when to contact a provider, and methods to improve overall mental health, including maintaining a healthy diet, using warm compresses, and engaging in support groups through the Canadian Skin Patient Alliance.