Remote consultations for patients with hidradenitis suppurativa during the COVID-19 pandemic: a single-centre experience.

Remote dermatology consultations largely superseded face-to-face (FTF) consultations during the peak of the COVID-19 pandemic in the UK. Remote examination of patients with hidradenitis suppurativa (HS) brings particular challenges, given the propensity of HS to affect intimate body areas. To understand the impact of remote consultations on the care of patients with HS, a retrospective analysis was conducted of all consultations from 2 April to 29 October 2020 at the HS clinic at Imperial College Healthcare NHS Trust. In this group of patients with HS, 46.3% were black, compared with 7.0% of patients attending general dermatology clinics (P < 0.001). The majority (65.9%) of patients had previously received or were currently taking adalimumab. All consultations were performed by telephone and in 50.7% of the consultations, patients were assessed as having unstable (u)HS, with 81.1% of these uHS episodes leading to a change in pharmacological therapy. The decision-making process was aided by patient-submitted photographs at only 8.1% of consultations involving uHS, for reasons of patient privacy, comfort and data security. The data suggest that HS is an inherently unstable disease despite maximal medical therapy, and this study highlights important reasons for the assessment of patients with HS by FTF consultations where safely possible.

The escalation of the COVID‐19 pandemic in March 2020 and the associated UK national lockdown required immediate conversion of face‐to‐face (FTF) dermatology consultations to remote consultations. Video consultations, or telephone consultations accompanied by patient‐submitted photographs, have been widely used in dermatology during this time. Video or photographic assessment of intimate body areas in particular must be handled with caution because of issues regarding patient privacy, informed consent and image storage., Before requesting a remote assessment of an intimate body area, clinicians must carefully consider factors such as patient comfort, clinical necessity and intrinsic limitations in the specific assessment technique used. As intimate body areas (including the groin, mons pubis, genitalia, perineum, perianal area, buttocks, breasts) are often affected in patients with hidradenitis suppurativa (HS), a study was performed to assess the impact of remote consultations on the care of patients with HS during the pandemic.

Report

Patient attendances at a specialist HS clinic at Imperial College Healthcare NHS Trust from 2 April to 29 October 2020 were identified retrospectively using hospital records. The date of 2 April 2020 was chosen as the start date of the evaluation period (EP) as this was the first scheduled HS clinic date after the commencement of the UK national lockdown, while 29 October 2020 was selected as the end date as clinic consultations returned to FTF after this date, following a local risk assessment conducted by the hospital. All consultations during the EP were conducted via telephone. A pre‐COVID‐19 control period (CP) was selected by identifying all consultations in the HS clinic during the same corresponding dates in 2019 (all conventional FTF).

During the EP, 73 remote consultations in the HS clinic were attended by 41 different patients, compared with 71 FTF consultations attended by 40 patients during the CP, indicating no drop in outpatient activity during the pandemic. All patients had a current or prior rating on the Hidradenitis Suppurativa Physician Global Assessment (HS‐PGA) of at least moderate disease. The mean patient age in the EP was 42.2 years and sex distribution was 51.2% male (n = 21) and 48.8% female (n = 20). Grouped by ethnic origin, there were 13 white (31.7%), 19 black (46.3%), 6 Asian (14.6%) and 3 Arab (7.3%) patients. In comparison, of 100 consecutive patients attending general dermatology clinics in April 2020, 57% were white, 7% black, 22% Asian and 14% Arab. The demographic data showed that, compared with general clinics, a significantly higher proportion of patients attending the HS clinic were black (P < 0.001, χ2 test), supporting previous studies showing a higher prevalence of disease in this group.

At the start of the EP, 14 patients (34.1%) had no prior exposure to adalimumab, 6 patients (14.6%) had previously received and ceased adalimumab therapy (2 in remission, 2 stopped due to adverse effects, 2 failure to respond) and 21 patients (51.2%) were actively receiving adalimumab. Other treatment regimens used included tetracycline antibiotics, dapsone, acitretin, spironolactone, and a combination of rifampicin plus clindamycin – either as monotherapy or in combination with adalimumab.

During the CP, patients at 43 (60.6%) of 71 consultations (30 patients; 75%) were assessed as having unstable (u)HS based on symptomatology, whereas during the EP, 37 (50.7%) of the 73 consultations (23 patients; 56.1%) involved uHS (difference was not significant by χ² test). uHS was not associated with age, sex, ethnicity, or prior or current adalimumab use.

At 30 of the 37 uHS consultations (81.1%) during the EP, a joint decision was made to change medical therapy. Such changes included a switch in the oral antibiotic regimen (including dapsone) (12 patients; 40.0%), initiation of adalimumab (4 patients; 13.3%), adjustment of adjunctive therapy in patients taking adalimumab (11 patients; 36.7%), withdrawal of oral therapy (2 patients; 6.7%) and conversion of adalimumab to oral antibiotic (1 patient; 3.3%). Elective surgery was not available as a management option during this period, owing to temporary suspension of all surgery other than life‐ or limb‐saving, as part of the hospital’s emergency COVID‐19 response.

Patient‐submitted photographs were used at only 3 of the 37 consultations (8.1%) involving uHS in the EP to inform the therapeutic decision‐making process. Of these three patients, two had severe HS requiring urgent treatment with adalimumab, while the other was an 80‐year‐old man who had asked his daughter to conduct the remote consultation on his behalf.

The presented data offer an overview of activity at this single‐centre HS clinic prior to and during the COVID‐19 pandemic. Of note, HS was deemed to be unstable at over half of all FTF and remote consultations during the CP and the EP, respectively, despite a high rate of adalimumab use, reflecting the ongoing paucity of effective treatment options in this disabling disease.

On the whole, management decisions in the EP were made on the basis of telephone conversations, without recourse to patient‐submitted photographs or video. A high prevalence of anxiety and depression exists among patients with HS,, and pre‐COVID‐19 experience of FTF HS consultations informs us that the act of clinical examination itself frequently induces patient distress and embarrassment. Requesting patient‐submitted photographs or video examination of HS‐affected skin in remote consultations, where physician–patient rapport is harder to establish, can generate significant patient unease. Therefore, in the interests of patient comfort, the approach at this centre was to request images of HS‐affected skin only if essential, e.g. urgent commencement of adalimumab. This approach also minimized the potential for problematic issues around patient consent and security of image transmission and storage.

In summary, the switch to remote consultations and the absence of an accompanying examination meant that most patients with unstable disease in the EP were treated ‘blind’. While not ideal, this approach was considered the best compromise in difficult circumstances. Patients with HS form a unique subgroup ​in dermatology, for whom FTF consultations bring overwhelming advantages over remote, given the high rates of unstable disease, the intimate body areas involved, requirement of an emotional bond between physician and patient, and the need to palpate the skin to assess lesion type. The lack of FTF contact may disproportionately affect patients of black ethnicity, given the higher burden of disease in this group. Future planning of dermatology services should involve the prioritization of FTF consultations for patients with HS where safely possible.

Despite the availability of biologic therapy (adalimumab) for HS, a high proportion of patients experience periods of unstable disease.

Studies indicate the burden of HS disease disproportionately affects black patients.

Requests for photographic or video assessment of patients with HS should be handled sensitively, given the propensity of the disease to affect intimate body areas and the high prevalence of anxiety and depression in these patients.

FTF consultations bring important advantages for patients with HS, including facilitation of intimate body area examination, establishment of rapport and lesion palpation.

Prioritization of FTF consultations for patients with HS should be considered during future planning of dermatology services.