10.5826/dpc.1204a192
Introduction: Hidradenitis suppurativa (HS) is a chronic, disabling skin disorder which is characterized by recurrent attacks of nodule, abscess, sinus tract formation which eventually leads to significant scarring. Oral/topical antibiotics, oral retinoids and TNF-alpha inhibitors are used to control disease activity and improve symptoms.
&nbsp;
Objective: In the present study, we aimed to determine the prevalance of COVID-19 real-time polymerase chain reaction (RT-PCR) positivity and Covid-19 related symptoms in relation to the age, gender, body mass index (BMI), disease duration, accompanying systemic diseases, treatment used for HS, treatment duration and smoking.
&nbsp;
Methods: We conducted a comparative, cross-sectional study of 178 patients diagnosed with HS in a referral hospital. Age, gender, smoking status, BMI, treatment modalities used for HS, the presence of COVID-19 related symptoms, history of close contact to a person with COVID-19 and COVID-19 RT-PCR results were determined by a telephone questionnaire and checked from medical data records.
&nbsp;
Results: Sixty-three patients were female, whereas 115 patients were male. During Covid-19 pandemic, 94 out of 178 patients had Covid-19 related symptoms; Covid-19 RT-PCR test was performed in 109 (61.2%) patients. Thirty (27.5%) cases tested positive for Covid-19 whereas 79 (72.5%) tested negative.
&nbsp;
Conclusions: Patients having Covid-19 related symptoms were shown to have statistically significantly higher mean age compared to the ones who did not have any symptoms (p=0.031). No statistically significant relationship was found Covid-19 RT-PCR positivity and the type of treatment administered for HS when categorized as TNF-alpha inhibitor, oral retinoid, topical antibiotic and oral antibiotic group (p&gt;0.05).
text/xml
2160-9381
2259
en
Basak Yalici-armagan
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Covid-19, hidradenitis supurativa, treatment
The Impact of Covid-19 Pandemic on Hidradenitis Suppurativa Patients: a Cross-Sectional Study From Tertiary Referral Hospital
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2021-12-17
2022-10-31
2022-12-02
e2022192
Dermatol Pract Concept
Introduction: Hidradenitis suppurativa (HS) is a chronic, disabling skin disorder which is characterized by recurrent attacks of nodule, abscess, sinus tract formation which eventually leads to significant scarring. Oral/topical antibiotics, oral retinoids and TNF-alpha inhibitors are used to control disease activity and improve symptoms.
&nbsp;
Objective: In the present study, we aimed to determine the prevalance of COVID-19 real-time polymerase chain reaction (RT-PCR) positivity and Covid-19 related symptoms in relation to the age, gender, body mass index (BMI), disease duration, accompanying systemic diseases, treatment used for HS, treatment duration and smoking.
&nbsp;
Methods: We conducted a comparative, cross-sectional study of 178 patients diagnosed with HS in a referral hospital. Age, gender, smoking status, BMI, treatment modalities used for HS, the presence of COVID-19 related symptoms, history of close contact to a person with COVID-19 and COVID-19 RT-PCR results were determined by a telephone questionnaire and checked from medical data records.
&nbsp;
Results: Sixty-three patients were female, whereas 115 patients were male. During Covid-19 pandemic, 94 out of 178 patients had Covid-19 related symptoms; Covid-19 RT-PCR test was performed in 109 (61.2%) patients. Thirty (27.5%) cases tested positive for Covid-19 whereas 79 (72.5%) tested negative.
&nbsp;
Conclusions: Patients having Covid-19 related symptoms were shown to have statistically significantly higher mean age compared to the ones who did not have any symptoms (p=0.031). No statistically significant relationship was found Covid-19 RT-PCR positivity and the type of treatment administered for HS when categorized as TNF-alpha inhibitor, oral retinoid, topical antibiotic and oral antibiotic group (p&gt;0.05).
Basak Yalici-armagan
2022/10/31
10.5826/dpc.1204a192
e2022192
Department of Dermatology and Venereology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
2160-9381
Covid-19, hidradenitis supurativa, treatment
en
e2022192
Kwok S, Adam S, Ho JH, et al. Obesity: A critical risk factor in the COVID-19 pandemic. Clin Obes 2020;10:e12403.
The Impact of Covid-19 Pandemic on Hidradenitis Suppurativa Patients: a Cross-Sectional Study From Tertiary Referral Hospital
https://dpcj.org/index.php/dpc/article/download/2259/1812
  Impact of COVID-19 Pandemic on Hidradenitis
Suppurativa Patients: a Cross-Sectional Study From
            Tertiary Referral Hospital
Ecem Bostan1, Adam Jarbou1, Aysen Karaduman1, Duygu Gulseren1, Basak Yalici-Armagan1,
                                  Neslihan Akdogan1


1 Department of Dermatology and Venereology, Hacettepe University, Faculty of Medicine, Ankara, Turkey



Key words: COVID-19, hidradenitis suppurativa, impact, treatment
Citation: Bostan E, Jarbou A, Karaduman A, Gulseren D, Yalici-Armagan B, Akdogan N. Impact of COVID-19 Pandemic on Hidradenitis
Suppurativa Patients: a Cross-Sectional Study From Tertiary Referral Hospital. Dermatol Pract Concept. 2022;12(4):e2022192.
DOI: https://doi.org/10.5826/dpc.1204a192
Accepted: March 21, 2022; Published: October 2022
Copyright: ©2022 Bostan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Ecem Bostan, MD, Hacettepe University, Faculty of Medicine, Department of Dermatology and Venereology,
Ankara, Turkey, Phone: 03123051704, Fax: 0 3123054127, E-mail: bostanecem@gmail.com




  ABSTRACT             Introduction: Hidradenitis suppurativa (HS) is a chronic, disabling skin disorder which is character-
                       ized by recurrent attacks of nodule, abscess, sinus tract formation and scarring. Oral/topical antibiot-
                       ics, oral retinoids and TNF-alpha inhibitors are used for the treatment of HS.
                       Objectives: In the present study, we aimed to determine the prevalence of coronavirus disease 2019
                       (COVID-19) real-time polymerase chain reaction (real-time PCR) positivity and the presence of
                       COVID-19 related symptoms in relation to the age, gender, body mass index, disease duration, treat-
                       ment used for HS, treatment duration and smoking.
                       Methods: We conducted a comparative, cross-sectional study of 178 patients diagnosed with HS in a
                       referral hospital. Age, gender, smoking status, body mass index, treatment modalities used for HS, the
                       presence of COVID-19 related symptoms, history of close contact to a person with COVID-19 and
                       COVID-19 real time-PCR results were determined by a telephone questionnaire.
                       Results: Sixty-three patients were female, whereas 115 patients were male. During COVID-19
                       ­pandemic, 94 out of 178 patients had COVID-19 related symptoms; COVID-19 real time-PCR test
                        was performed in 109 (61.2%) patients. Thirty (27.5%) cases tested positive for COVID-19 whereas
                        79 (72.5%) tested negative.




Original Article | Dermatol Pract Concept. 2022;12(4):e2022192                                                                      1
                       Conclusions: Patients having COVID-19 related symptoms were shown to have statistically signifi-
                       cantly higher mean age compared to the ones who did not have any symptoms (P = 0.031). No statisti-
                       cally significant relationship was found COVID-19 real time-PCR positivity and the type of treatment
                       administered for HS when categorized as tumor necrosis factor-alpha inhibitor, oral retinoid, topical
                       antibiotic and oral antibiotic group (P > 0.05).




Introduction                                                          time-PCR) positivity and the presence of COVID-19 related
                                                                      symptoms in relation to the age, gender, body mass index
Hidradenitis suppurativa (HS) is a chronic, inflammatory, de-         (BMI), smoking status, accompanying systemic diseases, dis-
bilitating skin disorder characterized by painful, deep-seated        ease duration and different treatment modalities used for HS.
nodules and abscesses, draining sinus tracts and cicatrisation
[1]. The disease is more likely to be seen in the intertriginous
areas of the body including groin, gluteal area, axillae and
                                                                      Methods
inframammary region [1]. HS is staged according to the type,          We conducted a cross-sectional, descriptive study of 178 HS
extent and severity of the skin lesions [2]. Single or multiple       patients who were followed up in our dermatology outpatient
nodules or abscesses without sinus tracts and cicatrix forma-         clinic. All 178 participants were clinically diagnosed with HS
tion refer to Hurley stage 1; recurrent nodules or abscesses          and further receiving various treatment modalities according
with limited sinus tract formation and scarring refers to Hur-        to disease stage in our center’s chronic dermatologic illnesses
ley stage 2; whereas stage 3 disease is characterized by dif-         outpatient clinic between January 2018 and September 2021.
fuse involvement of the affected area by nodules/abscesses,           Only patients who were under active-continuous treatment
multiple interconnected sinus tracts and cicatrisation [2].           for HS during COVID-19 pandemic, were included. Local
    Genetic, environmental, endocrinologic, bacterial and             ethics committee approval was obtained for the present
host defense related immunologic factors as well as obesity,          study (the date, project number, decision number: Septem-
smoking have all been implicated in the etiology of HS [3].           ber 7, 2021, GO 21/934, 2021/14-66). An oral questionnaire
Depression, inflammatory bowel disease, spondyloarthrop-              composed of 15 questions related to the demographical data,
athy, diabetes mellitus, hyperlipidemia and metabolic syn-            HS disease and COVID-19, was formed (Supplementary
drome are among the common associated comorbidities in                File 1). The answers were obtained via a telephone survey
HS patients [4]. Low self-confidence, sexual dysfunction, im-         and an oral informed consent was taken from all the patients
pairment of daily functioning, chronic anxiety and depres-            before the start of the survey. The accuracy of questions re-
sion all lead to poor life quality for HS patients [5,6].             lated to COVID-19 status of the participants, characteristics
    In the early stages of the disease characterized by only a        of treatment given for HS and treatment duration, was also
few nodules or abscess, only systemic antibiotics in combina-         verified from the medical data records.
tion with topical antibiotics or intralesional corticosteroids, are      IBM SPSS for Windows Version 20.0 was used for the sta-
usually enough to control disease activity [7,8]. However, ad-        tistical analysis. Numerical variables were shown as mean ±
vanced stages require both surgical intervention and systemic         standard deviation (range: minimum-maximum), whereas
treatment modalities. Tumor necrosis factor-alpha (TNF-α)             categorical variables were given as percentages and frequen-
inhibitors (especially adalimumab and infliximab) are the             cies. Shapiro-Wilk test was used to determine if the numer-
much-preferred agents used in the treatment of advanced stage         ical variables are distributed normally. Fisher’s exact test or
HS, in combination with topical and systemic antibiotics [9].         ­Chi-Square test was used to compare the differences between
    During coronavirus disease 2019 (COVID-19) pandemic,              patients receiving various different modalities for HS (­ divided
the safety of biologic agents is one of the most frequently           into 4 groups as oral antibiotics± topical antibiotics, oral ret-
investigated issues in dermatology practice. The use of an-           inoids± topical antibiotics, TNF-α inhibitors ± oral/topical
tibiotics and TNF-α inhibitors in the patients with HS does           antibiotics and only topical antibiotics).Logistic regression
not seem to increase the risk for COVID-19 [10].                      analyses (in which age, gender, BMI, the presence of any
                                                                      other systemic disease and smoking were included as inde-

Objectives                                                            pendent variables) were also performed taking the presence of
                                                                      COVID-19 symptoms and COVID-19 real time-PCR results
In our study, we aimed to investigate the prevalence of               (positive or negative) as the dependent variables. P ­values less
COVID-19 real-time polymerase chain reaction (real                    than 0.05 were considered statistically significant.



2                                                                         Original Article | Dermatol Pract Concept. 2022;12(4):e2022192
Results                                                                nephrologic diseases whereas five other (2.8%) patients had
                                                                       prior history of malignancy. Endocrinologic disorders such
A total number of 178 patients were included in the study.             as diabetes mellitus, hypothyroidism and hyperlipidemia
The mean age was 35.69 ± 11.21 years (range:16-61).                    were seen in 33 (18.5%) cases, whereas respiratory diseases
Sixty-three (35.4%) patients were female, whereas 115                  (most ­commonly asthma, allergic rhinitis) were present in 11
(64.6%) patients were male. Fifty-two (29.2%) patients had             (6.2%) patients.
Hurley stage 1 disease, 52 (29.2%) patients had Hurley stage               During COVID-19 pandemic, 94 (52.8%) out of 178
2 disease whereas 74 (41.6%) had stage 3 disease. The mean             patients had COVID-19 related symptoms such as fever,
BMI was 27.55 ±3 .30 kg/ m2 (range:17.09-43.25); one                   anosmia, ageusia, malaise, sore throat, dry cough, di-
(0.6%) patient had a BMI of <18.5 kg/m2 (underweight);                 arrhea and myalgia. COVID-19 real time-PCR test was
31 (17.4%) patients had a BMI in 18.5 to 24.9 kg/m2 range              performed in one hundred nine (61.2%) out of 178 pa-
(optimal). One hundred ten (61.8%) out of 178 cases were               tients. Thirty (27.5%) cases tested positive for COVID-19
determined to fall within the overweight category (a BMI of            whereas 79 (72.5%) tested negative. Forty-seven (26.4%)
25-29.9 kg/m2) whereas 36 (20.2%) patients were within the             cases had a history of close contact to someone with a
obese category (a BMI of >30 kg/m2). One hundred nine out              confirmed diagnosis of COVID-19. Of 109 patients with
of 178 patients were current smokers, the mean pack-years              COVID-19 real-time PCR test, 30 (27.5%) had positive
of smoking was 21.06 ± 14.12 pack-years (range: 3-80).                 test result whereas 79 (72.5%) were tested negative. The
The mean duration of treatment for HS was 18.37 ± 18.90                average age of patients with positive real-time PCR was
months (1-108) whereas the average duration of the disease             statistically significantly higher compared to the patients
was 119.38 ± 91.97 months (2-552).                                     with negative result (p=0.007) (Table 1). There was no
    Forty-eight (27%) cases were on oral antibiotics                   statistically significant relationship between gender ver-
(­doxycycline, clindamycin and rifampicin, only clindamy-              sus COVID-19 r­eal-time PCR positivity (P = 0.275) and
cin, tetracycline) treatment either alone or combination with          BMI vs COVID-19 real-time PCR positivity (P = 0.873)
topical treatment modalities. Thirty (16.9%) patients were             ­(Table 1). There was no statistically significant difference in
on oral retinoid (isotretinoin or acitretin) treatment whereas         COVID-19 r­ eal-time PCR positivity between smokers and
85 (47.8%) were using TNF-α inhibitors either alone or with            non-smokers (P = 0.111) (Table 2). There was no statisti-
oral/topical antibiotics. Out of 85 patients from anti-TNF-α           cally significant relationship between the mean pack-years
group, 9 (10.58 %) patients were under infliximab treat-               of smoking of patients who tested positive and negative for
ment, whereas 76 (89.41%) were under adalimumab treat-                 COVID-19 (P = 0.222) (Table 2). We found a statistically
ment. Patients with stage 2 and 3 HS were additionally                 significant relationship between COVID-19 real-time PCR
using colchicine. Out of 178 cases, 75 (42.1%) patients had            results and the mean disease duration for HS (P = 0.031)
at least one systemic disease. Nineteen (10.7%) patients               (Table 3). The patients with positive real-time PCR results
had rheumatologic illnesses (most common ones being Fa-                have a higher mean disease duration compared to the ones
milial Mediterranean Fever, Behçet disease and ankylosing              with negative COVID-19 real-time PCR results. However,
spondylitis); 22 (12.4%) patients had cardiovascular dis-              no statistically significant relationship was found between
eases most frequently being hypertension, coronary artery              the positive results of COVID-19 real-time PCR and the
disease and heart failure. Five (2.8%) case presented with             mean duration of treatment for HS (P = 0.716) (Table 3).




     Table 1: Covid-19 Real Time-PCR results in relation to the age, gender and body-mass index.
 COVID-19 Number                          Age (years)                         Gender                       Body-mass index
     real    of
 time-PCR patients                                                      Female        Male
   results  (n)    Mean              SD     Minimum Maximum              N (%)        N (%)     Mean      SD     Minimum Maximum
Negative           79      35.65     9.94       17            60       27 (79.4) 52 (69.3) 27.38 3.17              17.09        38.74
Positive           30      42.07 11.75          20            61        7 (20.6)    23 (30.7) 27.72 3.62           20.2         37.72
Total            109       37.41 10.80          17            61        34 (100)    75 (100) 27.48 3.29            17.09        38.74

SD = standard deviation.
The average age of patients with positive COVID real time-PCR was statistically significantly higher compared to the patients with negative
result (P < 0.007). There was no statistically significant relationship between the gender vs COVID-19 real time-PCR results (P = 0.275).
Additionally, there was also no statistically significant relationship between the body-mass index versus COVID-19 real time-PCR results
(P = 0.873).



Original Article | Dermatol Pract Concept. 2022;12(4):e2022192                                                                           3
 Table 2. Covid-19 Real Time-PCR results in relation to smoking status and pack-years of smoking.
                                            Smoking status                        Pack-years of smoking (among smokers)
    Covid-19 Real ­      Number                                          Number
      Time-PCR              of         Non-smoker         Smoker            of
       Results           patients        N (%)             N (%)         patients        Mean          SD       Minimum         Maximum
 Negative                    79          24 (63.2)        55 (77.5)          55           21.73       15.11          4                 80
 Positive                    30          14 (36.8)        16 (22.5)          16           25.75       14.85         10                 54
 Total                     109           38 (100)         71 (100)           71           22.63       15.04          4                 80

There was no statistically significant difference in COVID-19 real time-PCR positivity between smokers and non-smokers (P = 0.111).
Among smokers, no statistically significant relationship was found between the mean pack-years of smoking of patients who tested positive
and negative for COVID-19 (P = 0.222).



    Table 3. Covid-19 Real Time-PCR results in relation to disease duration and treatment duration.
                                                                                       Covid-19 Real Time-PCR Results
                                                                             Negative                Positive                   Total
 Disease Duration              Number of Patients                               79                       30                      109
 (months)                      Mean                                           109.29                  155.40                   121.98
                               Standard deviation                             82.15                   112.99                    93.43
                               Minimum                                            2                       4                       2
                               Maximum                                         432                      552                      552
 Treatment Duration            Mean                                           19.37                    16.77                    18.65
 (months)                      Standard deviation                             19.15                    13.80                    17.81
                               Minimum                                            1                       1                       1
                               Maximum                                          84                       48                       84

Statistically significant relationship was present between COVID-19 real time-PCR results and the mean disease duration for HS (P = 0.031).
The patients with positive real time-PCR results have a higher mean disease duration compared to the ones with negative COVID-PCR
results. However, no statistically significant relationship was found between the positive results of COVID-19 real time-PCR and the mean
duration of treatment for HS (P = 0.716).




               Table 4. Covid-19 Real Time-PCR results with respect to the treatment groups.
                                                                             Treatment Groups
                                  Oral antibiotics                                         TNF-alpha inhibitors
                                     ± topical          Oral retinoids ± topical              ± oral/topical               Only topical
      COVID-19 Real                 antibiotics                antibiotics                     antibiotics                  antibiotics
     Time-PCR Results                  N (%)                     N (%)                            N (%)                       N (%)
 Negative                            20 (74.1)                   15 (78.9)                         35 (67)                   9 (81.8%)
 Positive                             7 (25.9)                    4 (21.1)                         17 (33)                    2 (18.2)
 Total                               27 (100)                    19 (100)                         52 (100)                    11 (100)

No statistically significant relationship was found between COVID-19 real time-PCR positivity and the type of treatment administered for
HS when the treatment modalities are divided into four categories as oral antibiotics± topical antibiotics, oral retinoids± topical antibiotics,
TNF-alpha inhibitors ± oral/topical antibiotics and only topical antibiotics (P = 0.657)



No statistically significant relationship was found between               categories as TNF- α inhibitors ± oral/topical antibiotics
COVID-19 real-time PCR positivity and the type of treat-                  and others (P = 0.248). In all patients, with a confirmed
ment administered for HS when the treatment modalities                    diagnosis of COVID-19; anti-TNF-α treatment was im-
are divided into four categories as oral antibiotics± topi-               mediately suspended until full recovery from the disease.
cal antibiotics, oral retinoids ± topical antibiotics, TNF-α              Lastly, there was no statistically significant relationship be-
­inhibitors ± oral/topical antibiotics and only topical antibi-           tween COVID-19 real time-PCR results and the presence
otics (P = 0.657) (Table 4 and Figure 1) or divided into two              of previous malignancy history; respiratory, cardiovascular,



4                                                                              Original Article | Dermatol Pract Concept. 2022;12(4):e2022192
                                                      PERCENTAGE OF PATIENTS WITH
                                               POSITIVE COVID-19 RT-PCR VS TREATMENT TYPE



                                  50.0%

                                  45.0%
    PERCENTAGE OF PATIENTS WITH




                                  40.0%
      POSITIVE COVID-19 RT-PCR




                                                                                           33.0%
                                  35.0%
                                                  25.9%
                                  30.0%
                                                                   21.1%
                                  25.0%                                                                           18.2%
                                  20.0%

                                  15.0%

                                  10.0%

                                  5.0%

                                  0.0%
                                          Oral antibiotics   Oral retinoids      TNF-alfa inhibitors     Topical antibiotics
                                              (n=27)            (n=19)                (n=52)                  (n=11)

                                                                     TREATMENT TYPE



Figure 1. The percentage of the patients with a positive COVID-19 real-time polymerase chain reaction (RT-PCR) result according to the
treatment type.



nephrological diseases, endocrinologic and rheumatologic                      significantly higher pack-years of smoking compared to the
disorders (P > 0.05).                                                         ones with no symptoms (P = 0.024) (Figure 4).
    Patients having COVID-19 related symptoms were                               As expected, there seems to be a statistically significant
shown to have statistically significantly higher mean age                     relationship between the presence of COVID-19 symptoms
compared to the ones who did not have any symptoms                            and COVID-19 RT-PCR positivity (P < 0.001) (Table 5). Of
(P = 0.031). The percentage of patients with COVID-19 re-                     109 patients who were tested for COVID-19, 75 (68.8 %)
lated symptoms according to the treatment type was shown                      had COVID-19 related symptoms; 30 (40%) cases out of 75
in Figure 2. We found no statistically significant relation-                  cases with COVID-19 related symptoms, were tested positive
ship between the presence of COVID-19 symptoms and                            for COVID. Thirty-four patients who did not demonstrate
the gender (P = 0.241), BMI (P = 0.472), cigarette smoking                    any symptoms still gave COVID-19 PCR test, were all tested
(P = 0.272), treatment duration (P = 0.353), disease dura-                    negative. Of 109 patients who were tested for COVID-19, 43
tion (P = 0.850) and given treatment type when grouped as                     (39.45 %) had close contact to someone with a confirmed
oral antibiotics± topical antibiotics, oral retinoids, TNF-α                  diagnosis of COVID-19; whereas 66 (60.55%) did not have
inhibitors ± oral/topical antibiotics, colchicine and topical                 any close contact. Twenty-seven (62.8%) cases out of 43 with
antibiotics (P = 0.124). Patients with cardiovascular disease                 close contact to a person diagnosed with COVID-19 had
were shown to present with COVID-19 related symptoms                          positive RT-PCR result. We found a statistically significant
compared to the ones with no accompanying cardiovascular                      relationship between the history of close contact to some-
disease (P = 0.035). Additionally, patients who had at least                  one with a confirmed COVID-19 diagnosis and COVID-19
one systemic disease (classified as respiratory, nephrologic,                 RT-PCR positivity (P < 0.001) (Table 5). No patient was hos-
cardiovascular, rheumatologic, gastroenterologic, endocrino-                  pitalized for severe COVID-19 infection.
logic disorders) had higher probability to exhibit COVID-19                      Binary logistic regression analyses (in which age, gender,
symptoms (Figure 3). Lastly, patients who reported to have                    BMI, the presence of any other systemic disease and smok-
COVID-19 related symptoms were shown to present with                          ing were included as independent variables) were performed



Original Article | Dermatol Pract Concept. 2022;12(4):e2022192                                                                           5
                                                                         PERCENTAGE OF PATIENTS WITH
                                                                COVID-19 RELATED SYMPTOMS VS TREATMENT TYPE



                                         100.0%

                                          90.0%
      PERCENTAGE OF PATIENTS WITH




                                          80.0%
      COVID-19 RELATED SYMPTOMS




                                          70.0%
                                                                                                                         55.0%                         53.3%
                                          60.0%

                                          50.0%                                              40.0%
                                                                   35.4%
                                          40.0%

                                          30.0%

                                          20.0%

                                          10.0%

                                            0.0%
                                                           Oral antibiotics           Oral retinoids          TNF-alfa                            Topical
                                                               (n=27)                    (n=19)           inhibitors (n=52)                  antibiotics (n=11)

                                                                                             TREATMENT TYPE


Figure 2. The percentage of the patients with COVID-19 related symptoms according to the treatment type.




 A                    PATIENTS WITHOUT ANY SYSTEMATIC DISEASE (N=103)                             B      PATIENTS WITH AT LEAST ONE SYSTEMIC DISEASE (N=75)




                                                  38%                                                                                            40%
                                                                                                                                60%
                                                                 62%




                                    ABSENT COVID-19 SYMPTOMS   PRESENT COVID-19 SYMPTOMS                          ABSENT COVID-19 SYMPTOMS     PRESENT COVID-19 SYMPTOMS




Figure 3. The distribution of the percentages of the patients with absent and present COVID-19 related symptoms among the participants
without any systematic disease (A) and among the participants with at least one systematic disease (B)




taking the presence of COVID-19 symptoms as the depen-                                             the presence of any other systemic disease were considered
dent variable. Smoking (odds ratio [OR] 2.595; 95% con-                                            as independent variables) were also carried out by taking
fidence interval: 1.009-6.674; P = 0.048) and the presence                                         COVID-19 RT-PCR result (positive or negative) as the de-
of any other systemic illness (OR 6.968; 95% interval:                                             pendent variable. As a result, it was found that age, gender,
­2.754-17.631; P < 0.001) were associated with an increased                                        BMI and the presence of at least one systemic illness did
risk of developing COVID-19 related symptoms. In addition,                                         not c­ontribute significantly to the outcome of COVID-19
logistic regression analyses (in which age, gender, BMI and                                        test result.



6                                                                                                       Original Article | Dermatol Pract Concept. 2022;12(4):e2022192
                                                PACK-YEARS OF SMOKING VS. COVID-19 SYMPTOMS
                                           70

                                           60             60


                   PACK-YEARS OF SMOKING   50

                                           40

                                                                   32                                    33
                                           30
                                                                        p=0.024
                                           20                      20                                          21
                                                                                                               15
                                           10                      10                                          10
                                                          5
                                                                                                         3
                                            0
                                                     PRESENT                                     ABSENT
                                                                   COVID-19 SYMPTOMS


                 Figure 4. The Pack-years of smoking according to the absence and presence of COVID-19 symptoms:
                 Boxplot representing median values, 25-75% range (box) and minimum-maximum range (bars) of the
                 pack-years of smoking with respect to the patients with COVID-19-related symptoms and patients with-
                 out any COVID-19-related symptoms.




Table 5. Covid-19 Real-Time PCR results with respect to the presence of Covid-19-related symptoms
                   and close contact to someone with a diagnosis of Covid-19.
                                                             Covid-19                                 Close contact
                                                        related symptoms                  to someone with a diagnosis of Covid-19
                                                              N (%)                                       N (%)
  Covid-19 Real Time-PCR Results                      Not present           Present        Not present              Present      Total
 Negative                                               34 (100)             45 (60)         63 (95.5)           16 (37.2)     79 (72.5)
 Positive                                                0 (0)               30 (40)           3 (4.5)           27 (62.8)     30 (27.5)
 Total                                                  34 (100)            75 (100)          66 (100)              43 (100)   109 (100)
                                                               P < 0.001                                      P < 0.001

Statistically significant relationships were found between COVID-19 real time-PCR positivity versus history of close contact
to someone with a confirmed COVID-19 diagnosis (P < 0.001) and between COVID-19 real time-PCR positivity versus the
presence of COVID-19 related symptoms (P < 0.001).




Conclusions                                                                  females compared to males with a ratio of 3:1 [6,14]. Since
                                                                             patients with HS suffer from acute (bacterial superinfec-
HS is one of the most challenging diseases of dermatology,                   tions, lymphadenopathy) and chronic complications of the
which has a great impact on patients quality of life and pres-               disease (amyloidosis, chronic disease anemia, lymphedema,
ents with various associated comorbidities. The disease is                   lymphatic obstruction, significant scarring, chronic pain,
characterized by deep-seated, tender, inflamed, draining nod-                malodor and fistula formation) [15] ; early diagnosis and
ules and abscesses subsequently leading to sinus tract and                   adequate treatment of this debilitating disease are quite
scar formation mainly in the flexural areas of the body [11].                essential.
HS is most commonly seen in the third and fourth decades                          Topical and systemic antibiotics, anti-inflammatory
of life [12]. Since different clinical entities including furuncu-           agents, anti-androgens, oral retinoids, immunosuppressive
losis, nodulocystic acne, epidermoid cyst, cutaneous Crohn                   treatments, TNF-α inhibitors (especially adalimumab and in-
disease may be considered in the differential diagnoses of                   fliximab), apremilast, surgical intervention and laser excision
HS, a mean diagnostic delay of 7.2 years has been reported                   repair are among the miscellaneous therapeutic interventions
in a study [13]. The disease is more commonly observed in                    used for HS [16]. Generally, Hurley stage 1 HS is treated



Original Article | Dermatol Pract Concept. 2022;12(4):e2022192                                                                             7
with topical and systemic antibiotics, surgical procedures;           Patients with HS have multiple associated comorbidities
systemic antibiotics, oral retinoids, anti-TNF- α agents, sur-     including metabolic syndrome, obesity, diabetes mellitus,
gical deroofing or laser excision are used for stage 2 and 3       dyslipidemia, polycystic ovarian syndrome, thyroidal dys-
disease [16].                                                      function, axial spondyloarthropathy and cardiovascular-­
    From the start of COVID-19 outbreak in December 2019,          associated adverse events [22]. A recent meta-analysis revealed
the effect of immunosuppressive agents on the clinical course      that cardiovascular diseases, obesity, hypertension, history of
of COVID-19 is gradually being questioned by both physi-           smoking, old age are also risk factors for critical and mortal
cians and patients [17]. COVID-19 infection is a multiphasic       cases of COVID-19 infection [23]. Being male, smoking and
viral disease which commences with an antiviral response           being at an age greater than 65 years were shown to be as-
phase followed by an hyperinflammatory state [17,18].              sociated with COVID-19 disease progression [23]. Critical
The main cytokines that dominate the first (­antiviral) phase      COVID-19 cases had higher rates of having underlying dis-
differ from the cytokines which prevail the hyperinflam-           eases such as hypertension, cardiovascular disease and diabe-
matory phase [18]. Interleukin (IL)-15, interferon-α, inter-       tes mellitus compared to the non-critical COVID-19 patients
feron-β and interferon-γ are the major cytokines responsible       [23]. Even though, in our cohort no patient was needed to be
for viral clearance whereas TNF-α, IL-17, IL-6 and granu-          hospitalized for severe COVID-19, we found that the mean
locyte-monocyte colony stimulating factor preponderate             age of the patients with positive results of COVID RT-PCR
during the hyperinflammatory phase [17,18]. Therefore, it          was statistically significantly higher compared to the ones
seems reasonable to use anti-TNF- α and anti-IL-17 agents          with negative results (P < 0.007). Additionally, patients who
during the hyperinflammatory state of COVID-19 since               demonstrated COVID-19 related symptoms were shown to
these agents do not seem to affect the course of the antiviral     have statistically significantly higher average age compared to
phase [18]. In phase 3 trials of adalimumab for HS, it was         the ones who did not demonstrate any symptoms (P = 0.031).
shown that there is a slightly escalated risk for total infec-     In line with the data in the literature, patients who had any
tions and nasopharyngitis by 2.5% but there was no signif-         cardiovascular disease (most common one being hyperten-
icant difference between adalimumab and placebo group in           sion) were shown to have COVID-19 related symptoms at
terms of upper respiratory tract infections [19]. In line with     a higher rate compared to the ones with no accompanying
this observation, in our study we found that no statistically      cardiovascular disease (P = 0.035). Wang et al [24] showed
significant relationship exists between COVID-19 real-time         that hypertension prevalence was higher in COVID-19 pa-
PCR positivity and the therapeutic interventions used for HS       tients admitted to intensive care unit compared to ones who
when the treatment modalities are divided into four catego-        did not. In our study, we have also showed that patients who
ries as oral antibiotics ± topical antibiotics, oral retinoids ±   had at least one systemic disease had higher proportions of
topical antibiotics, TNF-α inhibitors ± oral/topical antibiot-     demonstrating COVID-19 symptoms compared to the ones
ics and only topical antibiotics (P = 0.657). Also, similar to     who did not have any known systemic comorbidity. A recent
our study, Marasca et al [20] reported their experience with       study by Lowe et al [25] revealed that patients with > 30
93 HS patients during COVID-19 pandemic. In this study,            pack-years of smoking were 2.25 times more likely to be hos-
75 patients were on adalimumab treatment, 15 ­
                                             patients              pitalized. Even though, we did not have any patient who was
were using oral antibiotics and 3 patients were not on any         hospitalized for COVID-19, our study disclosed that patients
treatment [20]. Only one patient reported COVID-19 re-             with COVID-19 symptoms were shown to have statistically
lated symptoms which subsided immediately and three pa-            significantly higher pack-years of smoking compared to the
tients (one under rifampicin+clindamycin treatment, the two        ones without any symptoms (P = 0.024). Lastly, we found
others under adalimumab treatment) had been isolated due           no statistically significant relationship between the presence
to a close contact to someone with a suspected diagnosis of        of COVID-19 symptoms/COVID-19 RT-PCR positivity and
COVID-19, without having positive real-time PCR test result        gender, BMI, smoking status (current smoker vs non-smoker)
[20]. Furthermore, Molinelli et al [21] declared that none         and treatment duration (P > 0.05). In contrast, a study which
of the 35 patients treated with adalimumab for HS in their         investigated the relationship between COVID-19 and met-
cohort group had any symptoms related to COVID-19 and              abolic associated fatty liver disease, showed that obesity
the ongoing biologic treatment was not discontinued in any         significantly increases the risk of having severe COVID-19
patient. Supporting the findings of this study, we also did        disease [26]. Since in our cohort population, not all the pa-
not find any statistically significant difference between the      tients with COVID-19 related symptoms and with a history
presence of COVID-19 symptoms and the given treatment              of close contact to someone with a confirmed diagnosis of
modalities when categorized as oral antibiotics± topical an-       COVID-19, were tested for COVID-19 we might have missed
tibiotics, oral retinoid, TNF-α inhibitors ± oral/topical anti-    some real positive COVID-19 cases which might have limited
biotics and topical antibiotics (P = 0.124).                       our findings.



8                                                                      Original Article | Dermatol Pract Concept. 2022;12(4):e2022192
    All in all, we would like underline once again that HS pa-              10. Giamarellos-Bourboulis EJ, Bettoli V, Jemec GBE, et al.
tients have multiple associated comorbidities some of which                     Anti-COVID-19 measurements for hidradenitis suppurativa pa-
                                                                                tients. Exp Dermatol. 2021;30 Suppl 1(Suppl 1):18-22. DOI:
are also risk factors for critical/mortal COVID-19 disease. In
                                                                                10.1111/exd.14339. PMID: 34085330. PMCID: PMC8207032.
our study, older age, higher pack-years of smoking, having at
                                                                            11. Wolk K, Join-Lambert O, Sabat R. Aetiology and pathogenesis of
least one systemic disease, having a cardiovascular disease,                    hidradenitis suppurativa. Br J Dermatol. 2020;183(6):999-1010.
were associated with increased risks of having COVID-19                         DOI: 10.1111/bjd.19556. PMID: 33048349.
related symptoms whereas higher disease duration of HS and                  12. Vazquez BG, Alikhan A, Weaver AL, Wetter DA, Davis MD.
older age were correlated with significantly higher levels of                   Incidence of hidradenitis suppurativa and associated factors: a
                                                                                population-based study of Olmsted County, Minnesota. J Invest
COVID-19 RT-PCR positivity. Treatment type did not seem
                                                                                Dermatol. 2013;133(1):97-103. DOI: 10.1038/jid.2012.255.
to contribute significantly to the outcome of COVID-19
                                                                                PMID: 22931916. PMCID: PMC3541436.
­
RT-PCR test and the incidence of COVID-19 associated                        13. Saunte DM, Boer J, Stratigos A, et al. Diagnostic delay in hi-
symptoms. We suggest the ongoing TNF-α inhibitor treat-                         dradenitis suppurativa is a global problem. Br J Dermatol.
ment should be continued in patients with HS, unless a de-                      2015;173(6):1546-1549. DOI: 10.1111/bjd.14038. PMID: 26​
finitive diagnosis of COVID-19 is established.                                  198191.
                                                                            14. Miller IM, McAndrew RJ, Hamzavi I. Prevalence, Risk Fac-
    Our study has some limitations since it was a single cen-
                                                                                tors, and Comorbidities of Hidradenitis Suppurativa. Dermatol
ter study and no control group was present. Further multi-
                                                                                Clin. 2016;34(1):7-16. DOI: 10.1016/j.det.2015.08.002. PMID:
center, prospective studies with large number of patients are                   26617352.
required to support our findings.                                           15. Yuan JT, Naik HB. Complications of hidradenitis suppurativa.
                                                                                Semin Cutan Med Surg. 2017;36(2):79-85. DOI: 10.12788/j.

References                                                                      sder.2017.022. PMID: 28538749.
                                                                            16. Agrawal A, Sharma YK. Errata: Review article: Hidradenitis sup-
 1. Lee EY, Alhusayen R, Lansang P, Shear N, Yeung J. What is hidra-              purativa: A systematic review and meta-analysis of therapeutic in-
    denitis suppurativa? Can Fam Physician. 2017;63(2):114-120.                   terventions. Indian J Dermatol Venereol Leprol. 2019;85(6):617.
    PMID: 28209676. PMCID: PMC5395382.                                            DOI: 10.4103/ijdvl.IJDVL_453_19. PMID: 31512583.
 2. Ovadja ZN, Schuit MM, van der Horst CMAM, Lapid O. Inter-               17.   Jones ME, Kohn AH, Pourali SP, et al. The Use of Biologics During
    and intrarater reliability of Hurley staging for hidradenitis sup-            the COVID-19 Pandemic. Dermatol Clin. 2021;39(4):545-553.
    purativa. Br J Dermatol. 2019;181(2):344-349. DOI: 10.1111/                   DOI: 10.1016/j.det.2021.05.010. PMID: 34556244. PMCID:
    bjd.17588. PMID: 30585304; PMCID: PMC6850108.                                 PMC8166518.
 3. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a com-         18.   Schett G, Sticherling M, Neurath MF. COVID-19: risk for cyto-
    prehensive review. J Am Acad Dermatol. 2009;60(4):539-361.                    kine targeting in chronic inflammatory diseases? Nat Rev Immu-
    DOI: 10.1016/j.jaad.2008.11.911. PMID: 19293006.                              nol. 2020;20(5):271-272. DOI: 10.1038/s41577-020-0312-7.
 4. Pescitelli L, Ricceri F, Prignano F. Hidradenitis suppurativa and as-         PMID: 32296135. PMCID: PMC7186927.
    sociated diseases. G Ital Dermatol Venereol. 2018;153(3 Suppl 2):       19.   Kimball AB, Okun MM, Williams DA, et al. Two Phase 3 Tri-
    8-17. DOI: 10.23736/S0392-0488.17.05772-8. PMID: 30468375.                    als of Adalimumab for Hidradenitis Suppurativa. N Engl J Med.
 5. Kirby JS, Butt M, Esmann S, Jemec GBE. Association of Re-                     2016;375(5):422-434. DOI: 10.1056/NEJMoa1504370. PMID:
    silience With Depression and Health-Related Quality of Life                   27518661.
    for Patients With Hidradenitis Suppurativa. JAMA ­Dermatol.             20.   Marasca C, Ruggiero A, Megna M, Annunziata MC, Fab-
    2017;153(12):1263-1269. DOI: 10.1001/jamadermatol.2017​                       brocini G. Biologics for patients affected by hidradenitis sup-
    .3596. PMID: 29117300. PMCID: PMC5817438.                                     purativa in the COVID-19 era: data from a referral center of
 6. Nguyen TV, Damiani G, Orenstein LAV, Hamzavi I, Jemec GB.                     Southern Italy. J Dermatolog Treat. 2022;33(1):592. DOI:
    Hidradenitis suppurativa: an update on epidemiology, pheno-                   10.1080/09546634.2020.1769828. PMID: 32403954.
    types, diagnosis, pathogenesis, comorbidities and quality of life. J    21.   Molinelli E, Diotallevi F, Simonetti O, et al. Management of
    Eur Acad Dermatol Venereol. 2021;35(1):50-61. DOI: 10.1111/                   patients with hidradenitis suppurativa during the COVID-19
    jdv.16677. PMID: 32460374.                                                    pandemic: Risk and benefit of immunomodulatory therapy.
 7. Tchero H, Herlin C, Bekara F, Fluieraru S, Teot L. Hidradeni-                 Dermatol Ther. 2020;33(6):e14256. DOI: 10.1111/dth.14256.
    tis Suppurativa: A Systematic Review and Meta-analysis of                     PMID: 32860474.
    Therapeutic Interventions. Indian J Dermatol Venereol Leprol.           22.   Cartron A, Driscoll MS. Comorbidities of hidradenitis sup-
    2019;85(3):248-257. DOI: 10.4103/ijdvl.IJDVL_69_18. PMID:                     purativa: A review of the literature. Int J Womens Dermatol.
    30924446.                                                                     2019;5(5):330-334. DOI: 10.1016/j.ijwd.2019.06.026. PMID:
 8. Zouboulis CC, Desai N, Emtestam L, et al. European S1 guideline               31909152. PMCID: PMC6938918.
    for the treatment of hidradenitis suppurativa/acne inversa. J Eur       23.   Zheng Z, Peng F, Xu B, et al. Risk factors of critical & mor-
    Acad Dermatol Venereol. 2015;29(4):619-644. doi: 10.1111/                     tal COVID-19 cases: A systematic literature review and
    jdv.12966. PMID: 25640693.                                                    meta-analysis. J Infect. 2020;81(2):e16-e25. DOI: 10.1016/j.
 9. Lowe MM, Naik HB, Clancy S, et al. Immunopathogenesis of                      jinf.2020.04.021. PMID: 32335169. PMCID: PMC7177098.
    ­hidradenitis suppurativa and response to anti-TNF-α therapy. JCI       24.   Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138
     Insight. 2020;5(19):e139932. DOI: 10.1172/jci.insight.139932.                Hospitalized Patients With 2019 Novel Coronavirus-Infected
     PMID: 32841223. PMCID: PMC7566733.                                           Pneumonia in Wuhan, China. JAMA. 2020;323(11):1061-1069.




Original Article | Dermatol Pract Concept. 2022;12(4):e2022192                                                                                    9
    DOI: 10.1001/jama.2020.1585. PMID: 32031570. PMCID:            Intern Med. 2021;181(5):709-711. DOI: 10.1001/jamaint-
    PMC7042881.                                                    ernmed.2020.8360. EPMID: 33492361. PMCID: PMC7835916.
25. Lowe KE, Zein J, Hatipoglu U, Attaway A. Association of    26. Kwok S, Adam S, Ho JH, et al. Obesity: A critical risk factor in
    Smoking and Cumulative Pack-Year Exposure With COVID-19        the COVID-19 pandemic. Clin Obes. 2020;10(6):e12403. DOI:
    Outcomes in the Cleveland Clinic COVID-19 Registry. JAMA       10.1111/cob.12403. PMID: 32857454. PMCID: PMC7460880.




10                                                                  Original Article | Dermatol Pract Concept. 2022;12(4):e2022192
