Perspectives of obstetricians/gynecologists on hidradenitis suppurativa care: a survey study : International Journal of Women's Dermatology

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Perspectives of obstetricians/gynecologists on hidradenitis suppurativa care: a survey study

Masson, Rahul BSa; Shih, Terri BSb; De, Devea R. BSc; Park, Sarah BSb; Parvataneni, Ram MDd; Goldberg, Aaron MDe; Sayed, Christopher J. MDf; Shi, Vivian Y. MDg; Hsiao, Jennifer L. MDh,*

Author Information
International Journal of Women’s Dermatology: December 2022 - Volume 8 - Issue 4 - p e064
doi: 10.1097/JW9.0000000000000064
  • Open

What is known about this subject in regard to women and their families?

  • Hidradenitis suppurativa (HS) disproportionately affects women of child-bearing age; thus, obstetricians-gynecologists (OB-GYNs) are important front-line providers for women with HS.
  • There is a paucity of research on the perspectives of OB-GYN providers regarding HS diagnosis and management.

What is new from this article as messages for women and their families?

  • Less than a fifth of surveyed OB-GYN providers were confident in managing HS during pregnancy (19.6%), counseling patients on how pregnancy/the postpartum period may affect HS (17.5%), and managing moderate-to-severe HS (16.3%).
  • OB-GYN providers infrequently performed procedural treatments or referred patients to mental health specialists, HS support groups, or nutritionists.
  • Increased HS educational resources for OB-GYN providers and collaboration between OB-GYN providers and dermatologists are needed to optimize HS care for women.

Dear Editors,

Obstetricians-gynecologists (OB-GYNs) are key front-line providers for hidradenitis suppurativa (HS), especially since HS disproportionately affects women of child-bearing age.1 Herein, we explored the perspectives of OB-GYN providers regarding HS care to elicit any knowledge and practice gaps.

An anonymous survey was distributed online between May and July 2022 through OB-GYN organizational listservs and in-person at the 2022 Annual American College of OB-GYN Meeting. OB-GYN providers over the age of 18 were eligible to participate. T-tests were used for comparative statistics between provider type and survey responses. A P value of <.05 was considered significant. The study is IRB exempt at the University of California, Los Angeles.

Demographics of the 104 respondents are summarized in Table 1. Less than 20% of respondents felt confident managing patients with moderate-severe HS (17/104, 16.3%), discussing how pregnancy/postpartum may affect HS (18/103, 17.5%), or managing HS in pregnancy (20/102, 19.6%) (Fig. 1). Compared to nonphysician providers, physicians were more confident in managing HS during pregnancy (P = .03) and discussing how pregnancy and the postpartum period may affect HS symptoms (P = .046). Attending physicians (11.5 mean years of practice) were more confident than other providers in all queried domains (P < .05).

Table 1 - Survey respondents’ demographic characteristics
Providers’ demographic characteristics N (%)
Gender (n = 104)
 Female 93 (89.4%)
 Male 11 (10.6%)
Age, Mean ± SD (range) (n = 104) 41.6 ± 9.7 (26–70)
Number of HS patients seen per month, mean ± SD (range) (n = 104) 1.6 ± 2.8 (0–24)
Type of provider (n = 104)
 Physician 95 (91.3%)
  Attending 76 (80.0%)
  Fellow 7 (7.4%)
  Resident 11 (11.6%)
  Unspecified 1 (1.1%)
 PAs/NPs/CNMs 9 (8.7%)
Scope of practice (n = 104)
 General OB-GYN 81 (77.9%)
 Maternal-fetal medicine 7 (6.7%)
 Urogynecology 4 (3.8%)
 Gynecologic oncology 4 (3.8%)
 Reproductive Endocrinology and Infertility 3 (2.9%)
 Other a 5 (4.8%)
Practice setting (n = 104)
 Academic 56 (53.8%)
 Community 38 (36.5%)
 Specialty group 10 (9.6%)
State of practice (n = 104)
 California 45 (43.3%)
 Virginia 16 (15.4%)
 Colorado 4 (3.8%)
 Indiana 4 (3.8%)
 Texas 4 (3.8%)
 Georgia 3 (2.9%)
 Iowa 3 (2.9%)
 North Carolina 3 (2.9%)
 Other b 22 (21.2%)
Disease severity of majority of HS patients seen (n = 74)
 Hurley stage I 43 (58.1%)
 Hurley stage II–III 20 (27.0%)
 Equal amounts of Hurley stage I and II–III 11 (14.9%)
CNM, certified nurse midwife; HS, hidradenitis suppurativa; NP, nurse practitioner; OB-GYN, obstetrics-gynecology; PA, physician’s assistant; SD, standard deviation.
aGynecology only (n = 2), Minimally invasive gynecologic surgery (n = 2), unspecified (n = 1).
bArizona, Kentucky, Michigan (n = 2 from each state); Florida, Illinois, Maryland, Minnesota, Missouri, New Hampshire, New Jersey, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Washington (n = 1 from each state).

F1
Fig. 1.:
Providers’ confidence levels regarding HS diagnosis and management and their treatment patterns. *N = 103 for diagnosing HS and discussing how pregnancy/postpartum may affect HS symptoms, N = 102 for managing HS in pregnancy. ^N = 73 for topical antibiotics, methotrexate, and cyclosporine, N = 69 for “other.” HS, hidradenitis suppurativa.

Top treatments prescribed “often”/“sometimes” include oral contraceptives (OCPs) (67.6%, 50/74), topical antibiotics (60.3%, 44/73), oral antibiotics (58.1%, 43/74), and spironolactone (51.4%, 38/74). The majority (91.9%, 68/74) had never prescribed biologics. Procedural treatments were infrequently performed for HS.

The majority of respondents “often”/“sometimes” referred patients to dermatology (89.3%, 67/75) and general surgery (46.6%, 34/73), followed by mental health specialists (22.2%, 16/72), HS support groups (19.2%, 14/73), and nutritionists (17.6%, 13/74). Respondents mainly preferred internet-based educational resources (99.0%, 101/102) and peer-reviewed papers (93.1%, 95/102) to learn more about HS.

Overall, we found that OB-GYNs were not confident in managing moderate-severe HS, and rarely prescribed biologic agents or performed procedures for HS. This highlights the importance of educating OB-GYNs regarding early referral of patients with HS to dermatologists for appropriate management.

Our results show that nearly one-fourth of respondents did not feel confident in diagnosing HS and almost half were not confident in managing mild HS. Important educational areas for OB-GYNs include earlier HS diagnosis, especially given the prevalence of misdiagnosis of HS,2 and management of mild HS. One German study found that approximately 30% of patients had consulted gynecologists for HS symptoms, but only around 5% were ultimately diagnosed by gynecologists.3 An additional high-yield management area to target for OB-GYNs is use of OCPs and spironolactone to help women who have hormone-related HS exacerbations.4

Our findings also underscore the importance of educating OB-GYNs regarding HS disease course and management during pregnancy and the postpartum period. There is a gap in counseling regarding HS and pregnancy,5 and OB-GYNs are uniquely positioned to help counsel patients during these times.

Study limitations include that respondents were predominantly female and U.S. based, which limits the generalizability of our findings. Increasing HS educational resources for OB-GYNs, particularly trainees and nonphysician providers, and encouraging care coordination between OB-GYNs and dermatologists will improve HS care, particularly for women with moderate-to-severe HS.

Conflicts of interest

JLH is on the Board of Directors for the Hidradenitis Suppurativa Foundation (HSF), has served as a consultant for Boehringer Ingelheim, Novartis, and UCB, and has served as a consultant and speaker for AbbVie. VYS is on the board of directors for the HSF, is a stock shareholder of Learn Health and has served as an advisory board member, investigator, speaker, and/or received research funding from Sanofi Genzyme, Regeneron, AbbVie, Eli Lilly, Novartis, SUN Pharma, LEO Pharma, Alumis, Pfizer, Incyte, Boehringer Ingelheim, Aristea Therapeutics, Menlo Therapeutics, Dermira, Burt’s Bees, Galderma, Kiniksa, UCB, WebMD, TARGET-Pharmasolutions, Altus Lab, MYOR, Polyfin, GpSkin and Skin Actives Scientific. CJS is a speaker for Abbvie and Novartis, consultant for Abbvie, Novartis, UCB, and Aclaris, and InflaRx, is an investigator for Abbvie, Novartis, UCB, InflaRx, Chemocentryx, and Incyte, and is on the board of the HSF. The remaining authors declared no conflicts of interest.

Funding

None.

Study approval

N/A

Author contributions

RM and TS: Participated in writing, reviewing, and editing this manuscript and analyzing data for this project. DRD, SP, RP, AG, and CJS: Participated in reviewing and editing this manuscript. VYS and JLH: Participated in reviewing and editing this manuscript and the conceptualization and administration of this project.

Data availability statement

Data are available upon request from authors.

Acknowledgments

We would like to thank the providers who participated in our survey, including members of the Society for Academic Specialists in General Obstetrics and Gynecology.

References

1. Sayed CJ, Hsiao JL, Okun MM; Hidradenitis Suppurativa Foundation Women's Health SubcommitteeHidradenitis Suppurativa Foundation Women's Health Subcommittee. Clinical epidemiology and management of hidradenitis suppurativa. Obstet Gynecol 2021;137:731–746.
2. Rick JW, Thompson AM, Fernandez JM, et al. Misdiagnoses and barriers to care in hidradenitis suppurativa: a patient survey. Australas J Dermatol 2021;62:e592–e594.
3. Kokolakis G, Wolk K, Schneider-Burrus S, et al. Delayed diagnosis of hidradenitis suppurativa and its effect on patients and healthcare system. Dermatology 2020;236:421–430.
4. Collier EK, Price KN, Grogan TR, Naik HB, Shi VY, Hsiao JL. Characterizing perimenstrual flares of hidradenitis suppurativa. Int J Womens Dermatol 2020;6:372–376.
5. Adelekun AA, Villa NM, Hsiao JL, Micheletti RG. Pregnancy in hidradenitis suppurativa-patient perspectives and practice gaps. JAMA Dermatol 2021;157:227–230.
Keywords:

hidradenitis suppurativa; obstetricians and gynecologists; medical education; health services research

Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of Women’s Dermatologic Society.