Abstract

Background: Real-world treatment patterns in Hidradenitis Suppurativa (HS) stratified by disease severity remain inadequately characterized.

Methods: Using the nationwide TriNetX database, two HS cohorts were defined based on diagnosis frequency: 2-3 vs. ≥4 encounters. Cohorts were propensity matched and treatment utilization compared.

Results: Among 60,508 patients (2-3 visits) and 58,114 patients (≥4 visits), those with ≥4 encounters were more likely to be Black or African American (38.3% vs. 32.7%, p<0.01) and less likely to be White (19.2% vs. 45.4%, p<0.01) compared to those with 2-3 visits. Higher disease burden was associated with increased use of antibiotics (85.3% vs. 65.2%), biologics (19.9% vs. 4.2%), systemic therapies, procedures and opioids (all p<0.01).

Conclusions: Increased disease intensity correlated with the need for higher-intensity care. This pattern follows current guidelines, which recommend a stepwise progression from antibiotics in mild disease to systemic and invasive therapies in moderate HS. A higher burden of disease is seen among Black or African American patients compared to White patients. Disparities in disease severity emphasize the need for proactive management and equitable access to care.

Keywords: Hidradenitis Suppurativa; Treatment Patterns; Disease Severity; Biologic Therapy; Health Disparities

Introduction

Although previous studies have identified commonly utilized and efficacious treatments for Hidradenitis Suppurativa (HS), real-world treatment patterns stratified by disease severity remain inadequately characterized [2,3]. HS affects approximately 1% of Western populations, disproportionately impacts women of childbearing age and is associated with obesity, metabolic syndrome and psychiatric comorbidity, all of which complicate therapeutic decision-making and adherence considerably [5]. Examining varying therapeutic strategies across HS severity levels may provide critical insights into the interplay between disease burden, chronicity and clinical management.

Methodology

Data was obtained from the de-identified, nationwide TriNetX database. Two patient cohorts were defined based on the frequency of HS diagnoses using International Classification of Diseases-10 (ICD-10) codes: one cohort with 2 or 3 distinct HS-coded encounters (L73.2) and the second cohort with ≥4 such encounters. The cohorts were 1:1 propensity score matched by age, race, sex, tobacco use, inflammatory bowel disease and BMI. Odds ratios were calculated to compare demographic distributions and post-index utilization of key treatments, including antibiotics (tetracycline, sarecycline, omadacycline, demeclocycline, doxycycline, tigecycline, minocycline, clindamycin, trimethoprim and derivatives, metronidazole), biologics (adalimumab, infliximab, ustekinumab, secukinumab, etanercept, risankizumab), intralesional injections, opioids and HS-related procedures (incision and drainage, debridement, excision of benign lesions and destruction of benign lesions).

Results

A total of 60,508 patients were included in the 2-3-visit cohort and 58,114 in the ≥4-visit cohort. Patients with ≥4 HS encounters were significantly more likely to be Black or African American (38.3% vs. 32.7%, p<0.01) and less likely to be White (19.2% vs. 45.4%, p<0.01) compared to those with 2-3 visits. Antibiotics were prescribed to 85.3% of patients in the ≥4 group compared to 65.2% in the 2-3 group (OR: 3.05; 95% CI: 2.96-3.14; p<0.01). Biologic use increased from 4.2% in the 2-3 visit cohort to 19.9% in the ≥4 visit cohort (5.56; 5.30-5.82; p<0.01) while similar use of systemic therapies, including immunosuppressants, increased from 3.2% to 9.5% (3.10; 2.93-3.28; p<0.01). Intralesional injections were more common in the ≥4 group (17.7% vs. 4.0%; 5.18; 4.94-5.43; p<0.01), as were HS-related procedures (36.7% vs. 16.0%; 2.97; 2.88-3.05; p<0.01). Use of opioids was also higher in the ≥4 group (58.4% vs. 40.5%; 2.02; 1.97-2.07; p<0.01) (Table 1).