Building a Multidisciplinary Hidradenitis Suppurativa Clinic

Introduction

Successful treatment of a patient with hidradenitis suppurativa (HS) requires a multidisciplinary approach. As such, establishing a multidisciplinary HS clinic is crucial to address this multifaceted disease. Having a basic treatment algorithm, expertise in the field, access to other specialties for referral, knowledge and access to the latest research, and quality improvement initiatives are all important in establishing a successful HS clinic.

Treatment Algorithm

Every patient with HS presents differently, and accordingly, every patient should have an individualized treatment approach. Having a multidisciplinary HS care plan has been associated with high levels of patient satisfaction. Implementing a standard treatment algorithm can be a valuable implementation tool and starting point for residents, physicians, and other practitioners, particularly those who are new to treating patients with HS. Establishing an institutional treatment algorithm can allow for the inclusion of institution-specific information regarding local specialized pharmacies, collaboration with non-dermatology colleagues, and important institutional contact information. Various international groups have provided information on region-specific guidelines that can be referenced as a starting point and are discussed further in Chapter 14 . Disease severity classification methods such as Hurley staging and stability questions should guide this initial treatment approach and algorithm. An example of an institution-specific algorithm from Henry Ford Hospital, Detroit, MI, has been published, and a skeleton structure is shown in Fig. 32.1 . The goal of medical treatment is to stabilize and maintain low HS activity, while the goal of surgical treatment is to debulk affected tissue with the possibility of potential remission. A multimodal, individualized, and multidisciplinary approach should be applied, and institutional and clinic resources will guide the creation of the algorithm with site-specific components.

Domains of Expertise

To establish a successful multidisciplinary HS clinic, the clinic should be customized to the needs of the patient. Billing and insurance coverage for HS medications are important considerations. Since adalimumab is the only FDA-approved medication for the treatment of HS, prior authorizations are often needed to obtain coverage for many medications including biologics as well as for procedural treatments and lasers (e.g., neodymium-doped yttrium aluminum garnet [Nd:YAG]). Having friendly and knowledgeable clinic staff who can help handle these issues and communicate effectively with the patient and insurance company is crucial. A staff member(s) dedicated to these tasks can help to reduce the administrative burden.

Having expertise in wound care is also fundamental in establishing a successful HS clinic. HS patients often require multiple dressing changes per day due to chronic wounds and persistent drainage. Wound care supplies can consequently result in an extremely costly burden for patients. Determining the optimal wound dressing regimen and having helpful and affordable wound care recommendation options for patients is therefore essential (see Chapter 20 for comprehensive wound care management). If the HS clinic performs more invasive surgical procedures, including traditional surgical excisions or carbon dioxide (CO ₂ ) laser excisions, having nursing staff with expertise in wound care is necessary to manage patients postoperatively and at follow-up visits. Access to a specialized wound care clinic can also aid in caring for patients who have chronic or post-operative, slow-healing wounds.

Knowledge regarding cutting-edge HS research is important to be able to convey this information to patients with HS as well as answer questions that arise from patients regarding new treatments. Staying up to date with current treatments and guidelines is also paramount. Having a research unit that conducts clinical trials or performs basic science research within your HS clinic offers a significant advantage, particularly with subject recruitment and the establishment of HS biobanks. Basic science HS research leads to a better understanding of the disease and leads to new treatment options with the goal being an eventual cure. Working closely, collaborating, and understanding the needs of basic scientists helps dramatically to advance the field of knowledge. If basic scientists researching HS require tissue or serum from patients with HS, where better to collaborate than with an HS specialty clinic? Having a dedicated and knowledgeable clinical research team can help facilitate the collaboration between clinical and basic science research. Understanding and working with institutional review boards is often an arduous process that can be managed effectively by a clinical research team.

Quality Improvement

Given the widespread prevalence of HS with an estimated 0.1% to 2% of the population affected and the relatively small number of physicians with an expertise in HS, specialty HS clinics can quickly become saturated. Thus, quality improvement initiatives to continuously improve the clinic as it grows are important. Videos on the various HS procedures can be created to be viewed by patients so they can be aware of what to expect pre-, intra-, and postoperatively. This also cuts down on lengthy physician explanations in a clinic.

In addition, implementing a shared HS clinic with multiple providers can help to decrease patient wait times. Educating other physicians in the department about the institution-specific HS treatment algorithm can help facilitate bringing others on board to participate in the HS specialty clinic. Implementing sub-clinics within the HS specialty clinic can also be beneficial. Establishing a nursing wound care clinic and educating nursing staff to care for chronic and post-operative HS wounds can help with clinic flow. Establishing an urgent HS referral sub-clinic to triage complex patients can also help with some of the more serious acute problems that patients with HS can experience, including flares, pain, and infection. Establishing a dedicated medical laser clinic can allow for patients to come in for scheduled laser treatments to be performed by nursing staff or residents to free up physician visit appointments for others with more acute needs. Additionally, given the ever-increasing research into HS, new treatments continue to emerge. Treatments including ertapenem and infliximab are administered intravenously; thus, establishing an infusion center within the clinic or having easy access and a partnership with a nearby infusion center can be of valuable assistance to patients.

Core Specialties for Referrals and Collaboration

As previously stated, the management of patients with HS is often a multidisciplinary effort. HS is associated with numerous comorbidities and often requires input from multiple specialties ( Fig. 32.2 ). Given this fact, close collaboration is often required with colleagues within other specialties. Establishing these relationships for referrals and collaboration is essential. Compiling a handout for local physicians, medical staff, and patients with relevant contact information can be an invaluable tool. Comorbidities and systemic associations are discussed further in Chapter 8 .