Frequently Asked Questions about Hidradenitis Suppurativa (HS) and COVID-19

April 6, 2020

 

For Providers

What is COVID-19, and how is it different from the flu or other infections we have dealt with?

• Coronaviruses are a large group of RNA viruses that cause respiratory illnesses. Mostly, COVID19 causes mild upper respiratory tract symptoms. Most morality occurs when the lower respiratory tract is involved, with cytokine storm causing ARDS and shock.
• The novel coronavirus (SARS-CoV-2) occurs naturally, enters the body through respiratory droplets (either inhaled or by touching mouths, nose, eyes) and causes the illness called COVID-19.
• Coronavirus enters the cells of the lung via ACE receptors.
• Coronavirus can survive in the air for up to 8 hours, and can last for up to 72 hours on some
  surfaces.
• Coronavirus is structurally different from the influenza virus. Compared to the seasonal flu, the novel coronavirus causes more severe illness and has higher death rates (estimated to be 10x higher).
• Based on limited data, all age groups can contract COVID-19. However, some subsets of people are at higher risk of severe illness or death than others, including: 

• • Adults over age 65 years
  • Infants
  • People with heart, lung or kidney disease
  • People with cancer undergoing cancer treatment
  • People on immunosuppressive medications

• Symptoms of COVID-19 include fever, shortness of breath, cough, loss of smell, loss of taste, and uncommonly nausea, vomiting, diarrhea. However, many people infected with this virus can harbor and spread infection without any symptoms.
• HS itself does not appear to be a specific risk factor for COVID-19. However, if someone has any of the associated comorbidities listed above or is on immunosuppressive medications, they may have increased risk for developing severe illness if infected with the novel coronavirus.

How does COVID-19 alter the treatment of HS?

• HS itself does not appear to be a specific risk factor for COVID-19.
• HS patients who are well-controlled on a stable treatment regimen should continue that regimen, including immunomodulating agents.
• Diligent protective measures are key for people on immunomodulating drugs, including social distancing, shelter at home, hand hygiene, masks, avoiding touching your face, and avoiding anyone who has had contact with COVID-19 or who is ill.
• If patients develop symptoms of COVID-19 or have a known exposure to someone with COVID-19, they should call their healthcare provider. The healthcare provider may recommend delaying a dose of immunomodulator if you are sick.
• There is some data to suggest that non-steroidal anti-inflammatory drugs (NSAIDs) may worsen COVID-19. However, the World Health Organization (WHO) currently states that there is not enough data to recommend avoiding NSAIDs. They recommend that acetaminophen is probably a safer choice that NSAIDs until more we have more data.
• There is some early data suggesting that spironolactone may increase ACE expression. Some have hypothesized that this could worsen COVID-19, however, there are currently no recommendations to prescribe or avoid spironolactone.
• The medical community is establishing a registry to study the risks and clinical course of COVID-19 infection in HS patients, and to learn how to best treat COVID-19-infected HS patients.

How should biologic medications for HS be managed during the COVID-19 pandemic?

• At the present time, biologic medications do not appear to be associated with an increased risk of COVID-19. In a recent report on cohort of Chinese patients with inflammatory bowel disease on biologics, none had COVID-19.
• If HS patients are well-controlled on biologics, for now they should continue on their current regimen, such as anti-TNF (adalimumab [Humira], infliximab [Remicade]), anti-IL-12/23 (ustekinumab [Stelara]), and anti-IL-17 (secukinumab [Cosentyx]).
• Healthcare providers and patients should develop a plan to determine which symptoms might warrant a delayed dose.
• Biologics can stay in the body for many weeks, so even if a dose is delayed, patients should be advised that they still need to practice protective measures.
• It is not recommended to stop biologics unless there is a good reason as there is a possibility of flare that could ultimately lead patients into healthcare facilities, and as there is a risk of developing anti-drug antibodies that may reduce future efficacy.
• Any HS patients on biologic medications should be instructed in good hand hygiene, social distancing, and limiting potential exposure.

How should immunosuppressive medications for HS be managed during the COVID19 pandemic?

• Broad immunosuppressive therapy such as prednisone and methotrexate confer a higher theoretical risk of susceptibility to infections than more specific immunomodulators. Patients with COVID-19 symptoms or a diagnosis of COVID-19 should contact their healthcare provider as these medications may need to be stopped.
• There is some early data that immunosuppressive and immunomodulating medications may have a role in treating the COVID19-induced cytokine storm that causes severe respiratory distress (ARDS).
• Known cytokines responsible for this cytokine storm include IL-6, IL-1, IL-18 and IFN-gamma. Agents targeting these cytokines (such as IL-6 inhibitors) are typically not the same as the biologic treatments for HS. IL-1 inhibitors have been used occasionally for HS off-label, but to our knowledge, this does not increase susceptibility to COVID-19.

 

For Patients

What is COVID-19, and how is it different from the flu or other infections we have dealt with?

• Coronaviruses are a large group of RNA viruses that cause respiratory illnesses.
• The novel coronavirus (SARS-CoV-2) occurs naturally, enters the body through respiratory droplets (either inhaled or by touching mouths, nose, eyes) and causes the illness called COVID-19.
• Coronavirus can survive in the air for up to 8 hours and can last for up to 72 hours on some surfaces.
• Coronavirus is structurally different from the influenza virus. Compared to the seasonal flu, the novel coronavirus causes more severe illness and has higher death rates (estimated to be 10x higher).
• Based on limited data, all age groups can contract COVID-19. However, some subsets of people are at higher risk of severe illness or death than others, including:

• • Adults over age 65 years
  • Infants
  • People with heart, lung or kidney disease
  • People with cancer undergoing cancer treatment
  • People on immunosuppressive medications

• Symptoms of COVID-19 include fever, shortness of breath, cough, loss of smell, loss of taste, and uncommonly nausea, vomiting, diarrhea. However, many people infected with this virus can harbor and spread infection without any symptoms.
• HS itself does not appear to be a specific risk factor for COVID-19. However, if someone has any of the associated comorbidities listed above or is on immunosuppressive medications, they may have increased risk for developing severe illness if infected with the novel coronavirus.

How does COVID-19 alter the treatment of HS?

• HS itself does not appear to be a specific risk factor for COVID-19.
• HS patients who are well-controlled on a stable treatment regimen should continue that regimen, including immunomodulating agents.
• We recommend speaking with your healthcare provider before making any medication changes. Decisions about biologic use should take into account your disease severity, how your HS has responded to the biologic agent, and your risk factors. There is a possibility of disease flare with discontinuation of HS medication that could ultimately lead patients into healthcare facilities, as well as a risk of developing anti-drug antibodies that may reduce future drug efficacy. If you think you need to delay a dose, please first discuss with your healthcare provider.
• Diligent protective measures are key for people on any therapies that modulate the immune system, including social distancing, shelter at home, hand hygiene, avoiding touching your face, and avoiding anyone who has had contact with COVID-19 or who is ill.
• If patients develop symptoms of COVID-19 or have a known exposure to someone with COVID-19, they should call their healthcare provider. The healthcare provider may recommend delaying a dose of immunomodulator if you are sick.
• Patients should discuss initiation of biologics with their healthcare provider and decide together on a plan for HS management that takes into account their interactions with the public, ability to self-isolate, age or comorbidities that could be a risk factor for COVID-19 severity.

What is the reason for the social distancing and sheltering in place?

• Although shedding of coronavirus virus is most abundant in symptomatic people, viral shedding occurs from both asymptomatic and symptomatic people. Children in particular appear to have high rates of asymptomatic carriage.
• Maintaining a distance of at least 6 feet from people outside of your household limits exposure to respiratory droplets.
• Social distancing helps to limit the spread of the novel coronavirus, or to “flatten the curve”, and reduce the peak number of COVID-19 infections.

Will there be any issues obtaining medications for HS patients?

• At present, there are no reported shortages of HS medication supply chains.
• Many biologics are supplied through specialty pharmacies that often mail medications to patients. If possible, patients on immunomodulatory medications should utilize these mail services to obtain their medications without having to physically go into pharmacies.

What should patients do to address HS flares while maintain social distancing guidelines?

• Patients and healthcare providers should develop an HS Action Plan so that patients know when their HCP is available, how best to contact them, and what to do if they have an HS exacerbation.
• Patients and healthcare providers should discuss regimens that can be initiated or maintained now to prevent disease flares, including oral antibiotics, oral contraceptives, spironolactone, retinoids, and/or metformin.
• Low-dose oral corticosteroids may be prescribed by your doctor as an option to help control flaring disease, however, strict social distancing is critical in this case as prednisone is an immunosuppressant.
• At home, patients can maintain a healthy diet and their own mental health. Warm compresses and topical antibiotics may help. If a patient thinks their HS requires medical attention, they should reach out to their healthcare provider by phone or telehealth modalities first to avoid exposure to healthcare facilities.

If I think I need to see a provider, what should I do?

• Establish a plan with your healthcare provider now so you can avoid going into healthcare facilities.
• If you feel sick, stay home, practice social distancing and talk to your healthcare provider.
• If you need medical advice for HS symptoms or develop COVID-19 symptoms, call your regular healthcare provider. If they are not available, call your local urgent care.
• If you have to go to see a healthcare provider, call ahead to know the protocol for the clinic.
• If the emergency department or urgent care clinic have been the primary place you go to get help for your HS, make an appointment for telehealth instead now.
• If you are on Medicaid, reach out to local offices that accept Medicaid or academic centers for your care.
• Telehealth now allows healthcare providers to see patients from far distances.

Should I have a surgery if it was planned?

• In order to reduce patient exposure to COVID-19 and to make space in hospitals for COVID-19 patients, most elective surgeries are being re-scheduled. Obtaining post-operative care resources may also be very challenging at this time.
• Patients should contact their surgeon to discuss if their surgery is essential or elective.
• The primary reason for surgery at this time would be a large infectious abscess. Patients should contact their healthcare provider, preferably by telehealth, if they think they have an infectious abscess.

What about health care providers who are on biologics?

• Advice for management of people on immunomodulating agents in high-risk settings is evolving.
• Good hand hygiene and use of appropriate personal protective equipment (PPE) are essential.
• Zinc supplementation may be helpful, and nasal mucosa lubrication may limit intranasal viralcolonization.

Tips for Telehealth

• We are all learning how to do this.
• There are now less restrictions across state lines.
• This pandemic may accelerate our use of telehealth in general, both in academic centers and private practices.
• Telehealth reduces potential exposure to SARS-CoV-2, and may have additional advantages for patients including being more private and more convenient for some.
• Patients should call to find out their provider’s telehealth approach.
• Find a private place to do the call.
• Take dressings off ahead of the tele-visit.
• Patients may be asked to press on the affected area and report sensations/tenderness etc.

Hibiclens is often used for HS, what can I use if I can’t find it?

• Dilute bleach baths are one option. For a full bathtub of water (40 gallons), use a half cup of bleach. For a half-full tub of water, add a quarter cup of bleach, and soak in the tub for 10 minutes.
• Benzoyl peroxide wash, which can be found in the acne aisle at your local drugstore, is another option. Leave on the affected areas for a few minutes in shower, and then wash off.
• Antimicrobial soaps can also be used in the affected areas.

How can HS patients obtain short-term disability from their employers during the COVID-19 pandemic?

• HS is not currently officially classified as an autoimmune disease that qualifies for at-risk disability offered by some employers, and it is not thought that HS patients are at higher risk for infection or complications.
• If you have a comorbid condition or an immunomodulating treatment for your HS, or if other extenuating circumstances exist, your doctor may be able to support your short-term disability claim with letters or helping to fill out paperwork.

 
Podcast Hosts:
Dr. Hadar Lev-Tov, University of Miami
Dr. Raja Sivamani, University of California Davis

Podcast Participants:
Dr. Ilt Hamzavi, Henry Ford Hospital, President HSF
Dr. Joslyn Kirby, Penn State University
Dr. Haley Naik, University of California San Francisco
Dr. Vivian Shi, University of Arizona Health Services
Dr. Stephanie Goldberg, Virginia Commonwealth University School of Medicine
Ms. Sandra Guilbault, Patient Advocate, Hope for HS