Colleen Cotton, MD: Clinician Collaboration, Treatment Personalization for Pediatric Hidradenitis Suppurativa

Colleen Cotton, MD

Credit: Childrens National Hospital

During the second part of her Q&A interview with HCPLive, Colleen Cotton, MD, further explored some of the topics covered in her upcoming presentation at the 8th annual Symposium on Hidradenitis Suppurativa Advances (SHSA) Conference on October 13 -15 regarding the topic of pediatric HS.

Cotton serves as an Attending Physician for the Division of Dermatology at Children's National Hospital, and she is an Assistant Professor of Dermatology for the George Washington School of Medicine and Health Sciences.

HCPLive: How do you approach personalized treatment plans for children with HS, taking into consideration factors such as age, severity, and patient preferences?

Cotton: We try to have an algorithm or some general guide of ‘okay if this, do this.’ But it is really tricky, because HS is a multifactorial disease. And I really truly appreciate that in my pediatric patients, because, you know, while friction plays a role, hormones play a role. Insulin resistance plays a role. Weight plays a role. All of those things can have very different levels of importance, depending on the patient in front of you.

I can have somebody who says ‘I don't have any HS lesions, except for the week before my period,’ and that's going to be very different from a 40-kilogram, 17-year-old male patient with horrific draining sinus tracts. That that treatment is going to be a lot different, and that discussion is going to be a lot different. It becomes difficult to follow a specific algorithm. Often I will have the discussion first with the family, explaining ‘This is what we know about HS and we know that it is multifactorial, based on what you've told me,’ after I kind of go through all the things with them. This is where I think we're gonna get the most bang for our buck in terms of trying to get your HS under control.

Sometimes that flies, sometimes it doesn't, particularly when we're talking about injections or biologic therapies. Sometimes we might have to take a step back and try something else. First, whatever they're comfortable with. I also let them know that some of these treatments take 3 - 6 months to really tell if they're working, and that's a hard sell for someone who's in pain in your office right at this moment.

…So those are some of my strategies. And then also, needles in general can be rough for adolescents. It's something that definitely exists in adults, and I think is probably under-appreciated. But needle-phobia, for sure, is a problem in pediatric patients. And I'm very fortunate in that I have a psychologist that I work with in my HS clinic and who works with us in dermatology, and she has sort of created a modified needle-desensitization protocol for kids to over the course of a few weeks, to try to make them more comfortable with that concept of a biologic injection.

HCPLive: Could you share your insights on the importance of a multidisciplinary approach to treating pediatric HS, involving dermatologists, pediatricians, and other specialists?

Cotton: HS is probably one of the more multidisciplinary conditions that we manage. Part of that comes from how many different ways patients get to us in dermatology: they may come from the surgeon, they may come from a gynecologist, they may come from the ER, they may come from the pediatrician. They can come from lots of different places, so part of it is making sure that we're contributing to the education of these providers who are sending patients to us.

You know, it doesn't take that much to send them back a letter about the patient that they sent to us. And just a small blurb of an education of what HS is and what it's not. That it's not an acute condition with periods of flares, that it is a chronic condition with scarring, that it's not a failure of personal hygiene or a bacterial infection, that this is an inflammatory response that's disordered, that involves the hair follicle and it's not a sweat gland disease.

All of those things, I think, can be helpful from a multidisciplinary standpoint at the beginning, then once you get these patients. I think it's important to make sure that they're being screened appropriately for comorbidities, whether that's you doing it or whether that's their pediatrician doing it, and you need to guide them on what they need to be looking for, because they don't have any reason to know what they need to be looking for.

…That's also really important: to find people who you can refer your patients to but also make sure that they know about the treatment of HS and that they don't do the wrong thing or inadvertently work against what you're trying to do. I had a patient once who I sent to a nutritionist, and the nutritionist told them that if they just ate better than they wouldn't have HS. I said ‘that's not how that works.’

Like it's a you shouldn't make them feel like it's their fault. But that's kind of what they did. And really kind of understanding that we can improve these things. But it's not just because you're eating a certain thing or just because you're overweight, that you have this condition. And it's not like if we fix that problem, it would just go away. So it’s really important not only to have a team but make sure you have the right people on your team.

HCPLive: How can healthcare professionals, including pediatricians, better educate themselves about the latest developments in pediatric HS treatment to improve patient care?

Cotton: A shameless plug, personally: we just published a state of the art review in the Journal Pediatrics in May of this past year, that sort of is a review of all the most recent information on pediatric HS. It's already out of date, there have been other new pediatric HS studies, but it's still a good, comprehensive overview of what the disease is: How does it progress? What other comorbidities do you have to think about? And what are the treatment options that are available?

Because I think for pediatricians and providers, you're not going to be managing moderate to severe HS, but you need to know how to recognize it. And you need to know when your patient might not be getting the most appropriate care, because not all dermatologists have been educated on this condition.

HCPLive: What are the main takeaways or recommendations you would like to convey to the medical community and researchers regarding the treatment of pediatric HS based on your presentation?

Cotton: I think I'm hoping that people walk away with a sense that HS is a pediatric disease, and not to forget about it. When you're seeing your pediatric patients, I hope that people walk away kind of understanding the similarities and differences and some of the extra challenges. We talked about the diagnostic challenges. There's also a really significantly higher family history component of HS particularly in younger patients as compared to older adults.

And that's, that's a family dynamic that you have to deal with. Whatever the parent has or has not been taught, or has or has not figured out about their own condition. Whether or not the kid is going to be as bad as their parent or worse than their parent and their parent doesn't know how to manage it. Those are important things to think about.

When we're used to taking care of adults, we think about the patient. But in pediatrics, we really have to think about how we're treating the family, and that definitely extends to pediatric HS as well because of that potentially strong familial component. I'm also hoping people take away that we would love to have more people interested in studying and treating pediatric HS, and that this is really a need we have.

There's so much more research that needs to be done in terms of understanding the condition and having good treatments available. So I'm really hoping to convince people that it's worth doing and that we would love to work together.

The quotes contained in this article were edited for the purposes of clarity.