Reducing the pain of hidradenitis suppurativa wounds

The pain of hidradenitis suppurativa (HS) has been described as: ‘sharp and searing, like being struck with a fireplace hot poker from the inside. It is the type of pain that makes you yelp with surprise. It can make walking, reaching or even sitting impossible. This makes it challenging to complete everyday tasks or even leave the house.’¹

HS is defined by the National Library of Medicine as ‘a chronic inflammatory skin condition with lesions including deep-seated nodules and abscesses, draining tracts and fibrotic scars. These lesions most commonly occur in intertriginous areas and areas rich in apocrine glands. Among the most common are the axillary, groin, perianal, perineal, and inframammary locations’.²

Patients with HS consider pain to be one of the worst symptoms³ as well as the most important contributor to impairment of their quality of life (QoL),^4–6 and one of the most intolerable features of the disease.⁷ An international survey of 1299 HS patients found that 62% rated their pain as ‘moderate’ or ‘higher’, with 4.5% describing it as the ‘worst possible’.⁷ A large case–control multicentre study showed pain to be the highest in patients with HS, among several other dermatological conditions.^8,9 Patients with HS also reported worse pain and mental health compared with other chronic diseases, such as hypertension, heart failure, diabetes, myocardial infarction and depression.¹⁰ Pain in HS correlates more highly with QoL impairment than even disease severity.^3,11 HS has one of the most devastating impacts on QoL of any skin disease^12–14 due to poor mental health,¹⁵ loss of employment, impaired intimacy,¹⁶ chronic pain^3,11 and substance misuse disorders.⁷

The International Association for the Study of Pain defines pain as: ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage’;¹⁷ to some degree almost every person with damaged skin or a wound will experience pain.

Much of the work related to wound pain has been conducted during dressing changes.18 In a multinational study conducted by the European Wound Management Association (EWMA), clinicians rated dressing changes as the time of greatest pain to their patients.¹⁹ In addition, dried out dressings and aggressive adhesives were most likely to cause pain during dressing removal.²⁰ It has been demonstrated that patients report more pain with gauze dressings than with any other advanced wound care dressings.²¹ Wounds contain fragile tissues, and the removal of an aggressive dressing can cause trauma not only to the wound but to the periwound tissue as well. Using dressings that promote atraumatic removal to prevent trauma from occurring is one way to limit pain on dressing removal.¹⁸ The MAPP (Medicine Ambulatoire Plaies et Pansement) Study evaluated 5850 patients with acute and chronic wounds, and found most (79.9%) reported ‘moderate to severe’ pain and that this was most often related to dressing selection.²²

A published survey of 908 patients with HS from 28 countries found that 81% reported pain during their dressing changes and that there was overall dissatisfaction with existing dressings, with reasons including: discomfort and embarrassment from bulky dressings that inhibit movement; difficulty securing and keeping dressings in place in areas of the body that are challenging to dress; fear of leakage, odour and dressings falling off; as well as the time required for dressing changes.

Patient-reported experiences included comments such as:²³

‘The removal of the bandages is uncomfortable and tears my skin.’

‘It's embarrassing to ask others to apply the dressings’

‘It's a never-ending issue. Relationships ending due to dressing wounds all the time. It's depressing that others don't understand the frustration of a wound not healing or reopening, causing depression and suicidal thoughts.’

‘I feel alone and isolated, constantly worrying about leaking, smell, dressings falling off. It has impacted every aspect of my life, to the extent that I really have no life.’

Traditionally, wet-to-dry gauze has been used to dress wounds. Dressings that create and maintain a moist environment, however, are now considered to provide the optimal conditions for wound healing. Moisture under occlusive dressings not only increases the rate of re-epithelialisation but also promotes healing through moisture itself and the presence initially of a low oxygen tension (promoting the inflammatory phase). Gauze does not exhibit these properties; it may be disruptive to the healing wound as it dries and cause tissue damage when it is removed.²⁴

Dyson et al.²⁵ compared the effects of moist and dry conditions on dermal repair in a porcine model. An adhesive polyurethane dressing was used as a moist dressing, while gauze dressing exposed to air ensured dry healing conditions. They showed that both the inflammatory and proliferative phases of dermal repair were shorter for wounds under moist conditions when compared with those healing under dry conditions.²⁵ In another study, a moist environment resulted in less necrosis, faster healing, and better quality of healing than the dry environment.²⁶ A study into specific dressing types found that ‘inflammatory cells easily bind to superabsorbent dressings and become locked in a highly absorbent core, thereby wicking harmful bacteria and inflammatory mediators away from a fragile wound base’.²⁷ Such dressings can ‘absorb high exudate levels without adhering to the fragile wound base and thus prevents wound bed damage and periwound maceration’.²⁷ They may also help reduce the concentration of inflammatory cells in the wound bed, as they can bind wound exudate and lock it within their core due to their wicking action.²⁸

Published guidelines by the British Dermatological Nursing Group recommend the following when addressing pain for patients with HS:²⁹

• Choose soft, flexible dressings, ideally adhesive-free, retained with garments or bandages if appropriate
• Consider advanced dressings for wound bed if cavity or ulcerated lesions present
• Ask yourself—will adhesive dressings cause this patient more pain? If the answer is yes—try garment or bandage-based solutions.

Similarly, recommendations from an international panel of experts published in the Journal of the American Academy of Dermatology in 2023 stated:³⁰

• Woven gauze tends to stick to the wound bed and result in painful dressing change and should be avoided
• Dressing should be kept in place using atraumatic material and methods
• When removing a dressing, every effort should be made to achieve an atraumatic technique in order to avoid pain and discomfort.

It should be stated, however, that while evidence and learnings from other skin and wound conditions are helpful, informative and should be highly translatable, there are few, if any, studies of the performance of, and outcomes from, the use of dressings specifically on patients with HS. An exception to this is a study involving the use of a HS-specific lesion dressing system (Hidrawear, Hidramed Solutions Ltd., Ireland) specifically designed for patients with HS. The 21-day, single-arm, unblinded trial found statistically significant reductions in pain levels for all patients. Patients that required pain relief in advance of dressing change at the baseline were able to cease pain medication by day 21.³¹ The study also demonstrated significant improvements in QoL using the Dermatology Life Quality Index tool, as well as greater patient comfort, confidence, and ease of product use compared to the standard of care.³¹ These benefits are provided by the dressing's mode of action that removes the need for adhesives while utilising a unique SecureLock Technology Locking Tab to secure its high performance superabsorber dressings to a discrete baselayer worn by the patient. This also means that the patient is able to quickly and easily change dressings themselves as needed (Table 1).

Table 1.

Average reduction in wound care impact criteria from day 0–21

DLQI—Dermatology Life Quality Index; HS—hidradenitis suppurativa

In summary, for patients with HS, pain is a major issue and generally considered by them to be one of the the worst symptoms and a major driver of impaired QoL. Pain can be significantly reduced through use of modern moist wound healing dressings instead of dry dressings, the avoidance of adhesives and adherent dressings wherever possible, and the adoption of new HS-specific wound care solutions as they emerge and the evidence base for them develops. While it is critical to treat the underlying disease state, it should not be forgotten that relatively easy and simple changes in the day-to-day management of HS lesions can quickly and significantly improve patients’ pain levels and QoL.