LAUSR

https://doi.org/10.1016/j.ijwd.2020.04.001 2352-6475/ 2020 The Author(s). Published by Elsevier Inc. on behalf of Women’s Dermatologic Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). The clinical complexity of hidradenitis suppurativa (HS) strongly suggests the utility of a multimodal management approach, aimed not only at the direct and obvious morbidity stemming from the skin, but also at the many, broader cooccurring morbidities (e.g., metabolic syndrome or depression; Saunte and Jemec, 2017). In this issue, Dr. Touhouche et al. (2020) describe their preliminary experience with an ‘‘Integrated multidisciplinary approach to Hidradenitis Suppurativa in clinical practice”. The authors provide a fine example of their multimodal management approach to HS (i.e., an approach to the individual patient by which numerous specialists provide closely coordinated [by dermatologists] care at many different levels, ranging from major surgery to dietary advice). The patients who participated in the multidisciplinary approach seemed to share clinical characteristics that are representative of the hospital-based HS population generally reported in the literature. Treatments offered were also well described, and the paper thus provides important early data on a subject that is widely recommended in reviews and guidelines but poorly studied with the scientific rigor that such intensive treatment deserves (Alikhan et al., 2019; Ingram et al., 2019; Zouboulis et al., 2015). The paper also raises several important points. First is the question of methodology. Although this paper does not purport to be anything but a systematic description of the authors’ experiences, it will provide background for future studies. The methodological difficulties in comparing complex treatments with routine treatment present a very real problem in the evaluations of multimodal treatments. Although cluster-randomization is one obvious way forward, it is not an ideal way in an area where operator-dependent treatments such as surgery are involved. The area therefore generally deserves additional methodological attention. Second, the paper raises the problem of outcomes. The present study is to be recommended for including a range of outcomes allowing for a better clinical characterization of the patients. A problem in HS research is that numerous outcomes have hitherto been used in different studies, making direct comparisons difficult. Two important initiatives have been taken in this context: the registry of the European Hidradenitis Suppurativa Foundation (which defines a set of clinical features to characterize patients) and the HIdradenitis SuppuraTiva cORe outcomes set International Collaboration (which defines the outcome domains to be assessed; Daxhelet et al., 2016; Thorlacius et al., 2018). The standardized data sets provided by these two initiatives open the possibility for more studies, which would in turn become more easily comparable. Finally, the paper raises the question of adherence by physicians as well as by patients. Outside a structured HSmultimodal management setting, obtaining surgery for patients with HS may be a challenge (Bouazzi et al., 2020). HS surgery requires the specialists involved to be motivated and bold in their therapeutic approaches, but the onus is not only on those providing care. Although nonattendance does not appear to be greater in patients with HS, it would appear that in a substantial proportion of cases the treatment was accepted (e.g., a significant proportion of patients refused the offered consultations with smoking cessation and nutrition specialists and some refused surgery; Lindsø Andersen et al., 2019). Increasing patient involvement in therapy may need additional patient education as part ofmultimodalmanagement of HS. A holistic approach does not onlymean that all treatments are on offer, but also that all those involved are on board.