Acta Dermato-Venereologica 99-7CompleteContent | Page 27

703 SHORT COMMUNICATION The Refined Hurley Patient Questionnaire: An Accurate Self-assessment Instrument for Deriving the Correct Refined Hurley Stage in Hidradenitis Suppurativa Angelique RONDAGS 1 , Rob J. VOLKERING 1 , Iana TURCAN 1 , Yolinde S. ZUIDEMA 1 , Ineke C. JANSE 1,2 and Barbara HORVÁTH 1 Department of Dermatology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, NL-9700 RB Groningen, and Department of Dermatology, Meander Medical Centre, Amersfoort, The Netherlands. E-mail: [email protected] 1 2 Accepted Jan 23, 2019; E-published Jan 23, 2019 Hidradenitis suppurativa (HS) is a chronic, debilitating, inflammatory skin disease that mainly affects body folds (e.g. axillae and groin) (1). Primary lesions include deep- seated inflammatory nodules, abscesses, and sinus tracts (1). The diagnosis of HS can be made easily due to its clear, distinct clinical presentation. Deckers et al. (2) have reported that patients with HS can score their own disease severity according to the original Hurley classification. However, the purpose of the Hurley classification was to assess HS in a single affected body region in order to guide surgical intervention (3). It was not intended to classify HS disease activity and severity in the whole patient and to assist in extensive treatment plans including, for example, anti-inflammatory options (3, 4). Therefore, a modification of the Hurley classification was proposed by a Dutch HS expert group in 2017: the “refined Hurley classification” (5). In contrast to the original Hurley classification, the 7-stage refined Hurley classification assesses not only the presence of sinus tracts, but also inflammatory symptoms and the extensiveness of the disease (3, 5). Refined Hurley stages I and II are subdi- vided into A, B and C, corresponding to mild, moderate and severe disease. Stage III is not subdivided and corresponds to severe HS disease. This was recently confirmed by a con- struct validation study (6). Furthermore, a comprehensive treatment ladder is added to the flow chart (5). The aim of this study was to develop and investigate the reliability of a patient self-assessment questionnaire corresponding to the items addressed in the refined Hurley classification, in order to derive the refined Hurley stage. METHODS Subjects and study design Consecutive patients with HS were recruited at the dermatology outpatient clinic of the University Medical Centre Groningen (UMCG), a tertiary referral centre for HS. Subjects were eligible if they were diagnosed with HS by a dermatologist, were older than 18 years, and were capable of completing the questionnaire in Dutch. A patient symptom self-assessment questionnaire was deve- loped by HS experts based on the refined Hurley classification flow chart. Following a pilot study performed with 16 patients (Appendix SI 1 ), several modifications were applied to the concept questionnaire. Patients with HS were requested to complete the definitive questionnaire (the refined Hurley classification ques- tionnaire for patients with HS (Appendix SII 1 )) before their regular https://www.medicaljournals.se/acta/content/abstract/10.2340/00015555-3126 1 consultation at the dermatologist. The refined Hurley stage was derived following the flowchart by an investigator (RV) (5). The dermatologists were requested to report a detailed dermatological examination and report the refined Hurley classification, as they also do in daily clinical practice. The percent agreement of data entry between 2 investigators (RV and AR), based on a sample of 10 out of 75 (13.3%) randomly chosen subjects, was 97.2%. No formal sample size calculation can be performed for this type of study. Based on literature on methodology and similar studies in the same field, the aim was to include 75 subjects in the final cohort testing (2, 7). For this type of study, medical ethics com- mittee approval is not required under Dutch law. Statistical analysis Descriptive statistics were used to describe the study population. The inter-rater agreement and reliability between the HS patient’s derived refined Hurley stages and physician’s reported refined Hurley stages were calculated. Next, the inter-rater agreement and reliability of the presence of sinus tracts and HS disease severity, defined by the refined Hurley classification, was calculated. For the inter-rater agreement, percentages of agreement between physicians and patients were calculated manually. Because the refined Hurley classification is a nominal scale, a Krippendorff’s alpha (α) is suitable to determine the inter-rater reliability (8). Statistical analysis was performed using IBM SPSS Statistics 23.0 for Windows (SPSS, Chicago, USA). p-values ≤ 0.05 were considered statistically significant. RESULTS A total of 75 subjects participated in this study. An over- view of the patients’ characteristics is shown in Table I. Approximately one-third were patients visiting the dermatology outpatients clinic (UMCG) for the first time . Table I. Patients’ characteristics (n  = 75) Characteristics Age, years, mean  ± standard deviation Female sex, % Body mass index, kg/m 2 , mean  ± standard deviation Smoking status, n (%) Non-smoker Ex-smoker Current smoker New (first visit) or control patient, n (%) New Control Refined Hurley classification stage, according to physician, n (%) Refined Hurley IA Refined Hurley IB Refined Hurley IC Refined Hurley IIA Refined Hurley IIB Refined Hurley IIC Refined Hurley III This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2019 Acta Dermato-Venereologica. 40.5  ± 12.7 72.0 29.4  ± 6.0 13 (17.3) 19 (25.3) 43 (57.3) 26 (34.7) 49 (65.3) 22 (29) 5 (7) 8 (11) 8 (11) 11 (15) 16 (21) 5 (7) doi: 10.2340/00015555-3126 Acta Derm Venereol 2019; 99: 703–704