A petition for all patients with hidradenitis suppurativa to receive the HPV vaccine

Hidradenitis suppurativa (HS) is a chronic inflammatory disorder of the hair follicles manifesting as painful nodules with draining sinus tracts. Due to protracted inflammation, cutaneous squamous cell carcinoma (SCC) can arise in longstanding lesions, complicating ∼4.6% of cases [1]. The resultant SCCs are particularly aggressive with both substantial local invasion and increased risk of metastasis generating a mortality rate near 50% [2]. While there are numerous reported cases of SCC arising in HS, more research is required to categorize the patients at highest risk for this rare, yet severe, complication [1,2]. This improved understanding will aid in optimizing medical management as well as standardizing screening protocols for malignancy to improve prognosis through earlier diagnosis and treatment.

While no consensus has been reached in the current literature, there are a handful of recognized characteristics that are associated with increased risk for this serious complication. First, SCC complicating HS is seen more frequently in men, which is likely due to the typical location of their lesions in the perineal, perianal, and gluteal regions. Additionally, heavy smoking is an apparent risk factor [1,2]. Lastly, human papillomavirus (HPV) infection, specifically high-risk subtypes such as HPV-16, has been associated with many of the reported cases [3]. Notably, incidence rates of HPV infection and its cutaneous manifestations have been found to be higher in patients with HS as compared with the general population even when controlling for all other risk factors of sexually transmitted disease [4]. This finding may be due in part to the proclivity toward recurrence or exacerbation of HPV infection after initiation of anti-TNFα therapy, which is commonly used in the treatment of HS [5]. While HPV infection remains the most controversial proposed risk factor, it is also modifiable and thus important to address. The HPV vaccine has previously been recommended for male patients with genital HS, but we believe this recommendation should include all patients with HS regardless of age, sex, or location of disease [6].

HPV affects most sexually active individuals at some time in their lives and is a principal cause of common warts, genital warts, and anogenital cancers. The HPV vaccine was initially produced for women aged 9–26 years as primary prevention against cervical cancer, which has proven successful [7]. There has been continued enhancement in the value of this vaccine as a result of increasing viral strain coverage and expanded indications. A remarkable result of this growing awareness of the vaccine’s necessity for men and women alike was its approval for adults aged 27–45 on 10 October 2018. Further, on 26 June 2019, the CDC Advisory Committee on Immunization Practices voted to recommend shared clinical decision-making for vaccination of adults aged 27–45 [7]. Assessment of vaccine efficacy in this older cohort did reveal that persistent HPV infection after vaccination was more common; however, antibody titers remained several-fold above those following natural infection suggesting improved outcomes with vaccination nonetheless [8]. Despite enhanced endorsement for vaccination of this demographic, outright recommendation does not exist and insurance companies may elect to deny coverage for the vaccine in this age group. This issue poses a significant barrier to care for HS patients. As responsible clinicians we must be their advocates.

The routine medical management of HS is extensive with the goal of preventing and detecting complications of disease and achieving minimal activity despite inevitable chronicity. The addition of the HPV vaccine to this regimen is simple, of little-to-no harm, and with the potential impact of preventing a fatal complication [9,10]. While all HS patients would benefit from HPV vaccination, cost and availability remain inherent limiting factors. Should these limitations prove prohibitive, epidemiologic consideration aids in selecting the highest risk patients for vaccination: (1) patients <25 years due to the age-dependent decrease in vaccination efficacy [8] and the greater average number of quality years provided; (2) male sex (86% of affected patients) [11]; (3) anogenital disease (100% of affected patients) [2]; and (4) anti-TNFα therapy use, which is 5x more likely to cause non-melanoma skin cancer in patients with HS than the general population [12].

In conclusion, despite the previously debated statistical significance of HPV infection as a risk factor for malignant transformation of HS, vaccination of these patients should be supported. Thus, we propose extending the current indications of the HPV vaccine to include all patients with HS.

Author contribution

A.D. drafted the manuscript. R.C.B. and S.R.C. revised the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).