236 Research Letters
JANUARY 2020
itch, they may also be less likely to perform searches
on Google.2 Overall, this study fills a major gap in
understanding the population-level burden of
pruritus and allows for a more comprehensive
analysis than research using health insurance or
health care reimbursement data because those data
sources generally only represent the severe cases of
pruritus and not the complete spectrum of itch
experienced in the general population.2
Shannon Wongvibulsin, PhD,a Raveena Khanna,
BA,b and Shawn G. Kwatra, MDb
From the Department of Biomedical Engineeringa
and the Department of Dermatology,b Johns
Hopkins University School of Medicine, The Johns
Hopkins University, Baltimore, Maryland.
Funding sources: US National Institutes of Health:
Institutional Predoctoral Training Grant - T32,
U.S. National Institutes of Health: Ruth L. Kirsch-
stein Individual Predoctoral NRSA for MD/PhD:
F30 Training Grant
Conflicts of interest: Dr Kwatra is an advisory
board member for Menlo and Trevi Therapeutics
and has received grant funding from Kiniksa
Pharmaceuticals. Dr Wongvibulsin and Rav-
eena Khanna have no conflicts of interest to
declare.
Reprints not available from the authors.
Correspondence to: Shawn G. Kwatra, MD, Cancer
Research Building II, Johns Hopkins University
School of Medicine, 1550 Orleans St, Baltimore,
MD, 21231
E-mail: kwatra.shawn@gmail.com
REFERENCES
1. Weisshaar E, Apfelbacher C, J€ager G, et al. Pruritus as a leading
symptom: clinical characteristics and quality of life in German
and Ugandan patients. Br J Dermatol. 2006;155(5):957-964.
2. Zink A, Schuster B, R€ uth M, et al. Medical needs and
major complaints related to pruritus in Germany: a 4-year
retrospective analysis using Google AdWords Keyword
Planner. J Eur Acad Dermatol Venereol. 2019;33(1):151-156.
3. Nuti SV, Wayda B, Ranasinghe I, et al. The use of Google
Trends in health care research: a systematic review. PLoS One.
2014;9(10):e109583.
4. Govind K, Whang K, Khanna R, Scott AW, Kwatra SG. Atopic
dermatitis is associated with increased prevalence of multiple
ocular comorbidities. J Allergy Clin Immunol Pract. 2019;7(1):
298-299.
5. Grandhi R, He A, Semenov YR, Kwatra SG. Seasonal variation of
itch: a study using real-time data from 2004 to 2016. J Am
Acad Dermatol. 2017;76(3):563-564.
https://doi.org/10.1016/j.jaad.2019.06.029
J AM ACAD DERMATOL
Hidradenitis suppurativa has an
enormous impact on patients’ lives
To the Editor: Health-related quality of life (HRQOL)
encompasses global parameters of overall well-
being including physical, emotional, and social
functioning. There is little information on the relative
impact of hidradenitis suppurativa (HS) on HRQOL
compared with other chronic medical conditions. We
assessed the impact of HS using the Short Form
Health Survey (SF-36) (a validated and reliable tool
that can be used to compare the HRQOL between
populations with disparate conditions1), compared
the impact of HS to that of other major medical
conditions, and determined the effect of HS severity
(based on Hurley stage) on HRQOL.
A total of 153 individuals with a clinical diagnosis
of HS (International Classification of Diseases,
10th revision, code L73.2) were recruited in our
clinic (n ¼ 30) and through mail (n ¼ 123) between
June and September 2018; 67 SF-36 surveys (27 clinic
and 40 mail) were completed. The SF-36 is a 36-item,
self-report survey assessing 8 domains of HRQOL:
physical functioning, role-physical, bodily pain,
general health, vitality, social functioning,
role-emotional, and mental health. A score of 0 to
100 is calculated for each subcategory, with higher
scores indicating better HRQOL. The 8 domains are
combined into physical component (PCS) and
mental component (MCS) summary scores. Subjects
self-reported disease severity using a validated HS
self-assessment tool that assigned a Hurley stage.2
HS SF-36 scores were compared with historical
control scores of individuals without HS that were
derived from entirely different samples, including
healthy adults and those with chronic diseases, from
the National Survey of Functional Health Status study
and with the scores of patients with psoriasis from a
previous Wake Forest School of Medicine study.3,4
Data were analyzed using SAS 9.4 software
(SAS Institute Inc., Cary, NC). The Student t test
and analysis of variance tests were used for
between-group comparisons.
The average age of respondents was 39 years; 90%
were female, and 57% were African American. A total
of 86 patients (56%) with comparable demographics
(mean age, 36 years; 80% female; 38% African
American) did not respond. Patients with HS had
worse HRQOL than healthy adults in all SF-36
domains (Table I). The HRQOL of patients with HS
was worse than for patients with psoriasis with
respect to MCS and 3 domains: body pain, social
functioning, and role-emotional. The mean PCS and
MCS scores for patients with HS were lower
compared with norms for patients with most other
J AM ACAD DERMATOL Research Letters 237
VOLUME 82, NUMBER 1

Table I. SF-36 scores of healthy adults versus patients with psoriasis and hidradenitis suppurativa
SF-36 domains NSFHS (N = 2474), mean (SD) WFSM psoriasis (N = 317), mean (SD) HS (N = 67), mean (SD), [Range]
Physical functioning 84.15 (23.28) 66.0 (31.1) 69.2 (28.1)* [0-100]
Role-physical 80.96 (34.00) 58.0 (42.8) 54.5 (42.2)* [0-100]
Body pain 75.15 (23.69) 59.5 (26.1) 47.5 (24.8)*y [0-100]
General health 71.95 (20.34) 56.5 (24.6) 52.1 (16.8)* [17-85]
Vitality 60.86 (20.96) 45.4 (23.6) 39.4 (20.6)* [5-100]
Social functioning 83.28 (22.69) 73.4 (25.5) 61.9 (29.2)*y [0-100]
Role-emotional 81.26 (33.04) 64.3 (42.5) 33.3 (43.4)*y [0-100]
Mental health 74.74 (18.05) 64.0 (19.5) 64.0 (20.2)* [12-100]
Physical component summary 50.00 (10.00)z 41.2 (14.2) 40.9 (6.3)* [28.5-53.3]
Mental component summary 50.00 (10.00)z 45.7 (11.4) 40.0 (6.4)*y [25.9-54.0]

HS, Hidradenitis suppurativa; NSFHS, National Survey of Functional Health Status; SD, standard deviation; SF-36, Short Form Health Survey;
WFSM, Wake Forest School of Medicine.
*HS sample mean is significantly lower than that of NSFHS healthy adult comparison population: P \ .001.
y
HS sample mean is significantly lower than that of WFSM population with psoriasis: P \ .01.
z
Standardized t scores.

Fig 1. Hidradenitis suppurativa. SF-36 scores in hidradenitis suppurativa compared with other
chronic conditions. The (A) lower physical component summary (PCS) and (B) mental
component summary (MCS) scores indicate worse health-related quality of life. The vertical bar
indicates the score for subjects with hidradenitis. Hidradenitis was associated with lower PCS
scores than 10 of the 12 other medical conditions; only congestive heart failure (CHF) and
sickle cell disease (SCD) had lower PCS scores. Hidradenitis MCS scores were lower than all
other conditions except depression. The norm for patients with SCD was obtained from
comprehensive sickle cell centers clinical trial consortium data.5 CLD, Chronic lung disease;
DM, diabetes mellitus; HS, hidradenitis suppurativa; MI, myocardial infarction.

chronic conditions, including cancer (Fig 1). There
were no significant differences in PCS and MCS
scores between patients with different Hurley stages
(P [.05).
HS is a debilitating disease that can interfere with
many activities of daily life. Our data suggest that HS
may have a greater impact on HRQOL than psoriasis
and other chronic medical conditions. Hurley stage
and HRQOL do not appear closely related; even mild
HS may have a major impact on HRQOL. Although
our sample size was small, the magnitude of HS
impact was large enough to detect statistically
significant associations. Despite the nonresponse
rate, the similar demographics of populations who
did and did not respond suggests a representative
sample. Although severity was self-reported, the
measure was validated by comparison with
physician-assessed severity.2 We used historical
controls and did not account for confounders such
as comorbidities, possibly biasing results. HS impairs
HRQOL and warrants empathetic doctors and
effective treatment.
238 Research Letters
Sree S. Kolli, BA,a Aditi Senthilnathan, BS,a Leah A.
Cardwell, MD,a Irma M. Richardson, MHA,a
Steven R. Feldman, MD, PhD,a,b,c and Rita O.
Pichardo, MDa
From the Center for Dermatology Research, Depart-
ment of Dermatologya; Department of Patholo-
gyb; and Department of Public Health Sciences,
Wake Forest School of Medicine, Winston-Salem,
North Carolina.c
Funding sources: None.
Disclosure: Dr Feldman is a speaker for Janssen
and Taro and a consultant and speaker for
Galderma, Stiefel/GlaxoSmithKline, Abbott Labs,
and Leo Pharma Inc; has received grants from
Galderma, Janssen, Abbott Labs, Amgen, Stiefel/
GlaxoSmithKline, Celgene, and Anacor; is a
consultant for Amgen, Baxter, Caremark, Ger-
son Lehrman Group, Guidepoint Global, Hanall
Pharmaceutical Co Ltd, Kikaku, Lilly, Merck &
Co Inc, Merz Pharmaceuticals, Mylan, Novartis
Pharmaceuticals, Pfizer Inc, Qurient, Suncare
Research, and Xenoport; is on an advisory board
for Pfizer Inc; is the founder of and holds stock
in Causa Research and holds stock in and is
majority owner of Medical Quality Enhance-
ment Corporation; and receives royalties from
UpToDate and Xlibris. Dr Pichardo has received
consulting support from AbbVie. Dr Cardwell
Ms Richardson, Ms Kolli, and Ms Senthilnathan
have no conflicts of interest to declare.
This work was presented at the Southeastern
Consortium for Dermatology meeting,
Charleston, SC, November 2018.
Reprint requests: Sree S. Kolli, BA, Department of
Dermatology, Wake Forest School of Medicine, 1
Medical Center Blvd, Winston-Salem, NC 27157-
1071
E-mail: skolli@wakehealth.edu
REFERENCES
1. Both H, Essink-Bot ML, Busschbach J, Nijsten T. Critical review
of generic and dermatology-specific health-related quality of
life instruments. J Invest Dermatol. 2007;127(12):2726-2739.
2. Senthilnathan A, Kolli SS, Cardwell LA, et al. Validation of a
hidradenitis suppurativa self-assessment tool. J Cutan Med
Surg. 2019;23(4):388-390.
3. Thalji LHC, Rubin R, Berckmans TR, Pardee BL. 1990 National
survey of functional health status: final report. Chicago, IL:
University of Chicago; 1991
4. Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr,
Reboussin DM. Psoriasis causes as much disability as
other major medical diseases. J Am Acad Dermatol. 1999;
41(3 Pt 1):401-407.
J AM ACAD DERMATOL
JANUARY 2020
5. Dampier C, LeBeau P, Rhee S, et al. Health-related quality of
life in adults with sickle cell disease (SCD): a report from the
comprehensive sickle cell centers clinical trial consortium. Am
J Hematol. 2011;86(2):203-205.
https://doi.org/10.1016/j.jaad.2019.07.009
Outcomes of surgical re-excision
versus observation of severely
dysplastic nevi: A single-institution,
retrospective cohort study
To the Editor: Recent retrospective cohort studies and
a systematic review showed low rates of cutaneous
melanoma (CM) at sites of histologically dysplastic
nevi that were clinically observed versus completely
excised1-3; few studies have included severely
dysplastic nevi (SDNs).4 A multicenter retrospective
analysis of 467 moderately dysplastic nevi without
clinical residual pigmentation after excisional biopsy
showed a lack of adverse patient outcomes with
observation alone.5
To further our knowledge on the best practices
regarding the treatment of dysplastic nevi, we
analyzed consecutive, clinically observed versus
re-excised SDNs to assess local recurrence and
histologic upstaging to CM or early, evolving
CM, including melanoma in situ and atypical intra-
epidermal melanocytic proliferation. We included
patients with SDNs diagnosed by a single dermato-
pathologist at the Veterans Affairs Palo Alto Health
Care System during May 15, 1991-October 15, 2015,
with follow-up for observed cases through May 31,
2019. Clinician biopsy intent was recorded as
excisional (complete) or partial (incomplete).
For statistical analysis, differences in baseline
characteristics between observed and re-excised
cases were assessed by independent t test or
Fisher’s exact test. For re-excised cases, pathologic
outcome was represented as no residual nevus,
residual nevus, or upstaged to CM or early CM.
Secondary pathologic review was performed
(by Dr Bailey and Dr Swetter) for upstaged
cases. Fisher’s exact test was used to assess the
relationship between margin status and re-excision
pathology. All analyses were conducted in SAS 14
(SAS Institute Inc, Cary, NC). The study was
approved by the institutional review boards at
Stanford University and Veterans Affairs Palo Alto
Health Care System.
Median patient age was 64 years, and 96.8% of
patients were male. Of 125 SDNs, 85 (68.0%) were
re-excised (4 of them elsewhere), and 40 (32.0%)
were clinically observed. Of the 40 observed cases,
34 (85%) had negative initial biopsy margins. Of the