Guidance on COVID-19 Vaccination in Hidradenitis Suppurativa Patients: A Modified Delphi Consensus of Experts

Introduction Hidradenitis suppurativa (HS) patients may be at increased risk of COVID-19 infection and complications from their medications and comorbidities. There is a lack of expert consensus on recommendations for the COVID-19 vaccine for HS patients. Herein, we aim to provide expert-driven consensus recommendations regarding COVID-19 vaccinations in HS patients. Methods A modified Delphi consensus survey developed by a core committee of 7 dermatologist HS experts consisting of 4 demographic questions and 12 practice statements was distributed to the US HS Foundation-sponsored provider listserv. Participants were attending physician HS experts. Survey results were to be reviewed by the core group and revised and resubmitted until consensus (≥70% agreement) was achieved. Results Among the 33 survey participants, there were 30 (87%) dermatologists, 1 general surgeon, 1 plastic surgeon, and 1 rheumatologist. Consensus for all 12 statements on vaccine counseling and HS treatment counseling was achieved after the first round. Discussion/Conclusion For now, this consensus can serve as a resource for clinicians discussing COVID-19 vaccination with their HS patients. These recommendations will need to be updated as new evidence on COVID-19 emerges.


Introduction
Hidradenitis suppurativa (HS) is frequently associated with comorbidities and often requires immunomodulating therapies [1]. COVID-19 vaccination rates remain low in parts of the USA and worldwide due to vaccine This article is licensed under the Creative Commons Attribution 4.0 International License (CC BY) (http://www.karger.com/Services/ OpenAccessLicense). Usage, derivative works and distribution are permitted provided that proper credit is given to the author and the original publisher. DOI: 10.1159/000521268 hesitancy, misinformation, lack of guidance for practitioners, and lack of vaccine access [2]. Anecdotally, we have witnessed COVID-19 vaccine hesitancy and misinformation in the HS patient population. Recent studies examining COVID-19 outcomes among patients with and without HS have shown that HS patients, many of whom were on immunosuppressive and immunomodulating therapies, do not have worse outcomes than the general population [1,3,4]. Regardless of observed outcomes, vaccination remains a public health priority. We aim to provide expert consensus recommendations regarding COVID-19 vaccination in HS patients.

Methods
We performed an anonymous RedCap modified Delphi survey of HS experts who are attending physicians and members of the US HS Foundation-affiliated provider listserv (Fig. 1). Practice statements were developed by a core committee of HS experts consisting of 7 board-certified dermatologists (6 practices in the USA, 1 in Australia). Participants answered 4 demographic questions and 12 practice statements (Table 1). Answer choices included: "agree without changes," "agree with changes" and "disagree, please provide comment." Survey results were reviewed and statements were to be revised and resubmitted until ≥70% consensus was achieved.

Results
Among the 33 survey participants, there were 30 (87%) dermatologists, 1 general surgeon, 1 plastic surgeon, and 1 rheumatologist. In terms of patient volume, 12% of participants report seeing >50 HS patients per month, 48% report 26-50 per month, 24% report 11-25 per month, and 15% report 1-10 per month. Consensus was achieved after the first round. Practice statements are outlined in Table 1.

Discussion
The consensus highlights that HS patients and their close contacts should receive the COVID-19 vaccination and follow preventative guidelines due to the potentially higher risk of COVID-19 complications. There should be no-to-minimal modification of HS treatment regimens, while patients receive their vaccination. HS patients should be reassured that there is currently no evidence to suggest that they have increased risk of vaccination-related complications or need routine antibody titer testing. Based on available data and our expert consensus, with minimal exception, patients should receive the CO-VID-19 vaccine without modifications to treatment regimen or vaccination timing [1]. Immunomodulatory and immunosuppressive medications may alter vaccine response and infection risks; however, further investigation is needed. Of note, recent guidelines from the Centers for Disease Control and Prevention recommend that patients on immunosuppressants and all biologics receive an additional dose of the vaccine [5]. Although there is no evidence to show that HS independently increases risk of poor outcomes from COVID-19 infection, comorbid conditions such as diabetes mellitus, obesity, and tobacco use may contribute to immune alteration [1,6].
Ongoing studies, such as the University of California San Francisco led Global Hidradenitis Suppurativa CO-VID-19 Registry, will provide further data to guide recommendations in this patient population. Initial findings demonstrate that biologic therapies have not been associated with increased COVID-19 severity [7,8].

Conclusion
Many proposed statements currently lack data-driven evidence given limited available information on CO-VID-19 vaccination on HS patients. This consensus was performed prior to the recommendation of a third vaccine dose people who are moderately to severely immunocompromised [5]. Participants were limited to US experts, and these recommendations may not generalize to other countries.
Presently, this expert consensus can guide clinicians on COVID-19 vaccination in HS patients. These statements shall be updated appropriately as our understanding of COVID-19 and HS improves.