Episode 1: Joint Pain in Paradise: A Closer Look at Arthritis and HS

Medscape

22-05-2025

This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.
Ginette A. Okoye, MD: Hello. I'm Dr Ginette Okoye. Welcome to the Medscape InDiscussion podcast series on hidradenitis suppurativa (HS). Today we'll be discussing the diagnosis and treatment of arthritis in HS with our guest, Dr Rebecca Manno. Dr Manno is a board-certified rheumatologist specializing in autoimmune and inflammatory conditions such as rheumatoid arthritis (RA), lupus, vasculitis, and scleroderma. She practices at Comprehensive Orthopaedic Global in the US Virgin Islands and is an adjunct assistant professor of medicine at Johns Hopkins University. Thank you for joining us today, and welcome to the Medscape InDiscussion podcast.
Rebecca Manno, MD, MHS: Hi. Thank you so much for having me. This is such a pleasure.
Okoye: Well, I am particularly excited to have you because, as you know, patients with HS often report joint symptoms and arthritis and arthropathy. I would love to get the definitions of those from you; they're known comorbidities of HS, and they contribute to the quality-of-life impact. But the joint symptoms haven't been well characterized, and they're often described by people like me, dermatologists. I don't think we quite have the expertise that you have in describing the joints, examining the joints, and knowing which imaging tests to record. I'm thrilled to have this conversation so you can help us all get better at this.
Why don't you tell us a little bit about how you came to develop an expertise in HS.
Manno: This story starts with a little bit of background on my personal career journey. I did my medical training, including rheumatology fellowship, at big academic centers in Baltimore, Maryland. And I joined the faculty in the Division of Rheumatology at Johns Hopkins in 2011. Throughout all of this, as with many of us who trained at big academic centers, you have access to every specialist and subspecialist in medicine that you can imagine.
This makes it easy to stay in your rheumatology lane or whatever your specialty is. It made it easy to stay in my RA, lupus, vasculitis, gout lane, because for anything that expanded beyond your specialty, there's somebody right down the hallway who can help.
Five years ago, I made a big career and life change and moved to the Virgin Islands, where I am currently the only full-time rheumatologist. I went from a big academic center with a huge medical infrastructure and an infinite number of providers and specialists to the opposite of the spectrum. The Virgin Islands is an amazing, close, tight-knit community, but we do have limited resources, especially when it comes to healthcare. Specifically, in our Virgin Islands territory, we have very, very limited dermatology access in general. Most of the HS is cared for either by primary care doctors or surgeons. So really, the way that I started having a referral pathway for HS patients was from my surgical colleagues. I had a conversation with one of our outstanding surgeons. He said, 'Rebecca, I just don't want to operate on this person again. I know that there are these medications out there, and we probably can do better for him. Would you see this patient and see if you can help?' And I said, absolutely. This opened the door to conversations and collaborations in our medical community here between rheumatology, surgery, and the primary care doctors and dermatology when we have some help there as well, about how to best take care of these patients.
Okoye: Wow. That's, that's an amazing example of this kind of cross-specialty care for patients. After this episode, you may have several dermatologists interested in coming to the Virgin Islands to help you.
Manno: Absolutely.
Okoye: When you've been seeing patients with HS who have joint symptoms, what are the most common symptoms you've encountered, and which joints are more commonly affected?
Manno: When I see patients with HS and arthritis in my clinic, there are two pathways or two scenarios. The first pathway is a patient who may be referred to me specifically for HS. Let's talk about that scenario first.
When that patient is referred to me for HS I'm looking at their skin, but I'm a rheumatologist, so I'm going to start talking to them about their joints, whether they like it or not. I'm going to ask them about joint pain, swelling, stiffness, and striking inflammatory symptoms. And it is certainly a large proportion of these patients who do have joint symptoms; it can be a spectrum.
The next step then is evaluating that, so if there is obvious synovitis or swelling on exam. I'll go down the path of evaluating them for a defined rheumatic disease. Do they have undiagnosed RA? Do they have undiagnosed axial spondyloarthritis? And sometimes I find those things, and then sometimes I don't.
Yet on my exam of this patient who was sent to me for something that doesn't have to do with their joints, there is synovitis on exam. In those patients, it tends to be in the small joints of the hands. So the proximal interphalangeal (PIP) joints, sometimes the metacarpophalangeal (MCP) joints, enthesitis, and tendonitis, especially in the elbows and knees.
Large joint arthritis is less common, but I've certainly seen it in the knees and ankles as well. In general, if these patients do not have a defined rheumatic disease that I can attribute their inflammatory arthritis to, and it's associated with the HS, it tends not to be a destructive arthritis. I have seen some exceptions to that rule.
The second scenario would be a patient referred to me for joint pain — a typical rheumatology consult. We get these all the time, patients with joint pain. And then I uncover an HS diagnosis. These are patients in whom, truthfully and regrettably, I probably would have missed the HS diagnosis 5 years ago in Baltimore because HS is not a comorbidity in rheumatology we typically ask about. In our history or in our review of systems, when we're working up an inflammatory arthritis or joint pain, we're good at asking about psoriasis, skin manifestations of lupus or dermatomyositis, ulcers for pyoderma, and erythema nodosum for sarcoidosis. But we don't ask about HS. And I realized that when I started asking about it — and we'll be looking for it on our physical exam as well — but I recognize that if I didn't ask about it, a lot of patients may not tell me about it. They are embarrassed. They think that it's not relevant to what we're talking about. If I don't ask about it, and then I find it on physical exam, I say, why didn't you tell me about this? And they're like, oh, well, that's nothing. You see how patients may not bring that to the forefront, and that could be whatever subspecialist they're seeing, either because they're ashamed, they're embarrassed, or they don't think that you can help with it. They're worried that you're going to be judging them for something. That was eye-opening to me as well.
Okoye: What I heard there is rheumatologists should be asking more about HS symptoms, and certainly dermatologists should be asking more about joint symptoms. Now that I have a captive rheumatologist, I have so many questions, one of which is, what are the typical symptoms you'll find in enthesitis or tendonitis?
Manno: With enthesitis and tendonitis, it tends to be pain with active resistance. For example, let's talk about epicondylitis, which is an enthesitis or a tendonitis. It's really common, and it doesn't have to be indicative of a systemic inflammatory disease. Typically, that's your tennis elbow or your golfer's elbow — anything where you apply resistance to the insertion point of the tendon. For example, lifting your coffee cup or a gallon jug of water, when you're applying resistance to that tendon at the insertion point, it is going to elicit pain. It's a good way to try to differentiate that pain from arthritis. Arthritis will be painful, even with a passive range of motion.
Okoye: For a dermatologist who hasn't had your training, how would you describe a quick joint exam?
Manno: I think there are a couple of ways. First would be asking the questions. Even before laying hands on the patient, the doctor should ask questions about their joint symptoms. I think this is a space that is wide open for investigation.
Similar to 'how now' with psoriasis and psoriatic arthritis, there are several simple screening instruments to use if patients are experiencing inflammatory joint symptoms, which should then prompt the referral to rheumatology. I think the same could be said for something similar for HS in the future.
Start even just with a simple question: 'Do you have joint pain?' Because patients will sometimes say no, they're all right. Then you're done. When they say yes, the question is which joints and how long does it last? And is there swelling associated with it? The question of which joints, that's going to help to direct your physical exam, especially as a dermatologist, because I don't expect you to do the head-to-toe joint exam.
How long? If they say, oh, I had a pain in my knee for 5 minutes last week, that's okay. It's better. We're done. But if the answer is, I have had this pain in my hands and in the morning, I can no longer hold my coffee cup because my hands are so stiff now, the focus of the exam is going to be on the hands and the small joints.
Then you can ask, is there swelling associated with it? The patient may say, no, there's no swelling, or they'll say yes, there absolutely is. That also helps you to really pay close attention to those joints where if there has been swelling. Especially if they say that there's been swelling in a large joint, such as the knee, you can ask: Has it been large enough to where someone has drained fluid out of your knee? Something like that. We'll get a better sense of how long this has been going on and how severe.
Then, when moving to the physical exam, admittedly, some of the more subtle synovitis, especially in the small joints of the hands and the wrists that I have seen in HS, can be more subtle. But I have absolutely seen the more robust, synovial hypertrophy — thickening of the joints and the small joints of the hands and in the feet with these patients.
Certainly, looking at the joints that are the most affected is important. Does it look swollen? Are you seeing normal landmarks palpating it? Do you feel any fluid? Is it tender when you push on the joint itself, or is it not tender when you push on the joint and it's tender when you push somewhere else, like on a tendon insertion point?
A quick and easy exam that we often teach medical students and our fellows to quickly look for synovitis in the MCPs or in the metatarsophalangeal joints (MTPs) is what's called an MCP squeeze or an MTP squeeze, where you just squeeze across two through four of the MCPs or one through five on the MTPs. If you do that and patients don't have synovitis or pain, it should elicit nothing. But if there is synovitis there, then patients will say, that's painful. So that's a good screening test instead of going joint by joint in the small joints of the hands, where it can be tricky, or in the feet.
Okoye: Super high yield. I agree with you that there's room in HS for this type of screening tool. I hope you might be willing to work with a dermatologist to create that.
Manno: Yes.
Okoye: Let's move on to treatment. What are your go-to treatment options for patients with both HS and arthritis?
Manno: Nonsteroidal anti-inflammatory drugs (NSAIDs) absolutely have a role to help acutely with the pain and the inflammation of arthritis. Many of the patients that I see are younger, so we aren't dealing with as many of the other comorbidities that may negate the use of NSAIDs, but of course we have to use them carefully given other medications they're using or if there's renal insufficiency and so on. I like NSAIDs quite a bit. I like topical NSAIDs, especially for the hands or for the knees. They can be very effective. They are not going to be as effective for other joints, such as the shoulders, for example. And then systemic NSAIDs if that's appropriate for the patient.
I do find that the biologics, if we are using them to treat their HS, also treat the arthritis, which certainly can be effective. And if there is a clearly defined inflammatory arthritis, methotrexate can be helpful as well. I have not seen improvement in the joint symptoms or, if there is an inflammatory arthritis associated with the HS, with antibiotic regimens alone.
Okoye: That makes sense. Let's go back to the NSAIDs. Are you referring to NSAIDs over the counter, such as ibuprofen, or are you referring to prescription NSAIDs?
Manno: It depends on the specific patient scenario. I will often use the COX2 inhibitors for two reasons. One, there is slightly better gastric protection. Some patients tolerate them a bit better, and they have a longer duration of action.
Ibuprofen only lasts about 4-6 hours. Patients are taking it multiple times throughout the day or are not taking it. Whereas naproxen and many of the COX2 inhibitors are once-a-day or twice-a-day drugs, which are easier for patients to take.
Okoye: You mentioned methotrexate. Do you combine methotrexate and biologics in some patients?
Manno: Absolutely. Certainly, if they have a defined inflammatory arthritis that is independent of the HS, then methotrexate in combination, especially with the tumor necrosis factor (TNF) alpha inhibitors, may give us additional benefit, especially for peripheral arthritis. This has not been studied in terms of if it's just HS-associated, but methotrexate in general can give a nice benefit for inflammatory arthritis of the small joints.
Of course, we have to be careful, depending on our patient population, if we have young women who are considering pregnancy, and so on. We have to ask all of those right questions. But methotrexate in combination especially with the TNF-alpha inhibitor can be a nice combo for inflammatory arthritis.
Okoye: That's interesting, because we use low-dose methotrexate around a range of 10 mg/wk for people whom we believe have anti-adalimumab antibodies or anti-infliximab antibodies. What's the range of the doses you're using for arthritis?
Manno: For inflammatory arthritis, we will usually use doses between 15 and 25 mg/wk.
Okoye: Okay, so a little bit higher. That's great. Dermatologists are quite comfortable with methotrexate, so that's certainly something we can add.
You mentioned topical NSAIDs. I'm not as familiar with that group of drugs. Can you tell us a bit more about those and which ones you prefer?
Manno: Diclofenac gel, which used to be prescription only, is now available over the counter, although some insurance companies will still pay for it if you write it as a prescription. It can be kind of expensive if purchased over the counter. It got its FDA approval for osteoarthritis of the hands and the knees because of the absorption; the joints are so close to the skin, which helps with easy absorption. I find it can be highly effective. I'll tell patients to apply it two to three times a day as needed. It is a little bit easier when you're in a warm climate, and so your knees may be exposed more, and you're not wearing long pants all of the time. It can be a great additional tool. And then it doesn't cause the gastrointestinal (GI) upset that we can see with NSAIDs.
Okoye: Back to the bigger picture question here: Do you think the joint disease in HS is HS of the joints, or do you think patients with HS are more likely to have other inflammatory types of arthritis?
Manno: I think this is a fantastic question, and I think this is the question that we should really have some good research agendas moving forward on. I think both are true. The data that do exist, especially in the dermatology literature, show us that patients with HS have an increased risk of also having another autoimmune disease.
We know that's true in autoimmune diseases in general. If you've got one, you're allowed to have as many as you darn well please. So, those data are very clear that there is an increase in prevalence of RA and axial spondylarthritis in patients with HS. I think there's no doubt that you can have more than one, but it should be very clearly defined.
If we're going to call it 'RA and HS,' it should be very, very clearly defined.
This is where serologies and even classification criteria can be very helpful. Now, I know classification criteria are not diagnostic criteria, but they give us some boundaries when we're thinking about how to consider the different organ manifestations of an inflammatory process.
Do I think that our HS patients are at higher risk for having these inflammatory processes? The data that we already have say yes, but there's a second scenario as well: the HS patients that don't have serologies, have an inflammatory arthritis, and have robust systemic inflammation.
Now, on the one hand, you could call these patients 'seronegative RA,' and they would meet criteria for seronegative RA. Technically, yes, these patients don't have antibodies. They have hypogammaglobulinemia; they have a sedimentation rate and a C-reactive that's through the roof. They have anemia of chronic inflammation.
You could call these patients 'seronegative RA,' but when you treat the HS, the arthritis improves. And now it gets complicated, because many of the treatments we're using for the HS also treat inflammatory arthritis.
I'm going to share a case with you. I fully recognize this is a case of 'N of 1.' This is quite an extreme case, but I've seen several other instances that are in this similar neighborhood. I had a young man with terrible HS: stage 3, multiple sites, multiple locations. He responded partially to TNF-alpha inhibitors and steroids. We struggled to have consistent medical therapy for him for a lot of reasons, mostly access to medications and care.
Ultimately, we sent him off-island to the United States, and he had multiple surgical procedures by a very skilled plastic surgeon; he was in the hospital for about a month and had multiple excisions and skin grafts. He did extremely well.
Let me tell you, when I first met this young man, he clearly had advanced HS, but he also had a raging inflammatory arthritis. He had synovitis of the small joints of his hands and his wrists, where he was developing contractures at his PIP joints. He had developed some deformity of his fifth PIP on both hands. He had joint pain to the extent that he wasn't able to work. It wasn't just the skin; it was the joint symptoms too.
When we sent him off-island, he had extensive surgical interventions. When he came back a couple of months later, I saw him. His arthritis was gone. His inflammatory markers were normal. His labs looked great. He was not on medical therapy. And he continues to do well today.
Now, I'm not saying that this surgical intervention is the way to go about it, but if this was all seronegative RA from the beginning, it should not have improved with this type of intervention.
That is an extreme example, and perhaps it is an outlier, but I think that it is telling us something about the robust inflammatory process of HS that goes beyond just the skin.
Okoye: It tells us about this idea that we're starting to develop now, which is that HS tissue itself drives the inflammation. So, by debulking so-called HS, you decrease systemic inflammation, and that is telling with your patient. Wow, there's lots of work to be done in this area.
Do you do serologies in these patients? Which ones?
Manno: I will check serologies to look for a concurrent rheumatic disease because if they have the inflammatory arthritis and they're anti-cyclic citrullinated peptide (CCP) high titer positive, I'm going to call that RA with HS.
I am going to check the antinuclear antibodies (ANA), and I will probably check double-stranded DNA if there are some joint symptoms associated with it as well. I want to know those things too, especially if I'm thinking about a biologic, and which ones to choose safely.
And then I'll check serologies based on any other specific signs or symptoms. If they're having any GI issues, I will work them up for inflammatory bowel disease. and I will check anti-saccharomyces antibodies.
I will check anti-neutrophil cytoplasmic antibody (ANCA), specifically perinuclear ANCA, which can be seen in inflammatory bowel disease as well. And of course, I'll have a GI workup for them too. But in general, unless I'm going down a path that they have an additional rheumatic disease, their serologies are going to be negative. But they will have hypogammaglobulinemia with immunoglobulin G levels that can be 2500 or 3000; they're polyclonal on serum protein electrophoresis. But it is just another example of how inflammatory they are.
Okoye: What do you think is the role of exercise or physical therapy for the joint symptoms in HS?
Manno: I think there is an important role for it. We know so much about the role of exercise in many of our rheumatic diseases that involve the musculoskeletal system, such as RA, dermatomyositis, and axial spondyloarthritis. We consider exercise to be just as important a part of the prescription as the disease-modifying antirheumatic drug or their biologic agent, and the data strongly support that. And it starts with some education for the patients who think, Am I going to make this worse? Especially when they're dealing with a musculoskeletal problem like arthritis, and I would say even with HS patients, because they're worried about moving too much.
From an arthritis standpoint, I can say definitively, no, you are not going to make it worse. Now, I'm not going to recommend that they go join a CrossFit gym and do really high-impact exercise that is high velocity. Things that are not high impact can still be extremely beneficial. It just means that they should be slow, controlled movements.
Absolutely, exercise is key. The goal of exercise is to increase strength and muscle mass, which will help with overall body composition. Weight management is important, but it's body composition. We want our patients not to be undermuscled, which is what they are. We want them to gain muscle.
I think something important, with our HS patients, is giving them an exercise prescription. I'll start with something very simple: find out what they like to do. They'll say, well, I like to go walking. Great. I want you to walk for 15 minutes once a week, and at the end of your walk, you're going to do 10 air squats, or you're going to do 10 step-ups.
Okoye: Very specific.
Manno: Very specific, and you're going to do that for a month, and then you're going to increase it to twice a week. Simple and specific, so it's achievable.
The other thing that I will do is refer our patients to a physical therapist for a home-based resistance exercise program, which can be supervised for some time by the therapist and then can be translated into something at home.
Okoye: Wow, Dr Manno, I have to go back and listen to this podcast to finish taking my notes for my patients. This has been enlightening, and I don't think that this resource exists anywhere else yet, so I really appreciate all you do for patients with HS. And I thank you for coming on the podcast.
Manno: I thank you for inviting rheumatology to the conversation about HS. We are definitely, as a community, happy to be here and be a part of this. Thank you for all that you're doing as well.
Okoye: Today, we talked to Dr Manno about the diagnosis and treatment of arthritis in HS. Thank you for joining us. Please take a moment to download the Medscape app to listen and subscribe to this podcast series on hidradenitis suppurativa. This is Dr Ginnette Okoye, for the Medscape InDiscussion podcast.
Association between Hidradenitis Suppurativa and Inflammatory Arthritis: A Systematic Review and Meta-Analysis
Comorbidities and Quality of Life in Hidradenitis Suppurativa
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Diagnostic Delay in Hidradenitis Suppurativa: Still an Unsolved Problem
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Management of Lateral Epicondylitis: A Narrative Literature Review
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Methotrexate and Its Mechanisms of Action in Inflammatory Arthritis
Hidradenitis Suppurativa and Rheumatoid Arthritis: Evaluating the Bidirectional Association