Intralesional triamcinolone for hidradenitis suppurativa and thoughts on confirmation bias
Dec. 2, 2016
Anyone who has treated the scourge of hidradenitis suppurativa (HS) has probably injected inflamed nodules and cysts with triamcinolone (TAC) successfully, resulting in very grateful patients. Despite the useful advent of adalimumab to the other (less than satisfactory) modalities of antibiotics, retinoids, immunosuppressants, marsupialization, and excisional surgery, sometimes all it takes to offer relief is a 30 gauge needle delivering steroids to the inflamed site.
Riis et al acknowledge that intralesional steroids (IS) have become a mainstay of treatment for HS, based on expert opinion rather than scientific rigor. In an open single-arm study, the authors sought to assess the outcomes of routine treatment using intralesional triamcinolone (triamcinolone acetonide 10 mg/mL) in the management of acute flares in HS. The authors found significant reductions in physician-assessed erythema (median score from 2-1, P < .0001), edema (median score from 2-1, P < .0001), suppuration (median score from 2-1, P < .0001), and size (median score from 3-1, P < .0001) at follow-up. A significant difference in patient-reported pain visual analog scale scores occurred after 1 day (from 5.5-2.3, P < .005) and from day 1 to day 2 (from 2.3-1.4, P < .002). The conclusion was that physicians and patients in the management of HS flares perceive intralesional injection of corticosteroids as beneficial by reducing pain after 1 day, and signs of inflammation approximately 7 days later.
The authors commence their discussion by stating: “Many traditional treatments have been introduced without the scientific evidence required today.”
My initial response to reading this article was a smug chuckle, wondering how much time and energy 8 authors expended confirming what every practicing dermatologist already knows. But then I asked myself, what if the authors found that there was no benefit to using IS for HS? Am I guilty of confirmation bias?
According to Althubaiti, “confirmation bias is a type of psychological bias in which a decision is made according to the subject’s preconceptions, beliefs, or preferences. Such bias results from human errors, including imprecision and misconception. Confirmation bias can also emerge owing to overconfidence, which results in contradictory evidence being ignored or overlooked. In medicine, confirmation bias is one of the main reasons for diagnostic errors and may cause inaccurate diagnosis and improper treatment management” (2).
The unfortunate reality of practicing medicine today (and more so in the future) is that we need data to justify everything we do — even something as straightforward as injecting triamcinolone into an inflammatory lesion of HS. I applaud the authors for performing this study. Should insurance companies start denying payment for IS because the procedure is an “unproven” modality, we will be able to contest that decision.
1. Riis PT, et al. Intralesional triamcinolone for flares of hidradenitis suppurativa (HS): A case series. J Am Acad Dermatol 2016; 75: 1151-5.
2. Althubaiti A. Information bias in health research: definition, pitfalls, and adjustment methods. J Multidiscip Health 2016; 9: 211-7.
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