Hidradenitis suppurativa is an inflammatory skin disease that causes painful lesions and scarring and which, though rare, can have disabling effects, both physical and mental. Rashidat Adeniba and Anne Harriss look at how occupational health can support those with the condition to return to work, examining the case of a female passenger vehicle driver.
Hidradenitis suppurativa (HS) a chronic, rare and disabling disease that often establishes with painful lesions which may cause hypertrophy and immobility (World Union of Wound Healing Societies, 2016). This case study explores the effects of HS on a woman employed as a passenger vehicle driver. It assesses the impact of her health on her ability to conduct her role and the recommendations for adjustments to support her return to work following her hospital admissions.
Emma (pseudonym) aged 36 is of Afro-Caribbean ethnicity and worked full-time in a safety-critical role. Any type of personal impairment can endanger the lives of themselves and others (Carter et.al. 2013).
About the authors
Rashidat Adeniba is an occupational health nurse and Anne Harriss is Professor Emeritus and course director at London South Bank University
HS is a persistent chronic inflammatory skin disease of the hair follicles; it causes painful lesions that can lead to hypertrophic immobile scars (British Association of Dermatologists, 2017; World Union of Wound Healing Societies, 2016). It affects around 1% of the population in Europe, often occurring in otherwise healthy adolescents and adults, with women being three times more likely to be affected than men and it affects African and Afro-Caribbean populations in particular.
Emma was diagnosed with HS three years previously. HS has had a significant impact on Emma’s physical and psychological wellbeing, causing embarrassment and depression. It has triggered fever and fatigue, preventing her from performing everyday activities such as carrying shopping and dressing because of her limited limb mobility from dermal contractures and lymphoedema (World Union of Wound Healing Societies, 2016).
Pathophysiology
HS is long term, repetitive and painful, especially where there is inflammation in areas of skin that consist of apocrine sweat glands (British Association of Dermatologists (2017). Blockages of hair follicles resulted in a combination of boil-like lumps, areas leaking pus and scarring.
The main areas affected by HS include the groin, armpits, perineum and buttocks (World Union of Wound Healing Societies, 2016). The causes of HS are unclear, the effects are inflammation leading to the development of infections within hair follicles resulting in abscesses (British Association of Dermatologists, 2017).
The hair follicles become obstructed by keratinised stratified squamous epithelium; these eventually rupture and their contents become deposited into the surrounding dermal tissue (Young, 2018). Apocrine sweat glands produce a sticky, cloudy and possibly odorous secretions (Slade et al 2003).
The symptoms for HS may reduce after menopause but symptom patterns vary from person to person, and patients with HS can have up to 30 active open abscesses in one area (National Institute for Health and Care Excellence (NICE) 2016).
There is usually a delay in diagnosing HS because it can be confused with simple infected lesions. There are no precise histological tests to confirm the diagnosis, which is made as a result of clinical presentation and examination of the affected area (Young, 2018).
Occupational health referral
The role of the occupational health nurse (OHN) in case management consists of supporting the employee and offering advice to managers on how to deal with the employee’s limitation (Chantry and Harriss, 2017), advising the manager of the reciprocal effects of the client’s health on work and their work on their health and wellbeing.
The aim is to assist the manager to understand how the employee can be supported while at work, particularly with respect of possible adjustments that will enable the employee to remain at work.
Following a referral from her line manager, Emma attended the OH department for a face-to-face assessment and confirmed her agreement for the referral by signing a consent form.
Emma had painful abscesses in both axillae and had been off sick from work for two months due to recurrent HS in both axillae, which she described as being the size of an orange prior to being drained six weeks prior to her OH assessment.
These required regular dressings undertaken by the practice nurse at her general practitioner (GP) practice. She described living with these chronic wounds as being challenging, as they significantly affected her quality of life (World Union of Wound Healing Societies, 2016).
The choice of treatment for HS is based on severity of disease, type and extent of lesions and resistance to previous treatments (World Union of Wound Healing Societies 2016). There are limited options for effective treatment in HS. It is important to explore co-morbidities and propose lifestyle recommendations, such as weight loss in obese sufferers, and cessation in smoking are found to be very beneficial in improving HS, and associated cardiovascular risks. Other advice includes the use of medicated soaps, wearing cotton underwear, particularly soft, and friction free bras. The wearing of loose clothing and especially avoiding tight jeans trouser is also recommended (Slade et.al, 2003).
Usually analgesia includes the use of non-steroidal anti-inflammatory drugs (NSAIDs). Opioids may be used if NSAIDs are not effective. Emma’s GP recommended ibuprofen 800mg as required and she was also prescribed prednisolone 7.5mg daily, which had been reduced from a daily dose of 20mg.
Systemic steroids such as prednisolone can be beneficial because of the general anti-inflammatory effects. However, relapse can be difficult to control when steroid dosage is reduced, especially if there are infections within the lesions (Slade et al, 2003).
Emma recounted that she had had both abscesses drained. According to Slade et al (2003), drainage of individual lesions can result in temporary relief, however recurrence is foreseeable. If the patient does not respond to medical treatment, surgical intervention is the alternative option. Decker et al, cited in Young (2018), found that most patients with HS who had been treated by surgical interventions reported they would recommend it to other patients.
Emma reported her wish to return to work but raised concerns that her work uniform might be uncomfortable, as it was likely to rub against her armpit. She was also concerned her abscesses could ooze while she was on duty. Emma indicated she was unable to wear her bra because of the location of the abscesses.
The OHN should confirm the employee has given consent for preparation and release of an occupational health report (Faculty of Occupational Medicine, 2018). At the end of the assessment, the OHN released a copy of the OH report to Emma’s manager. Emma reviewed the report before release ensuring that she was happy with the content and providing an opportunity for her to correct any unintended factual errors.
Psychological aspects of hidradenitis suppurativa
The skin is the largest and most visual organ of the body and has an important role in interpersonal relationships, self-esteem and perception of self and public image. People with HS can struggle with certain aspects of their lives because of the effects of HS. These can include abscess, fistulae and scarring causing soreness, exudate and odour in the affected area (Matusiak, et al 2010).
Emma expressed the view that she was experiencing some residual pain and discomfort in both armpits. Exudate from the lesion resulted in odour and stained her clothes, causing her embarrassment when in public places.
Ather et al (2006), cited in Young (2018), refer to embarrassment, self-consciousness, and social isolation of this condition, which is incapacitating and with adverse effects on the individual’s ability to function in employment and domestic roles (Nicoli et al, 2013 and Patel et al, 2017, cited in Young, 2018).
Emma communicated that she was reluctant to go out in case someone knocked into her, causing her wound ooze. HS is physically and psychologically debilitating for sufferers, resulting in social isolation, failed relationship and depression (Slade et al, 2003; Theut Riis et al, 2016).
Impact of hidradenitis suppurativa on quality of life
HS has been recognised to have a significant impact on quality of life because of its effects on an individual’s ability to perform common activities of daily living, including going to work, walking up and down stairs, lifting objects above the head or taking part in sports. Pain is the most distressing factors for patients with HS (World Union of Wound Healing Societies, 2016). Emma reported symptoms of pain, itchiness, oozing and she had several scars from previous lesions.
Functional assessment and impact of condition on role
Functional assessment is evaluating the functional components of the individual’s role and tasks. It provides the OHN with the information required to assess the individual’s specific circumstances (Everton et al, 2013). According to Murugiah et al (2002), assessment of fitness to work should evaluate personal aspects, work characteristics, work environment and other functional components. Emma’s role included collecting passengers’ fares, checking tickets and passes and giving timetable or route information. The nature of Emma’s role could be psychologically and physically demanding.
Psychological demands included the requirement of high levels of concentration, and the need to stay alert and focused whilst on duty. There were occasions when bus drivers were subjected to verbal abuse by passengers; this could affect their ability to maintain their focus. It was essential therefore that both managers and OHN paid attention to any inadequacy in concentration because of its safety-critical role (Heron and Greenberg, 2013). The physical demands of Emma’s role included sitting for long periods of time and repetitive movement whist operating vehicle controls, including controlling the steering wheel.
The functional impairment for a person with HS is the location of the abscess. HS lesions in the armpit are considered more painful than those in the groin. Furthermore, to reduce the conflicts between the disease severity and the disability experienced, both the physical and psychological impact of HS must be considered together (World Union of Wound Healing Societies, 2016).
Emma had been prescribed prednisolone to manage the inflammation from the abscesses. The side-effect of this medication includes mood changes, restlessness and inability to sleep. These were essential considerations regarding Emma’s ability to concentrate whilst undertaking work tasks.
Bowles and Harriss (2018) highlight that personal aspects relate to the assessment of the individual that must be related to the employee’s role. Driving was challenging for Emma, as she was still experiencing pain from the abscesses in both axillae and pain resulted in her being unable to raise her hands above her head.
It is essential to compare individuals to their work; OHNs must have a good knowledge of the job specification in terms of essential and desirable qualities required for the job (Murugiah et al, 2002). The OHN conducting Emma’s assessment showed good knowledge of her role and understood the impact of Emma’s role on her health and vice versa. During functional assessment, the advice given by the OHN must be based on vigorous principles that are legal, clear and evidence based.
Biopsychosocial model
The biopsychosocial model is used mainly to give OHNs information, indication or alert about a person or their problem. The biopsychosocial model was used in accessing Emma’s physical, social, psychological and behavioural aspects of her condition.
Red flags are the medical barriers. For Emma, these were wound healing as HS wounds can be problematic requiring lots of attention. Yellow flags include thoughts, feeling and behaviours, having unhelpful beliefs about pain and work, fear of movement and of re-injury (Watson, 2010). These were identified with Emma during the assessment. She expressed her concerns to go back to work because of the pain she was currently experiencing from the abscess in her armpits. She expressed fear of using public transportation, such as buses and trains.
Blue flags are considered as the employee and the workplace, including identifying any concerns in regards to the employee’s ability to meet the demands of job. Additionally, lack of support at work, the employee’s view that the job is very stressful, and poor communication between employer and employee. Consequently, it is important whether the employer has a flexible approach in the workplace to support modified duties or work options to help promote a return to work (Watson, 2010).
Emma lives with her husband and two children; she had excellent supported at home. On the contrary, she did not feel supported at work because of the poor relationship and poor communication with her line manager. It is important there is early and continued communication with employee and employer to help manager return to work effectively. Absence management is a manager’s responsibility, and managers should stay in contact with employer during sickness absence to help aid quick return to work (Everton et al, 2013).
Waddell and Burton (2003) state that people on sick leave should be encouraged and supported to return to work as soon as possible because work is therapeutic, it helps to promote recovery and rehabilitation. Furthermore, this leads to improved health outcomes, improves quality of life, wellbeing and reduces the detrimental physical, mental and social effects of long-term sickness absence.
As Emma had been off from work for two months, she now needed to start exploring her capability to return to work, which would facilitate and improve her quality of life.
Legal considerations
HS, as has been made clear, is a debilitating inflammatory disease that can have significant impairment on a person’s physical, emotional and psychological wellbeing. Emma could be considered under the Equality Act 2010. Besides, whether the Equality Act applies or not is a legal decision.
Jackson (2012) emphasises that a person with impairment must meet the three elements of section 6(1)(b) of the Equality Act 2010. These are: must have a significant adverse effect, must have a long-term effect that is likely to last for or have lasted 12 months, and must affect the person’s normal activities of daily living.
The legal aspect of fitness assessment may require a coherence between the occupational health service, GP, hospital consultant and employers (Murugiah et al, 2002). OHN must have awareness to ensure that employers are fully compliant with their duty to make reasonable adjustment.
The Equality Act’s employment code recommends that it is good practice for an OHN to put emphasis on any reasonable adjustment that may be needed, even when in doubt, if the person falls within the Equality Act 2010 (Kloss, 2012).
Adjustments to support a prompt return to work
Vocational rehabilitation is defined by Waddell et.al (2013, p. 5) as “whatever helps someone with a health problem to stay at, return to and remain in work”. Consequently, return to work is a significant aspect of an OHN’s role.
Prolonged absence from normal activities such as work can often be destructive to a person’s mental, physical and social wellbeing. Therefore, a timely return to appropriate work is beneficial to the client and their family by boosting recovery and reducing disability (Aylward et al, 2013).
As already outlined, Emma had been off sick for two months. Therefore, a return-to-work plan was important and a key outcome measure for workplace health management.
The decision as to whether the adjustment is reasonable should be made by the manager; the OHN role is to advise on functional capacity and make recommendations (Kloss, 2012).
During Emma’s OH assessment, she indicated that her GP had issued a fit note for a further four weeks’ absence to allow more time for her wounds to better heal. The fit note was designed to allow GPs to have more productive conversation about work and health-facilitating discussions regarding what the individual can do rather than what they cannot do (Aylward et al, 2013).
The following recommendations were discussed with Emma:
- A phased return to work undertaken over three weeks, with the first week working half days undertaking administration duties. From the second week, she would gradually increase her working hours. By the third week she should return to her role as a bus driver.
- Wearing a looser-fitting uniform to prevent any friction against her wound.
- Taking time off to attend hospital appointments and wound dressing at her GP practice if required.
Conclusion
HS is a debilitating disease that had a significant effect on Emma’s ability to function at work impacting on her physical and psychological wellbeing. An OH referral ensured her successful return to her normal full-time work responsibilities.
This was possible by addressing any barriers to an effective return to work. Effective communication between the manager, employee and OHN facilitated an effective return to work.
References
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World Union of Wound Healing Societies (2016) Understanding hidradenitis suppurativa. Available from: http://www.wuwhs2016.com/files/WUWHS_HS_Web.pdf
Young, T. (2018) Back to basics: understanding hidradenitis suppurativa, Wound UK, 14 (1), pp. 51-55.
