Guidelines for the management of hidradenitis suppurativa
Clinical Applications
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, August 1, 2019
In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, talks with Christopher Sayed, MD, about his recent JAAD article, “North American Clinical Management Guidelines for Hidradenitis Suppurativa.”
Dr. Schwarzenberger: I have always believed that hidradenitis suppurativa (HS) is one of the most debilitating conditions that we treat. However, there has not been much published in the past to help us best treat it. As such, I very much appreciate the time and effort you and your colleagues put into creating guidelines for the management of this challenging clinical problem. Have we made any advances in our understanding of this condition and, if so, has this knowledge improved our management of HS?
Dr. Sayed: Historically, misconceptions that the disease is primarily related to apocrine glands or infection have led to confusion in the approach to treatment. It is clear now that HS is a chronic inflammatory disease that predominantly affects the follicular unit. We have learned that inflammatory cytokines such as TNF-alpha, IL-1, IL-17, IL-23, and IL-36 are increased, which matches our understanding of other inflammatory diseases. There also seems to be a role for complement-mediated inflammation that is just starting to be understood and may implicate a role for dysregulated bacterial response mechanisms in driving the disease. Our understanding is improving, but we still have so much to learn compared to many less common and less severe diseases.
Dr. Schwarzenberger: We are learning more about HS comorbidities, including obesity and metabolic syndrome. Do we know which condition comes first? Can we improve the HS by treating the comorbid conditions?
Dr. Sayed: Much like in psoriasis, HS is linked to increased risk of metabolic syndrome, obesity, and even cardiovascular death. In fact, the risk in HS seems to be even higher than it is in psoriasis. While higher rates of obesity, smoking, and metabolic syndrome likely contribute to overall risk, it is clear that the risk is increased even when correcting for these variables. In the end, it is not surprising that the high burden of inflammation in these patients affects more than just the skin. To this effect, the Hidradenitis Suppurativa Foundation is currently developing comprehensive guidelines on HS comorbidities.
Dr. Schwarzenberger: While treatment should be individualized for all patients, can you recommend a reasonable first-line treatment regimen for HS? Do you treat men and women the same?
Dr. Sayed: This is such a difficult question because it is all related to the clinical scenario. For some patients with mild disease, intermittent antibiotic therapy with tetracyclines or clindamycin and rifampin in combination is a good starting point, especially if patients are developing new lesions. For female patients, adding combination oral contraceptives and/or spironolactone can also be helpful. If a patient describes one or a few recurrent lesions as opposed to new lesions arising, this may be a good opportunity for limited surgical intervention and minimal medical management, especially in older patients without disease progressing to new areas. A patient with extensive Hurley III disease may need to start with a biologic such as a TNF-inhibitor in addition to antibiotics, and ultimately will likely need surgery for the best long-term results.
Dr. Schwarzenberger: When do you call in the surgeons for help? What really works best?
Dr. Sayed: If a patient has limited sinuses that are persistently or recurrently inflamed, then surgical intervention is likely to be necessary. This can often be achieved in the outpatient setting by a dermatologist comfortable with local excisions and deroofing procedures. If a patient cannot tolerate local anesthesia or the disease is too extensive to be excised under local anesthesia, referral to a capable surgeon may be necessary. The best approach for patients with progressive disease will often combine medication to stabilize the disease, and then surgical intervention to address recalcitrant areas. For lesions that have been present fewer than 2-3 months, it is worth trying non-surgical interventions when possible.
Dr. Schwarzenberger: Adalimumab is FDA-approved for treatment of moderate-to-severe HS. Would it perhaps not make more sense to start it early to help prevent the debilitating scarring that results from chronic disease activity?
Dr. Sayed: This is hard to predict. For mild disease, it is often possible to control it using medical therapy and perhaps the addition of a laser for follicular destruction such as the Nd:YAG. If it is clear that a patient is not responding well to these methods, or if it appears that they are developing sinuses that may require surgical intervention, then there should be a low threshold to start a biologic such as adalimumab to attempt to halt progression.
Dr. Schwarzenberger: Do you have any predictions as to future directions in HS management? Will we still be treating patients 20 years from now the same way we are treating them today?
Dr. Sayed: There are several drugs in clinical trials for HS so I will be shocked if new FDA-approved treatments are not readily available 20 years from now. There needs to be a major push to better understand the science behind HS going forward since the approach in most trials now is to investigate drugs that have already been evaluated for psoriasis or other conditions and hope they work in HS too. I am hopeful that a better understanding of HS will lead to drugs that are better suited for this particular disease. Unfortunately, one thing that will likely not change is the need for surgical intervention in some patients. The physical change and scar associated with sinus tracts are unlikely to completely resolve in the short term with medications alone, which is the most challenging part of HS management that distinguishes it from psoriasis and other skin diseases. I am, however, hopeful that more dermatologists will be trained and prepared to offer some level of surgical intervention since so many patients currently struggle to find an adequately trained surgeon when they need one.
Dr. Sayed serves as associate professor and director of Medical Student Education in the Department of Dermatology at the University of North Carolina at Chapel Hill. He has served as a speaker, investigator, and an advisory board member of AbbVie; a principal investigator of GlaxoSmithKline and InflaRx; a speaker and investigator for Novartis; and an investigator of Tioga Pharmaceuticals, Inc., and UCB. The article appeared in JAAD https://doi.org/10.1016/j.jaad.2019.02.068.
