Time On Their Side: Strategies to Manage Hidradenitis Suppurativa

Therapeutic advancements make it possible for more people to get control of HS, but significant challenges to diagnosis and long-term management remain. Alexa Hetzel, MS, PA-C provides an overview of medical and procedural treatment options and emphasizes the importance of spending time with patients and letting them know you are their ally in care. Plus, April Armstrong, MD, MPH gives an update on OX inhibitors, and Sandri Johnson, MSN, FNP-BC addresses approaches to vitiligo treatment.

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Transcript

This transcript is provided as a courtesy and has not been reviewed or edited for accuracy.

Welcome to The Dermalorian Podcast from the Dermatology Education Foundation. Hidradenitis suppurativa or HS can have a significant negative impact on affected patients. The condition is often not properly diagnosed with estimates suggesting that patients go seven to 10 years without receiving a diagnosis and initiating appropriate treatment options to manage this condition are increasing. This fall, the FDA approved BIMZELX for Management of HS, joining HUMIRA and COSENTYX for this indication and several investigational treatments show promise. Dermatology Physician Assistant, Alexa Hetzel provides an overview of HS at its treatment. Alexa is a member of the DEF Advisory Council and was on faculty for the recent virtual Biologic and Small Molecules CME Bootcamp.

Speaker 2:

So what is HS? What is hidradenitis suppurativa? So it's really thought to be a disorder of some of the terminal follicular epithelium, excuse me, within the apocrine glands. And those apocrine glands are really the sweat glands, which is why we see a lot of HS pop up in sweat-bearing areas around the hair. So the axilla, the groin, inframammary, and neck areas. That doesn't mean though, that these patients can't have them everywhere. You have patients who have it suprapubically, they can have it all down their legs, their trunk. I have one guy who has a really big beard, he's got really horrible HS within his beard. And that can be difficult sometimes if it's only in those areas, if it's not in those classic areas that we see, like the axilla, the groin. So just don't necessarily brush those patients off. If they have regular acne, kind of look a little bit deeper at the lesions and how they look.

It is a chronic autoimmune condition, and I feel like patients, when they come into my office and they finally get a diagnosis or at any office and they get that diagnosis, they know. But once they actually get that diagnosis, their eyes get big and they're panicked even though they've been dealing with it usually for years, somebody just kind of I&D, sends them off or just kind of pushes them along. But a lot of the times these lesions can actually start off as comedones, so they look like blackheads. And when I'm doing skin checks on patients, I'm looking at their underarms, I'm looking underneath their breasts and I'm looking in their groin all the time for collections of comedones, those don't necessarily just exist on their own. So that might be a precursor or a very early signs of HS. So just make sure when you're doing those skin checks, you're looking at patients or you're looking at signs of clusters of comedones, then it progresses to recurrent cysts or abscesses and they're like, I'm getting this in the same spot over and over, or it's before my period if it's a female.

And then that leads to sinus tracts, tunnels that create from point A to point B that we don't want. And of course then it can lead to horrible scarring. And if it really is super progressive, some of these patients lose their ability to move. They might not be able to lift their arm up. They can also experience significant pain. Although patients can experience itching and discomfort, this is a truly painful condition where we actually rate patient's pain, or at least I check them every time and they get purulent discharge. So I already know when a patient comes in and they don't want to take off their pants because they usually have padding in there, because they know that they're draining or they immediately stand up to pull their pants back up and there's drainage on the table paper and they're embarrassed. So there's a lot of things that come with this that are psychosocial but also truly debilitating for these patients.

There are Hurley stages, which is how we can categorize how severe it is. It's not really, I think, all-encompassing enough, but we have stage one, two, and three. Stage one has one or more abscesses without sinus tracts or scarring. Stage two has recurrent abscesses with sinus tracts and scarring and usually in multiple but separated lesions, so they can kind of be sparse and spread out throughout the body. And stage three is usually a giant affected area where everything is interconnected. They have horrible sinus tracts that usually affect a large area of skin. So this happens a lot in the axilla and in the groin. And then when we look at treatment options, I'm always having conversations with patients about antiseptic washes, whether it's dial soap or HIPAA cleanse or benzoyl peroxides. I like patients to use those in the triangle areas, especially under the arms, under the breasts, and in the groin, even if they're having a flare or not I find that it helps decrease.

Is it perfect? No, nothing really is, but it helps. Warm compresses when those areas are active. Some people will use short-term oral steroids as a blanket anti-inflammatory to calm things down. I personally don't love oral steroids just because it leads to a whole slew of other things. I have patients who come in for catalog injections when they have a flare-up or I&Ds, unfortunately, if they need it with a larger abscess. You can use different topical agents as well as deroofing. We'll talk about deroofing in just a moment. When you go over medical treatments, you have to discuss pain and management because as I mentioned, patients are in a lot of pain and so sometimes they're afraid to bring that up, but it's also good for us to bring up. You want to talk about mental health? I have a lot of patients who are in Facebook group support groups just because they need somebody else.

They feel like they're alone on an island and they can't talk to anybody else besides these support groups. Wound care is important because these lesions are very difficult to treat. Avoiding triggers, tobacco sensation is huge. It helps calm down inflammation, but they might have something that triggers them specifically. Weight reduction is huge, not only because it decreases inflammation from that fat tissue, but also because then you have less skin and skin contact, which means hopefully less bacteria that's there as well. I use unfortunately, a lot of tetracyclines, minocycline and doxycycline, they help decrease that bacterial load. You can also combine Rifampin and clindamycin for long-term. There are good studies that show that patients who are on long-term rifampin and clindamycin get longer clearance, but unfortunately the lesions can come back and usually do. We have anti-TNFs, we have adalimumab, which is the first one that's been approved.

I feel like adalimumab solved a lot of our problems initially. Now we're getting a little bit more focused and understanding a lot of things in terms of what to expect within the disease. Other orals like moxifloxacin, rifampin, and metronidazole combined, IV artamin, you have hormonal treatments like spironolactone originally developed for blood pressure, now we found that it helps sometimes with hormonal acne as well as HS. You just have to be careful because sometimes with the doses that we need, you can get a little bit of lightheadedness. Metformin, although is not necessarily a hormonal treatment, it does help calm down some of those antigens as well, or retinoids like isotretinoin can be helpful.

Some other biologics, we have two other new ones which is correct, have secukinumab, which recently got approved as well as bimikizumab, which just got approved. Great options. We did the clinical research for bimikizumab in our office and our patients did very well. Unfortunately, with adalimumab and secukinumab high scores of 50. So 50% improvement or better is kind of what we're seeing. With bimikizumab, you can see anywhere from 7, 50, 75 and actually high score 100 data they have. So it's pretty impressive how we're getting a little bit more targeted and a little bit more focused for some patients that are truly suffering.

Speaker 1:

Procedural treatments are also available to manage HS, and we'll get to them in just a moment. But first we pause for this episode's Dermalorian Derm Decoder. Are you aware of OX inhibitors and their potential role in dermatology? Dermatologist Dr. April Armstrong provides an update.

Speaker 3:

So the OX40 and OX40 ligand pathway is something we are learning in atopic dermatitis. What is known is that the OX40 and OX40 ligand pathway, it's a part of the costimulatory mechanism that is very important for the T-effector cells. We know that the T-effector cells are critical in terms of their role in atopic dermatitis, and we now understand that OX40 and OX40 ligand, it's kind of like the baton on the conductor for an orchestra for a symphony where by tweaking how a conductor may conduct, we can actually direct how a song or a musical piece may come together. So if we imagine different T-cell subtypes as different parts of an orchestra, OX40 ligand and OX40 is sort of this master conductor that can direct the survival of pathogenic T cells or the regulatory cells so that it can actually up-regulate or down-regulate certain parts of this symphony.

So because of that, because of the multiple different subtypes of T-effector cells that are touched upon by the OX40, OX40 ligand, and because atopic dermatitis is such a heterogeneous disease, our hope is that by inhibiting either OX40 or OX40 ligand, what we'll have is a medication that can address various heterogeneous presentations of atopic dermatitis, but also have the ability of possibly giving people medications infrequently. The injections potentially we can perhaps dose it every eight weeks or longer with regards to some of these OX40 targeting biologics.

Speaker 1:

OX inhibitors are definitely something to keep an eye on in 2025. Now, let's return to Alexa Hetzel's update on HS.

Speaker 2:

When you look at the procedural treatments, I wouldn't recommend anybody just going off and being like, let's just try this. Learn it if you're going to do it from somebody who knows what they're doing because you don't want to create more scarring, more discomfort and more pain for these patients, you can do endo-YAG lasers. You can do local excisions. I have patients who have come back from wider local excisions, from plastic surgeons and general surgeons and the lesions can recur. They're miserable. They went through that whole surgery process for nothing. I have one patient who's in a clinical study right now who actually somebody removed her entire axillary skin and took grafts from her legs. She looks completely mutilated, unfortunately from the scarring that she has left over, but thankfully, her axillary lesions never came back, but she does have it still in the groin, suprapubic and neck area.

Deroofing, again, can be a little bit more difficult. I mean, you're kind of opening up those tunnels that can exist. Tricky, takes a long time to heal a lot of inflammation. So if you're going to do them, make sure that you learn it from somebody very well. The other thing we're studying in clinical trials are JAK inhibitors as well. So TBD to kind of see of how we do. In terms of a case, one of my patients, her first visit, she was 57 at the time, she presented to our office with a previous diagnosis of severe hidradenitis in the groin, chest, and axillary regions for 10 years. She felt like it was especially triggered during her cycle, so it gives us a little bit of a hormonal possibility. She had been treated by another dermatologist with long courses of doxycycline-kenalog injections and a secondary failure to adalimumab after two years of therapy.

So she initially responded to adalimumab and then lost efficacy over time, which is what we consider a secondary failure. Instead of being a primary failure where she didn't have any response at all. She saw another doctor in our office. She was given doxycycline, again, 100 milligrams BID and spironolactone 100 milligrams QD was told to follow up in six weeks and she reported her pain level at an eight. So at six weeks she didn't have much improvement and she had discontinued the spironolactone after one week because she felt extremely lightheaded. It was then discussed to possibly go into that oral JAK study, but she declined. She said she didn't want to be a Guinea pig, and then she followed up with me. These patients need a lot of hand-holding and the physician that she saw is a fantastic physician. She just doesn't have the hand-holding capability, so she ended up with me.

We decided to initiate secukinumab. I gave her her first dose in office, which is nice to be able to have that with our samples that our reps can prescribe us. And since she had been in an adalimumab before she had the labs that I needed, even though I drew brush new ones, they were just about to expire. I gave her samples to get her through for the first five weeks to take home and inject, and then she was followed up with me. We got everything approved. Her next visit at follow up, she felt like she had more good days than bad days, which unfortunately, unfortunately is kind of what we see with some of these HS patients. She still did have some weeping lesions in her groin. We decided to do SILVADENE application. She was wearing gauze on her legs, like I explained to some of my other patients have.

Again, tight hand-holding, so I was going to give her a little bit more of a leash, but she wanted to follow up in a month, which is totally fine. I'm happy to see her sooner. She felt like at this visit she was back to square one, that she was flaring again horribly in her groin and her underarms. But on physical exam, she was actually improving on therapy. She did have some flared lesions though, so I did agree with her on that, that were draining. So we did some kenalog injections, but continued secukinumab. She did get COVID, so she held dose for about two weeks, but no significant flares thankfully. After that, she recovered quickly and had no new complaints, which was a good thing with her and less drainage. So we were on our way.

Visit six she said it was the best that her skin had been in years. She had no drainage for a month consistently and stopped wearing the gauze pads, which I couldn't believe that she was willing to give those up. I feel like that was her safety blanket and she reported her pain at a level of two in reality. The scarring that she has unfortunately is never going to go away, but if we can control this uncontrolled inflammation, the redness will continue to resolve. And although, like I said, she may still have the scarring, she ultimately is very happy and I'm very happy. We're not going to see complete reduction of these lesions like we see in psoriasis and atopic derm.

Unfortunately, these patients will always have some memory of HS, but if we can get them more good days than bad days, I think that's significant. She was happy. So I would say big thing is we have a lot of options. Well, we have more options than we used to, but make sure if you're going to treat these patients, you give them the time that they need. They need some more hand holding and you have to appreciate that they are mostly embarrassed and it's a big deal that they came in. So just kind of take a step back and pause and let them vent and then go from there.

Speaker 1:

Another inflammatory skin disease that has gotten renewed attention is vitiligo. In this episode's Dermalorian clinical clip dermatology nurse practitioner Sandra Johnson, discusses topical treatment for this condition.

Speaker 4:

Now, we are trying to use a lot more of ruxolitinib, which we can use twice a day, and as you have seen, there's also not only approved for AD, but also for vitiligo. The interesting about ruxolitinib is that in the studies, even though they saw some significant improvement at week 12, 16, 20, 24, et cetera, the good results actually happened after the one year. So I have learned when it comes to this condition is to be extremely patient. Even as you keep patients on for two years or 104 weeks, you can expect a significant higher improvement of their vitiligo, whether you're looking at a 75% improvement by a VASI 75 or 90% improvement by VASI 90. So definitely be patient. We know that there are areas that will repigment a little bit faster, in the arms, the legs, the face of torso, basically the areas that have more follicular activity, and we have more bulges with stem cells that can bring those melanocytes themselves up and repopulate our melanocyte population.

Those areas will repigment faster, a little bit slower on the hands in the feet and the toes. And areas that will probably not repigment are the palms and the wrists and the soles as well. So the bottom line, once again, is to be patient. Getting those melanocytes stem cells to come out of the follicular bulge and travel up the follicle, it takes time. So make sure that you say that to the patients, that they do have a way of repopulating, but it's not going to happen quickly for some people. Future therapies are extremely exciting and there's a lot going on in vitiligo. Of course, there's some things that are going to be coming sooner and other ones that we might be seeing in the future. There's a couple of JAK inhibitors already out there that are doing phase three studies.

The one that I'm really excited about is the IL-15 biologics that will hopefully come into the market. We know that IL-15 is what is responsible for those memory cells in the epidermis. The ones that are remaining at the moment, you stop therapy, whether it's your steroid or you're using OPZELURA, the moment you stop the therapy, the vitiligo starts coming back, and that's because IL-15 is responsible for triggering those memory cells to recruit CD8 cells once again to come back and kill those new melanocytes. So this is probably where I am just kind watching what's going to happen since we do love biologics, that this might be something that is in our armamentarium very soon.

Speaker 1:

Even more to look forward to in the year ahead. That's it for this episode of The Dermalorian Podcast from the Dermatology Education Foundation. Thanks for listening. You can get more information about DEF at dermnppa.org. We look forward to bringing you updates on all the new developments in the year ahead. Happy New Year.