GLP-1s and HS: The Metabolic Connection

Dr. Michael Payette discusses innovative approaches to treating hidradenitis suppurativa (HS), with special focus on how GLP-1s are revolutionizing treatment by targeting inflammation. The conversation explores comprehensive management strategies for this challenging inflammatory skin condition that has historically been difficult to treat effectively.

• Board-certified dermatologist Dr. Michael Payette specializes in hidradenitis suppurativa treatment
• HS is a challenging inflammatory skin condition often misdiagnosed for years
• GLP-1 inhibitors (like Ozempic, Wegovy) reduce inflammation by decreasing metabolically active fat cells that produce inflammatory cytokines
• Treatment approach includes four components: topical antibacterials, oral medications, injectable biologics, and GLP-1 inhibitors
• Insurance coverage for GLP-1s remains challenging but workarounds exist
• Mental health benefits include both direct improvement from disease control and potential anti-inflammatory effects in the brain
• Patient resources include HS Foundation website, online support groups, and specialized clinics
• Multiple new treatments are in clinical trials, offering hope for better options in the near future

If you're dealing with painful, recurring boils or nodules, especially in the armpits, groin, or under breasts, don't be afraid to ask your dermatologist about HS. Visit the HS Foundation website to find specialized providers in your area.

Transcript

Introduction to Dr. Mike Payette

Speaker 1 0:00

Welcome to Dermot Trotter Don't Swear About Skin Care where host Dr Shannon C Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skin care experts to separate fact from fiction and simplify skin care. Let's get started.

Speaker 2 0:18

Welcome to the Dermot Trotter Don't Swear About Skin Care podcast. On today's show we have Dr Mike Payette, a board certified dermatologist practicing in Northern and Central Connecticut. He attained his bachelor's degree in biochemistry from Dartmouth College and a medical degree in his MBA from the University of Connecticut. Dr Payette has numerous peer reviewed publications, has authored a textbook and is a renowned national and international lecturer, has co-created an APP training program, which basically means he's out there helping train both physician assistants and nurse practitioners in dermatology, and he also has a clinic dedicated to HS or Hidrotonitis Separativa. So welcome to the show, mike. It's great to have you here.

Speaker 3 1:00

Thanks, shannon, I'm happy to be here.

Understanding Hidradenitis Suppurativa (HS)

Speaker 2 1:02

So one of the things that I wanted to talk more with Mike about is, you know, we've kind of seen all the rage nowadays about these GLP-1 inhibitors that are kind of just talked about sort of kind of mainstream Now, if you think about it on TV, really obviously targeting diabetes, but a lot of people are going after them, you know, for weight loss, and what people may not realize is we're actually using them in dermatology. And what people may not realize is we're actually using them in dermatology and specifically with hidronitis suppurativa. Hs is one of the reasons I wanted to bring Mike on because he has some experience with this and HS as a whole. So I wanted to talk more with him about that experience and maybe for some of you it might be a great treatment option for you. That needs to be thought a little bit more about.

Speaker 2 1:40

So, mike, first, you know HS as a disease state is something that you know. A lot of people don't even know about. They're walking around with it, haven't been diagnosed yet, and now it's getting a lot of attention in dermatology, which is very exciting. Why did you get interested in treating HS patients?

Speaker 3 1:56

You know it's funny, shannon, that's one of the most interesting questions I get all the time and I think when you're in training it's not one of the diseases that you traditionally would think of going after. A lot of reasons is because it's a very challenging disease. We historically did not have a lot of good therapies for it, but I started getting involved in it because it's really one of the more devastating diseases in dermatology and I consider myself to be an academic dermatologist and as an academic, although I'm in prior practice I think it behooves us to sort of take on these more difficult cases. And then over the past few years we've actually seen some new therapies that are now FDA approved for this condition and that space is growing rapidly. We have a lot of active clinical trials going on right now and we can actually make a difference. And so you know, kind of taking those things into consideration, I started seeing these patients on an elective basis, really Like if they were coming into the office.

Speaker 3 2:47

I said, sure, put them in my clinic, I'll take a look at them. And the stories that I would get from people about how long they had waited for their diagnosis, how many different physicians they had gone to see the impact on their social life, their relationships. Many of these people are unable to work. It really started to kind of touch me at an emotional level and so I started seeing, you know, asking myself really what can I do to help these folks out? And as you start working in that space and doing more trials and instituting therapies, it only takes this one patient to say, geez, doc. Thanks so much for like listening to me, for like really trying to. You know, really thanks so much for listening to me, for really trying to really recreate my belief in the healthcare system, where I've been sort of pushed to the wayside for so many years and I said, well, there's so much we can offer these people. And then you start doing research and you say what else am I missing here?

GLP-1 Inhibitors: Mechanism and Benefits

Speaker 3 3:38

So we've always approached hydradenitis from a concept of really two things. It's not infectious, we know that, but we've historically always treated it with antibiotics and topical sanitizers essentially. But it's really at a fundamental level, it's an inflammatory disease. So when you start pursuing the inflammatory component about it, you really start to understand the intricacies of all the different things that are kind of contributing to this as a really challenging case. So you know, I began combining multiple therapies yes, using some of the older school, you know oral antibiotic therapies and some of the newer FDA approved agents, but then started thinking outside of the box and saying what else can we do to really optimize this disease? And that's where I am really right now. I'm still growing in this space. Obviously, I think, as any physician who practices realizes you're never done learning, and so I kind of challenged myself to continue to get better. But that's kind of how I got into accepting this as a specialty.

Speaker 2 4:42

And you're right I think that you just mentioned. The attention it's getting is kind of exciting and there's new therapies that you know people are looking at and clinical trials ongoing, and one of the things that I mentioned earlier obviously in the broadcast was the GLP-1 inhibitors. Do you mind explaining briefly what exactly that type of drug is, just so people get a better understanding, and where you're seeing a role for this in the treatment of HS?

Speaker 3 5:06

Yeah, it's a great question. So I think you know probably everybody has heard of either one of these agents or you know know somebody who's on one. The common brand names are Ozempic and Regovi. There's also Manjaro and Zepbound. There's some compounded agents as well, which I'm not going to really touch on, but really what these medicines are. They're glucagon-like peptide agonists and they were really sort of pursued initially as a treatment for diabetes, and I think they play a huge role in that space. Many people probably know them more as weight loss agents, and that's not wrong, because these medicines do actually provide a lot of advantages in terms of weight loss, especially when we think about hydradenitis patients. Many of these patients not all of them, of course, but many of them tend to be heavier and overweight, if not obese, and so losing weight can be an important aspect of their treatment. But that's not really why I use them. In fact, when I talk to patients in the clinic, I always say one of the adverse benefits of these medicines is you might lose some significant amount of weights.

Speaker 2 6:07

Wait. Adverse benefit. Mike, come on.

Speaker 3 6:10

That's how I phrase it, because when I'm looking at an inflammatory disease, where I really see these medicines as providing benefit for patients is that they reduce your fat cells that kind of hang out in your central belly area. And these fat cells, we forget, are very responsive to different endocrinological signaling and they produce a lot of cytokines. Cytokines are chemicals that you know, basically are ways for cells to talk to cells, and these cytokines are very inflammatory, right? And so, in essence, the more central fat that one has, the more likely you are to have chemicals or cytokines that are producing inflammation, and so we can use these agents to reduce that inflammation. So that's why I phrase it as, yes, you're going to lose some weight and that's an adverse benefit, but that's not the real reason. The real reason is I can reduce the inflammation that's driving your disease, in this case hydradenitis, and in doing so make your disease more responsive to other therapies.

Speaker 2 7:11

Yeah, it's such a cool concept because I think people think of their fat as kind of, you know, just hanging out, not doing anything, and it's interesting to see the fat can really, you know, play a role. It's kind of metabolically active, like it's not as lazy as people might think. You know, when you kind of think, oh, fat's just hanging out and not really contributing to a disease state, that's really interesting in HS and, you know, in other diseases too, where you can kind of see the activity of it or how it's impacting other cells and how they communicate. And now we can potentially even change that. And I know you kind of called an adverse effect.

Speaker 2 7:41

But I'm thinking a lot of people out there thinking that's a great effect that I might want to take advantage of. And you're right that weight loss reduction can be helpful, you know, in HS, just in and of itself, and the benefit may be there for the patient too. But how exciting to kind of see that happen. So for somebody that wants to, maybe they're intrigued by this option. Are you using it in combination with other therapies? Are you using it by itself, or how do you bring it, I guess, on as a treatment? In essence, who's the right patient that needs that.

Speaker 3 8:11

Yeah, no, it's a great question. I just want to just touch on one thing. The reason I choose it as adverse benefit is I really don't want people to view being overweight in a setting of hydradenitis as something that they did to themselves, and I think if you talk to a lot of patients with HS, they feel belittled by many of their previous physicians, because what typically happens is you need to stop smoking, you need to lose weight.

Speaker 3 8:35

Previous physicians, because you know, what typically happens is you need to stop smoking, you need to lose weight, and that's not really the I mean. Yes, those things are important, but that's why I phrase it that way, because I'm rationalizing these medications for these folks so that they understand why I'm using them. And, yes, it's, you will lose weight, but you know it's more importantly that I'm reducing inflammation. So I just want to clarify that, just briefly. How do I introduce it? That's a million dollar question too right so.

Four-Bucket Treatment Approach

Speaker 3 8:57

I have. You know there's no one size fits all for managing hydradenitis. I look at it as for every patient. I kind of divide it into sort of four buckets. And those four buckets are, you know, using some topical over-the-counter options to reduce the presence of bacteria on the skin. Again, we know that bacteria are not a cause of this disease, but they can exacerbate it. So we often use topicals like chlorhexidine or hipoclens as a wash in the areas that you may be prone to having flares or areas where you're prone to have HS lesions.

Speaker 3 9:31

I think that's bucket number one. Bucket number two is your oral therapies. Those include oral anti-inflammatories and antibiotics. In the setting of women who may be having flares around their menstrual cycle or their period, we use anti-hormonal medicines or birth control. That's sort of bucket number two. Bucket number three is your medicines that are really drived or have been, you know, address inflammation. We have three of those that are approved in the space right now that are all injectable therapies. These medicines are targeting those chemicals that are, once they've already been produced, that are actually causing your HS to be problematic.

Speaker 3 10:08

And then bucket number four is this class of medicines called GLP-1s, and I'm a firm believer in informed consent.

Speaker 3 10:15

When I talk to every patient, I like to present all these options for them and I will leave it.

Speaker 3 10:19

As you know, we can be as aggressive as you want or we can go about this in a stepwise manner and some people will come in and they'll walk out on four therapies. They'll walk out with their chlorhexidine watch. They'll walk out with, you know, an antibiotic like doxycycline or antihormonal like spironolactone. They may walk out with a biologic medicine like either Humira, cosentix or Bimzelex those are the three. And they may walk out with a prescription for Zepbound. And that may seem like a lot for somebody to come into an office and walk out after the first visit, but I'm a believer, if your disease is that problematic for you and you finally found somebody who's willing to treat it, that I'm in your camp and I'm willing to manage these medicines for you. On the other hand, if you prefer to be a little bit more slow in your therapies, that's fine, too right. We can start with any one of those and then we can sort of add on as we see fit.

Speaker 2 11:08

Do you feel like, too, with talking more about the GLP-1 medications when you want to bring those on board? Is it a struggle to get those covered by insurance, especially if you're trying to use HS as a diagnosis, or is it something you've been able to get insurance to pay for?

Insurance Challenges and Practical Solutions

Speaker 3 11:24

Is there anything that's not a struggle with insurance? Good question, yeah, no, that's a great question too, and honestly, I work some Saturday clinics and every time I work a Saturday clinic I'm reminded of why I went into medicine because I don't have to deal with insurance at that time, because really, insurance is very challenging. So, yes, it's very difficult. There are some workarounds. If you think about, essentially, we have two classes of these GLP-1s we have those that are dedicated for diabetes and those that are dedicated for obesity, so they don't have an improved indication for hydradenitis. That's important. If you have somebody who already meets the you know the criteria for being diabetic, then they have an easier path to go on to Ozempic or Manjaro. If they tend to be overweight and don't have that diabetic component, they have to have a BMI of 30 or a BMI of 27 with a risk factor, and that is essentially all you really need to get the approval. But that doesn't mean you're going to get them approved, and I found that last year, in 2024, approval was much easier than it has already been this year, in 2025.

Speaker 3 12:32

And it's a lot of work in terms of appeals and peer-to-peer and going to bat for patients to try to get these medications and in some cases you still can't. Some insurances list them as non-formulary, and if it lists as a non-formulary option, then there's no path through an insurance. Luckily, there are some other workarounds there too. You can get these medicines directly through a company. They're still expensive, but they're less than they might be if you're just paying out of pocket via your regular insurance company or your regular pharmacy. And sometimes you have to get creative, right. Instead of taking it weekly, take it every other week or every three weeks as a way to sort of spread out the cost of the medications. But that's, I think. If you talk to any physician, you know yourself included, right, insurance is tough because they're really the roadblocks in therapies that we want to get for our patients.

Speaker 2 13:24

Yeah, that's the reality with everything that we do and I was just curious kind of from your experience with doing this probably more than the average, you know dermatologist, you know out there that you know is this something that's even feasible? Because a lot of people think, oh, I don't know if I could get that for my patient, but it's promising that you've had some success and I know it can be challenging but it sounds like it's definitely been worth it for those that you've actually gotten it for for your HS patients. If somebody comes in and you're thinking, okay, this is a good fit, I'm either going to add this in, you know, with everything, because we're going gun ho in a regimen, or I'm going to add a GLP-1, maybe later in the game. What type of side effects do you kind of walk them through to kind of just be on the lookout for, and is it pretty well tolerated overall?

Speaker 3 14:05

With regard to anything, or specifically GLP-1s.

Speaker 1 14:09

Yeah.

Speaker 3 14:09

So actually they're actually very well tolerated. There's a couple of contraindications for them. If you have, you know, a history of underlying thyroid disease in the setting of an acronym which is MEN, which is multiple endocrine neoplasia, then you really should be cautious and I think if that were to come up in my space I would probably still route that individual, you know, through an endocrinologist first. But in the absence of that, you know they're really generally very well tolerated. Most people will experience a little fatigue. They may experience a little bit of nausea with the first couple injections. Some women get some menstrual irregularities which you know is important to identify, but beyond that they're really, you know, they're generally very well tolerated.

Speaker 3 14:53

And I think one of the bigger questions is is you know, do you need to be on these medicines forever? And the answer to that is not necessarily. You know, when we use them for weight loss, most patients look at them as a tool to help get them there and then, once they get to their ideal weight, then you know, theoretically they can just with. You know, some dietary changes and you know behavior modifications maintain that without the need for these therapies In inflammatory diseases that might not be true and I think that because we're using them to reduce inflammation, you might always require some degree of them to help you out. That really remains to be seen.

Speaker 3 15:30

I've only been using these therapies now for a little over two years, so I can't really say what you know 10 years of medication will look like, but I sort of surmise that these are going to be, you know, part of the treatment algorithm for patients long term, because unfortunately, like many inflammatory diseases, we just don't have the tools yet to cure them. And I often, you know, joke with my you know, my good dermatology friends and even some of my patients that I've been working with for a long time is that unfortunately, we kind of stink at curing stuff. We don't have either the right medicine yet or the understanding or the knowledge to do that. We can manage things really well, but by the sense of managing it means that we have to continue to do something to keep that benefit. And so I think that in HS, unless we can figure out a way to actually really eradicate this condition, which I don't foresee in the very near future then yes, these medicines are sort of part of the long-term treatment plan.

Speaker 2 16:28

And with using the GLP-1s, what kind of results do you feel like you've seen, like if they had a tremendous impact, like I'm guessing never really used just by themselves per se, but maybe you have used it just alone, or maybe somebody's come in on it and you've done some minimal things to add into it, or if it's a part of a complex regimen, have you really seen that extra improvement or push that you're looking for with using these medications?

Speaker 3 16:51

A hundred percent, in fact, no-transcript. In terms of, just in general, I think these medicines are transformative and I don't want to use the word. It's malpractice not to use them, that would be wrong. But it's definitely under-treating patients if you don't incorporate this type of therapy as part of your platform when managing these patients, because I just think that what you can do with them is so powerful in terms of reducing inflammation and, if you think about it, if you can reduce inflammation, then you can reduce the need for other medical therapies or the same doses of those other medical therapies to control the condition.

Mental Health Benefits and Patient Resources

Speaker 3 17:52

I don't expect everybody to adopt them. I recognize that there's a lot of work in trying to get these medicines approved. There's a lot of don't get me wrong, there's definitely days where I'm frustrated. My patients are frustrated because we've been trying so hard and we just can't physically do it. But I look forward to a time when maybe these will actually be incorporated as part of the, you know, treatment algorithm guideline for managing, you know what has otherwise been a really challenging and, unfortunately, you know, terrible disease for patients.

Speaker 2 18:22

Mm-hmm, just out of curiosity, with our HS patients struggling, a lot of them with the mental health aspect that comes along with the condition depression, anxiety With having GLP-1s now as a part of your sort of treatment toolbox, do you feel like those medications I guess kind of two parts to the question. One do you feel like obviously it helps the mental health because it's improving their disease state, which I can kind of guess what your answer is on that. Or two, do you think GLP-1s in and of themselves have a positive impact on mental health? Just kind of your biochemistry background, just kind of what your thoughts are personally on that.

Speaker 3 18:58

Yeah, I mean. The first part to that question is, I think, obviously, yes, right, you know, when people start feeling better and looking better, you know we're in a space, where we live in a world now where that's of utmost importance it's feeling good and looking good. So I think when you start to see those changes, your mood definitely improves. And we forget that many of these diseases have as a huge comorbidity depression. That's a big part of a lot of inflammatory diseases and HS would be in the top of that list among probably the top five.

Speaker 3 19:27

But you're also 100% correct in that I think there's actually a anti-inflammatory benefit that is actually perceived in the brain at an underlying level. We know, you know, it's been well established that other therapies, like in psoriasis for example, when we start to control those inflammatory states, you know, depression improves and that's not necessarily just because your skin is clearing. It's because there's actually an anti-inflammatory benefit in the brain chemistry. That's above my pay grade to explain the actual mechanism of that, but yes, I 100% believe that by reducing you know inflammation we're going to see mood improvement.

Speaker 2 20:02

I think that's such a cool concept that people forget, I mean, the obvious, like you know, we talked about if their HSS is getting better. Often, yes, you know, depression, anxiety improves along with it. But to truly think you know how this impacts the chemistry of the brain and can really help with those you know that are suffering with mental health issues, especially surrounding their HSS, I just think that's so exciting and fascinating where we're headed, because you know, in the dermatology space for us to manage that that's not often something we would ever do. Primarily, often many of us we might refer back to their primary care or refer them to a psychiatrist or a psychologist to assist us, and it's hard to get patients to go, as you know, right, like there's a stigma with that.

Speaker 2 20:39

It's time, it's money and I hate to say it, but if we could actually be helping them biochemically too with something else that we're doing to help the inflammation with the HS, obviously in the skin, and another benefit could actually be in the brain, I mean, what a great way for us to really address both the quality of life issues with HS as well as just how the disease works. I just think that's fascinating. So very cool to see that and the last like minute or two we have here. I just wanted to give you an opportunity to kind of, you know, think about, you know, for anyone that has HS, what would you really say to a patient with HS, you know, and how would you want to communicate that to them here?

Speaker 3 21:15

Yeah, I think that you know this has been one of the challenges of the disease over the last few decades is that many of these patients, you know, first of all don't know what the disease is that they have. It often gets misdiagnosed, as you know, an inflamed cyst, or you know ingrown hair or boil or abscess, and so they're going to see, you know, their primary physician, they're going to urgent care and nobody's actually connecting the dots. That's number one. Number two the onset of the disease is often in puberty, which is a very challenging time for folks. You know you really don't have HS before puberty. That's a well-known thing, because there's a hormonal component and that's an embarrassing time, like many people don't want to show their armpits or their groin or their butt to their parents because they've got this, you know this spot there that they're kind of embarrassed about. So I think the first big thing I would say to anybody who you know might think they have HS is don't be afraid to ask. You know there's a lot more awareness, not just with us that specialize in the field, but in dermatology at large. You know, we kind of went through the psoriasis evolution, then the atopic evolution and now we're at the forefront of the HS revolution, where we have a lot of dedicated trials. As I mentioned, we have more and more dermatologists that are starting to specialize in this disease space, and so don't be afraid to go to your dermatologist and ask is this something you've seen before or do you know what this is? And even if they don't know right, hopefully they can refer you to somebody who does know. Or if they don't treat it or they are very honest with you and say, look, I don't use a lot of the more advanced therapies, at least they can refer you to somebody who can. So I would encourage people to not be afraid of it. You know to ask questions, because we can certainly help. You can certainly. There are other things you can do.

Speaker 3 22:51

Many patients with HS are part of support groups. There's actually one that we do in New England which is called Hope for HS. It's open to anybody. It's every eight weeks. It's an online platform where both patients and physicians can interact. There's support groups on Facebook, on Instagram, in fact. Ironically, a lot of my referrals come from other patients who I've treated, who are going out and sharing their story with patients that they talk to in their support groups.

Speaker 3 23:20

You can go to the Hydradenitis Foundation. The HS Foundation is a great website that talks about the disease and also lists providers that may be in your geographical area who specialize in your disease, and also lists the therapies that they actually use, which is also nice, too, right. So it's not just somebody who actually works in that space, but it also talks about what medications those people utilize as part of their treatment algorithm. So stay tuned for five years from now, because I think it'll be a much different landscape than it is right now.

Speaker 3 23:50

As I mentioned, we only have three approved therapies right now in the space. Many of us dermatologists, we use off-label things because that's all we have to work with, and I certainly will do that as well if I exhaust all of my labeled therapies. But I think we're going to see a lot of new expansion into this space. I myself am actually involved in clinical trials for HS actively, so I look forward to you know, five years from now, 10 years from now, 15 years from now being able to handle this disease in a much more effective way than even I can right now in 2025.

Speaker 2 24:23

That's such a great, I think, message to leave everyone with that there are new treatments and potentially even better treatments on the horizon and, like you said, you don't need to be ashamed, just ask, you know somebody, you trust your dermatologist, another doctor so you can get in, get the help you need, because HS is definitely, you know, a condition that deserves a lot of attention and these patients are finally getting some of that. I think that's what's so exciting. And then the GLP ones are definitely promising for this, for sure, and I look forward to seeing kind of where that goes into the future. Well, mike, I want to thank you for coming on. This has been great to kind of just do some good highlights here, what's going on, especially with HS and the GLP-1 space. If any of our listeners are trying to find you, do you mind sharing? I know you said your presence online is a little small, but do you mind sharing if they want to track you down or learn more about your practice?

Speaker 3 25:04

Yeah, so I work for Central Connecticut Dermatology, which is in Central Northern Connecticut. We have three offices that I work out of, and one in Cromwell, one in Avon and one in South Windsor. You can find me on the HS Foundation website. Ironically, google you could probably just type my name in and it'll pop up. I'm not very active.

Speaker 2 25:25

All good stuff, Hopefully all good yeah, Actually yeah yeah.

Speaker 3 25:28

Hopefully all good yeah actually some of those photos up there are from a long time ago and you realize how fast you age. But no, I think that just those are sort of the quick and easy options. But derm is a small world and many dermatologists, even on other parts of the country, know dermatologists. I know many derms on the West Coast, in the Central United States, Southern United States, you know, and the same would be true of those. And so, even if you're not 100% sure, you know you can talk to your dermatologist and that there's a decent chance that they, you know, have heard of our clinic or myself and vice versa. So you know, again, it just gets down to. Just don't be afraid to ask.

Speaker 2 26:06

Love. That. It's a great way to end Well. Thank you for joining us and stay tuned for the next episode of Dermot Trotter. Don't Swear About Skin Care.

Speaker 3 26:14

Thanks, Shannon.

Speaker 1 26:19

It's been a real pleasure. Thanks for listening to Dermot Trotter. For more about skin care, visit DermotTrottercom. Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.