Hidradenitis Suppurativa: Emerging Targets and What the Pipeline Means for Your Patients

In this session from Masterclasses in Dermatology Saturday Morning Live, Dr. Joseph F. Merola sits down with Dr. Alice B. Gottlieb -- dermatologist, rheumatologist, and one of the field's foremost experts in HS -- for a focused clinical conversation on where hidradenitis suppurativa treatment is headed.

Dr. Gottlieb walks through the current unmet needs in HS care, from better systemic control and earlier intervention to access, stigma, and multidisciplinary coordination. From there, the conversation shifts to the emerging pipeline: nanobodies targeting IL-17A/F and TNF/OX40L, BTK inhibitor remibrutinib, JAK inhibitors povorcitinib and upadacitinib, dual IL-1 alpha/beta blockade with lutikizumab, and newer IL-1 beta-targeted agents with Phase 2 data reported just days before this recording.

The discussion also covers combination therapy, the HS/Crohn's diagnostic overlap, procedural and surgical considerations, and the case for patient advocacy and reimbursement reform.

This episode is built for dermatologists, NPs, PAs, and any HCP managing HS patients who wants a working knowledge of the treatment landscape right now -- not a theoretical overview.

This podcast recording is for educational purposes only and does not offer CME credit. Want CME credit? Attend the next Saturday Morning Live session  — free to register at mcdsml.com.

Thank you for listening.

Transcript

SPEAKER_00 0:16

Good morning. You're listening to Master Classes in Dermatology Saturday morning live. I'm Joe Morola.

SPEAKER_01 0:22

And I'm Alice Gottlieb. Great to have you with us.

SPEAKER_00 0:26

This is your weekend clinical reset. We're fast, we're focused, we're built for real life, real clinic life.

SPEAKER_01 0:34

And we'll keep it efficient, practical, and a great way to start your morning.

SPEAKER_00 0:39

Each of these sessions is designed to give you something that you can take straight into practice.

SPEAKER_01 0:44

And we also want to thank our platinum supporters, Eli Lilly and Company, and Regeneron Pharmaceuticals Incorporated, for making this program possible.

SPEAKER_00 0:54

So wherever you're joining from, we're glad you're here.

SPEAKER_01 0:58

Welcome to Master Classes in Dermatology Saturday morning live.

SPEAKER_00 1:27

My co-director in uh this wonderful program, Saturday Morning Live, who instead of being in the uh interviewer seat, uh, is sitting in the hot seat. Uh Dr. Alice Gottlieb, friend and colleague who is also a dermatologist and rheumatologist at UT Southwestern Medical Center. What are the chances, Alice?

SPEAKER_01 1:48

I'm privileged to have the best boss in the world.

SPEAKER_00 1:50

I appreciate that. Well, I we we um uh I I I know you all are in for a real treat um with this session because Alice is uh, as you all know, a guru of um of HS as well as psoriatic disease in many other areas. Uh and we're really taking a deep dive this morning into HS. And so, Alice, because there's so much to cover, I'm gonna jump right in. Uh, and you know, these are a couple of really big questions. So we'll we'll try that we'll try to dialogue as much as possible, but I think we want to learn from you as well. The first big question I have for you is, and this is a big one, but what are our unmet needs currently in HS treatments? There's a lot of new stuff flying at us, there's a lot of older therapies. Where where are we? What's the unmet need, and what's what's sort of flying our way?

SPEAKER_01 2:38

So I'll take a helicopter view and then we can go into more detail. First of all, we need more effective treatments that are also safe because we seem to have hit a sort of a plateau. I do think we need to manage the comorbidities better. The comorbidities are at least as bad as that for psoriatic disease. I think here we have unmet needs in education, since dermatologists are not the only people that HS patients interface with. It's primary care HCPs, and by that I mean doctors, PAs, NPs, um, ER. They often show up in the emergency room. Uh dermatologists need better education, OBGYN and our plastic surgeons, because it's not always dermatologists who are doing the surgical repairs. We need to educate patients better. Many patients really don't know about their disease, and some of them are treated poorly. I mean, they're made to feel dirty, they're made to they're made to feel ashamed that they smoke or that they have more weight on than maybe you would want to have. So they they patients need to be educated that they are still beautiful, that they are still important human beings, and there's hope. Finally, not finally, penultimately, probably, we need earlier uh treatments to prevent scarring, etc. But also there's evidence many times over that the longer you have the disease, let's say 10 years being the cutoff, the worse the outcomes is when you finally do start to treat it. Early treatment is better. And I I feel very strongly about this and at this age where I think advocacy is needed. Many of my patients don't have access to these wonderful treatments, they don't have access to the weight loss drugs, uh, and many of them don't have the kind of insurances that give them access to good treatments, and for that matter, even perfect doctors. So access is a huge issue. And that's my summary of the unwind.

SPEAKER_00 4:34

That's right now. No, and yeah, I it's a it's a wonderful summary, and I think it just underscores how much we still have to go in uh in the HS arena. So I think we're gonna start to unpack that one by one because I have questions for you about comorbidities, I have questions about you know therapeutics. Uh maybe we'll start with the you know the positive hot topics, which is not to turn it on its head because we could talk about current treatment, you know, current therapy and algorithms, but you know, let's be forward-looking and let's be positive. Um, what's emerging in this space? What do we have right now that are sort of new classes and what's emerging that you're excited about? Because everyone wants to hear where you know where we're gonna bridge the gap in the coming years.

SPEAKER_01 5:16

So the first one I want to talk about are the nanobodies. Nanobodies are partial antibodies that are smaller in molecular weight and I guess theoretically thought to penetrate into deep lesions better. Uh, and we have two uh that I'm gonna highlight today. One of them is sonolocomab, which is an IL17 A and F nanobody. And the results are are looking very nice. They've raised the bar, and there's one study where they show that a high score of 75, not just 50, that there's a 17.5% placebo, and 34% reach the uh high score of uh 75 at week 16. Now we have another nanobody, but it's a totally different and new target. It's one that targets both TNF and OX40 ligand. And so um it's also low molecular weight, and uh it by doing so uh it's felt to target not only T cells but antigen-presenting cells and also B cells. That's one of the surprises. I mean, whoever thought of B cells five years ago? And only smart people did. I mean, and here they have a phase two study that shows that uh their high score 75 at week 16 was 54% getting the drug and 22% with the placebo. However, I do think that we have to wait and see what's going on further because uh you did see cantidiasis, uh, you did see increased liver tests, function tests, and genetic variants in the Oxfordy ligands pathway and Oxfordy ligand system have been reported to get Capuche sarcoma. And so I do think that we have to watch this out. And I believe that one of the problems with the atopic dermatitis study that also uh target this pathway is there were some cappuccine sarcoma. So we do have to look at the safety in bigger studies in phase two, but it's still very exciting because these numbers are very nice. Speaking of B cells, there's Remy brutinib, which is a pill. Um, and it's already approved for a chronic urticaria. We're gonna get urticaria back to dermatology, and uh, but now we're focused on HS, and who knew? Uh this was they're looking at a phase two study, high score of uh 50 at week 16, and uh let's take the 7 the 25 milligram dose. Uh 75% of patients achieved that high score of 50 with a placebo of 34.7. There was some increased bruising, but that was an expected side effect due to the mechanism of the drug. Not worried, but you already have uh the same drug is already on the market. So I think that's exciting. Uh, we also have two JAC inhibitors who are old friends, but uh who uh were being applied to HS. One of them is porvocidinib and the other one is UPA decidonib, and both uh porvocidinib has phase three studies uh looking at high score 50 at week 12, and uh roughly around 40% of patients achieve that high score 50 at week 12 versus 30 percent in the placebo. For UPA decidinib, the numbers look kind of similar, but they don't they haven't had a historical placebo. So I'm just gonna shut the historical placebo was 25%, and those who got the real drug, it was around 40%, 38% achieved that. Finally, we have a whole new class of um targets that people weren't thinking about except the very smart ones. One of them is luticizumab, which is an uh dual IL uh one alpha and IL1 beta monoclonal antibody. And most recently, like a week ago, we had a report of Abdacobart. I'm not sure I'm pronouncing it properly, but phase two study, it's a pure anti-IL-1 beta. And I'll first uh I'll take Abdacabart first. Phase two study, it's a press release, but they have a full kind of PowerPoint presentation. So the high score of 75 at week 16 was 42.9% versus a real uh placebo of 25%. Side effects so far looked pretty good. There were some injection site reactions, but it was equal across even the placebo group. Now, as as for the finale for this part of the talk, it's ludicizumab, which is a dual IL1 alpha and beta monoclonal antibody. This was only a single uh uh ARM study, so the high score of 50 at week 16 was 66%. They did observe neutropenia, elevated liver function tests, and a perianal abscess, um, which they list as adverse events. Um, so we have to see more uh with a placebo. But I think that's pretty exciting. We have some new targets that have never been tried before, new cell types that nobody was thinking of. And it are and there's more stuff coming, I'm sure. And uh I think if you have to have HS, it's good to have it now and not 10 years ago.

SPEAKER_00 10:28

Yeah, and Alice, I mean, I it's really I mean it's very encouraging. I um I agree with you. The B cell story, I would not wouldn't have I wouldn't have thought that. Uh so that's interesting to see. Um let me ask you just to push that before we change topic, um, what do you think also the future is regarding uh and I I think you're a fan, so I think I'm I'm speaking to a friendly audience. Uh, what do you think of combination therapy in the future? Because I have to say, you know, we hit these ceilings, these therapeutic ceilings. You and I know from psoriatic arthritis, we've been looking at combination approaches because we hit a ceiling and we're sort of hopeful there. What about combinations here? Does this open a path for combo therapy?

SPEAKER_01 11:09

Yes. Uh some of us are trying it already, but you can imagine it's very difficult, especially in a population enriched for Medicaid patients, to ask for two biologics, for instance, to be used. Or for that matter, even a JAC inhibitor plus a biologic, because JAC inhibitors cost about the same as biologics. So it's a very expensive form, and most of you get used to a lot of rejection, let's be honest. I mean, even with the commercially insured, you're but yes, I think there is a future for it. I I believe that uh there's an ongoing literature review of of actually led by Dr. Morola about combination treatments used in uh HS. And yes, people are trying to mix TNF blockers with ILC17 blockers, uh TNF blockers with um with JAC inhibitors. And of course, we've always tried to use other combination treatments like with uh uh refampin, you know, some of the older drugs, but I think what what you're really referring to are two new drugs put together.

SPEAKER_00 12:12

That's right. That's right.

SPEAKER_01 12:14

We need to those studies need to be done and supported because if we just wait for large case series in in real-world practice, I think the insurance companies are gonna have a problem with it. So the if you re if companies really want that done, they have to do it.

SPEAKER_00 12:29

And and you cover a lot of the sort of what's coming in in the in the in the immediate uh you know um uh current therapies arena. Uh how what's your experience been like with the IL-17 uh advancement? Because I know for many years we've had TNF inhibitors, of course, and many of us leaned into infliximab in particular, but what's the early experience been like with IL-17 inhibitors? Because I'm sure a lot of folks are either using them or thinking about using them in their um in their patient population presently.

SPEAKER_01 13:01

We have two IL-17 inhibitors that are actually approved for HS, Secukinumab, which blocks IL-17A, and BIMAKISIMAB, which blocks both A and F. Obviously, there has not been a comparator study between the two, so I'm not going to, you know, publicly state because it's only my opinion. Anyway, but both of them are are exciting. Uh and they not all uh Secukinumab came first. BiMAKISMab has done more different kinds of studies because like they've looked at uh and or even originally at draining tunnels and other things and just the high score and some of the standard regulatory scores. Um also uh with uh BiMAKISIMab, I know for a fact because I'm part of that study, it does matter to get a high score 75 versus a high score 90 versus only a high score 50 because the patient reported outcomes are better. And we should remember that uh as part of the work that the International Dermatology Outcome Measures Group did, the number one domain that patients and everyone else voted for was pain. This is similar to atopic dermatitis in that you don't have if you have a drug with atopic dermatitis that doesn't control it, you don't have a drug. If you have a drug in HS that doesn't control pain, you don't have a drug either. And I think it's very important to count the patient in. It's the number one domain.

SPEAKER_00 14:27

So Alice, I there's a long laundry list there. Um uh any thoughts about uh topicals? I know there's at least one study looking at topicals for mild disease. Is that is that in the in our future?

SPEAKER_01 14:40

It's actually in our present because uh, and we're doing it actually uh at UT Southwestern. It's with ruxolidinip topically uh for uh HS, but for mild HS, and the hope is that it'll be good enough to at least in mild HS give significant relief.

SPEAKER_00 15:00

Excellent. Thank you. So with that, you know, you sort of opened with some of the unmet needs. We're talking about therapeutic, you know, bridges to some of those unmet needs, but um I don't think anyone could talk about HS similarly these days to the psoriasis story without mentioning comorbidities. Comorbidities are you know a crucial part of the burden of disease on patients. Do you want to recap for us what some of the common comorbidities are? And you know, I maybe in the same breath, which ones you either directly address or you think about you know, comanagement of uh in the current era.

SPEAKER_01 15:38

I I believe that HS has worse comorbidities than psoriasis. Um and and uh and to give you an example, even the CRP levels, they're much higher. They're even higher than root psoriatic arthritis. I mean, they're approaching 20. The CRPs are like 17, 14 in a clinical study. This is a very high inflammatory burden disease. So obviously, you think about cardiovascular comorbidities, that includes all of the atherosclerotic disasters, whether it's a myocardial infarction, stroke, um, and also metabolic syndrome and all the components of metabolic syndrome, uh, obesity is clearly a problem. But I do want to point something out. Everybody assumes that an HS patient is heavy. That just isn't necessarily true. Some of my worst HS patients were skinny, and also some of the, I have no data to show for it, but I was thinking about it at Grand Rounds today at UT Southwestern. My ones with god-awful screaming cell carcinomas, they were mostly skinny men. And and it they get it.

SPEAKER_00 16:46

And so when doctors it's interesting, Alice, too. I've heard that from a few people that the skinny male patients can be some of the most refractory and have a lot of the the worst comorbidity. So it's an interesting observation.

SPEAKER_01 16:59

And so when, and of course, smoking, I don't know whether you count that as a comorbidity, but when doctors refuse to treat patients with serious treatments and tell them you have to lose weight and stop smoking first, is I think cruel punishment. And I'm very much against that. We need to manage it, but it is not up to us to withhold treatment because people are not the ideal shape that they're supposed to be in. All right, so cardiovascular metabolic syndrome, obesity, diabetes, not a surprise, it's obviously a component of metabolic syndrome. For women, PCOS, polycystic ovary disease, and um arthritis, and uh we we know that Crohn's disease, I know that's not arthritis, Crohn's disease is associated with HS, but seronegative spondylloarthropathy is associated with both of those. And if you look for it, you will find it. And in fact, uh we have an instrument that can be used in HS and that we've used already, that the idiom MSKQ questionnaire that is picking up musculoskeletal complaints, including seronegative spondylarthropathy, that nobody is asking in HS about. So I'll add arthritis to that. Of course, you can you can imagine with such a miserable disease that anxiety and depression is part of it. And of course, I just mentioned it before, malignancy. You really need you need to really look in all those cracks and crevices in areas you might not want to look at all the time, but you must look at it because it can be harboring very serious squamous cell carcinomas.

SPEAKER_00 18:40

Excellent. So I think it's safe to say the comorbidity burden is extremely high uh in the in this population. Uh you know, I don't know if we'll have time to cover all of these, but I have two questions in follow-up to you. So that that's a long list. And before we turn people off to the treatment of the comorbidities, maybe a high-level view of which ones you feel the Durham can own, screen for, which ones we co-manage. And the second piece, because I would be remiss if I didn't bring it up in 2026, you mentioned diabetes, obesity, uh, you know, you know where I'm going. You know, talk about impact of maybe GLP1 and and its and its uh and its um you know counterparts, uh GLP1, GIP, and other uh drugs in the current era in your thoughts for HS?

SPEAKER_01 19:30

So I I believe that what we can do that will have a big impact, even if we don't manage it directly ourselves, is to make sure that patients uh have a primary care doctor, that they s and yet they see their primary care doctor, and maybe even get a copy of the labs at minimum. At least do that, okay? That does not increase the workload terribly. Now, obviously, both you and I are internists and rheumatologists. We are not the average uh dermatologist, so we're comfortable giving statins. I'm comfortable giving you the monoclonal antibodies that lower LDL. But at the same point, the most important thing is make sure that these patients get good primary care. That includes management of metabolic syndrome, decreasing cardiovascular risks, um uh and and so that's that. And then getting to the weight loss drugs, I get almost um angry about the situation. Um of course they should have uh uh these weight loss drugs. It should be available freely, but it's not affordable and they they're just too expensive. And for these patients where a very high percentage of them are on Medicaid and and some on Medicare, uh, they're not gonna get it. They're simply not gonna get it. They're not gonna get uh and um I I when I was at Mount Sinai, I pushed the system to let dermatologists write for these drugs, but you you just bang your head against the wall because unless somebody has frank diabetes, many patients are just not getting it. And no matter what kind of discounts available, now they can't afford it. So I feel very strongly that this we must do it on the same point. We it's like being a diabetic in a candy shop. You just know that you can't partake of it because it's just not at this point, and it's not cheap enough. And I think there needs to be political advocacy to make this available and more affordable for the people who need it the most, actually.

SPEAKER_00 21:41

That's great. It is a good reminder for folks that there are on label indications for diabetes, for sleep apnea. In some cases, it's covered, and not all cases, and much less commonly, even with commercial, you know, for obesity. But of course, then there's yeah, there's other access issues. So, but yeah, I regard I look. Clearly going to change the face of many of the diseases that we treat uh over time. We've seen great data from psoriasis, psoriatic arthritis. I think we're still waiting in the HS arena. So you know it's it's sure to reach our um our our our armamentarium, as it were, one way or the other. Um so I think Alice, the next thing we have, you talked a little bit at the beginning about this, so maybe we can touch on it briefly. But the idea of treating early, you know, you used you talked about it as one of your unmet needs at the very beginning. We've seen now from studies in, again, because we know the psoriatic literature so well, guide study and others which have shown in psoriasis, treating early makes a big difference, makes a big difference in terms of uh you know uh um response to treatment, depth of treatment, uh, ability to take a break from treatment potentially, and maybe even disease modification in some arenas. What about HS? What do you what you know what what's the status there? When is it too late? What what what's early enough to treat?

SPEAKER_01 23:03

Well, so uh uh it's very important to treat early. I as I said, there are published papers that when they look at factors which um help treatment or or the opposite inhibit treatment effects, the one that comes out is if people have a disease duration of 10 years or more, that that's associated with a poorer response to treatment. Um it's also true that once you start seeing tunnels, the tunnels themselves are harder to treat than other areas of HS. So for both of those reasons, one should start treatment early. Um, one should treat her early one stages one and two. If obviously, you know, I might I as I said, I might be dead by the time a clinical trial would show that that has an effect on scarring. So what we really as dermatologists should learn how to use ultrasound to detect early tunnels, to at least detect inflammation. Um there are other reasons why one wants to use ultrasound, but I really think that if you're really interested in HS and the companies who are interested in HS should fund education programs. We have handheld units that could be like dermatoscopes only for inflammatory skin diseases. And so I I think that could help to make a study like that possible. I also think we need to intervene with surgery early. We uh first of all, first of all first of all, try to find a surgeon who wants to do it. Okay, is one, it's not so easy to find, whether it be a dermatologist or a plastic surgeon. And when you do find one, you don't want to just reserve that surgeon to repair the disasters at the at the end stages of HS where they can't move their arms up and down because they've got contractures, where they can't urinate properly because the HS has affected the urethra. I mean, all these kinds of horrible situations. I think in the beginning, when you have limited disease, like in one axilla, let the surgeon do their thing. I mean, so so maybe if they not everybody with limited disease goes on to extensive disease, you might actually nip the disease in the butt. There's even um and even hair removal lasers, something as simple as that may be helpful, which by the way is not covered by insurance. Yeah. That's an inequity issue there. But I think all of these things intervene with surgery earlier, use ultrasound to be able to detect early stuff, don't wait, you know. 10 years sounds like a lot, but if they start getting it as teenagers, by the time in their 20s, they've had it for 10 years.

SPEAKER_00 25:36

Yep. And Alice, I'm gonna ask you to maybe just pause and come back to the procedures because I at least one of the models that has worked well here at UT Southwestern, and you know, Alice sees these patients at Dr. Um O'Brien here, Jack O'Brien is, you know, has a whole program, and we have, you know, uh PA uh colleagues who are really uh one of which in particular is focused on seeing these patients both procedurally, medically, uh for trials. Not every place has these programs, but uh and the ability to set this up. But um can you comment on two layers here? Because one thing that we've seen work is to have the dermatologist potentially own some of the smaller procedures and then you know a little bit buffer the plastic surgeon and and help foster that relationship to say we're gonna send you the stuff where we really need you, we're gonna own the stuff that's a bit smaller or more manageable by the dermatologist, whether it's on roofing, whether it's some of these other smaller procedures that are billable, uh, that are reimbursable to some degree. Uh, you know, and and maybe just to comment on that, and uh, you know, we've been fortunate to have a pl great couple of handful of plastic surgeons at each of our respective institutions that own these. Any tips for folks in finding their go-to plastic surgeon that might own these, that might do some of the wound vac and other, you know, uh pieces of this?

SPEAKER_01 27:01

Um let me get to the easier one first. It gets under education. I think dermatologists don't get much education in surgical procedures for HS. I didn't. I mean, and so and I think if you're lucky enough to be a resident at UT Southwestern for many reasons, um one of them is access to Dr. O'Brien, they'll learn how to do this. So, yes, if if uh dermatologists uh who like doing many dermatologists like doing procedures, would be educated in it so they could do it efficiently. Um I I think that's part of my one of the in education initiatives I'm thinking of. So that should be there. I think some pressure should be put on the American Board of Dermatology to include that so that uh if it's on the test, people will study for it anyway. Uh so I think that's one maneuver. I think it's even when I was with them, I was at Sinai in New York City for, and I give you an example, for Medicaid patients, I could find only two surgeons willing to do it. And so, and the reason why whether they are most surgeons, whether they are plastic surgeons, they don't like doing it because it's it it's a lot of work at that stage and that it does not get compensated by the insurers particularly well, those bigger procedures. So I think the problem is that there's a paucity of people willing wanting to do these procedures. I don't quite know how you make that I mean that would be something maybe that at the level of the AAD RUB committee you could bring that up and actually change the, you know, a measure what it really takes to do these procedures and then and then work on getting on getting uh uh uh Medicare and and and other insurances to compensate it for what it's really worth because it is a lot of work, some of these procedures. I think so part of the reason education, part of it has to be I think uh political in the sense of getting it better reimbursed so people will do it. I think that it foundations should make available on the website a list of plastic surgeons and uh dermatologists who do surgical procedures so that patients can find them.

SPEAKER_00 29:22

And yeah, I maybe I'll just put in a plug here, too, and and uh and a shout-out. We have our one of our um amazing plastic surgeons uh from my old uh my my old haunts, uh Dr. Dennis uh Orgel, who's uh at Brigham and Women's Hospital. I mean, he's you know a leader in this. I mean, he sees these patients, sees some of the most complex, does a beautiful job, and he comes and speaks and tells us about the plastic surgery view at our annual master classes and dermatology meeting every year. Uh and he's really a model for this. There are many other around the country. I don't want to uh sell anyone short. Um but but uh what a wonderful educator and uh and and you know what a great service. So uh just wanted to wanted to make miracles. Really?

SPEAKER_01 30:07

Come to master classes, the annual meeting. It's every time it's he just you you see a miracle worker, and he's very modest about his abilities. And I wish we had more of these.

SPEAKER_00 30:20

So Alice, I uh you know, I think um we'll talk maybe since we're on education, just to just to kind of um close that loop. We talked a little bit about you know educating plastic surgeons, educating dermatologists and procedures and around some of the newer therapeutics, combo therapy, et cetera. But a lot of these patients who also started with the unmet need gap, that a lot of these patients are sh are not showing up to us first, unfortunately unfortunately, right? They there's this long delay in diagnosis. I don't know if I've seen a great quote that I believe in the delay of diagnosis. I think it's far longer than any of us, than even as quoted in the literature, especially for some of those earlier and milder cases. But tell us about, you know, how do we get in to educate and what do we who else needs education around this? Where else are these patients likely showing up and how do we educate?

SPEAKER_01 31:10

I think uh primary care is certainly an area uh area, uh emergency room, because these people come in and they all get their quote, they get their boils lanced, and that's all that's looked for. And then they might go home with some antibiotics, might not be the right one, but they go they go home for some with antibiotics. The other place is OBGYN, because the women will often it's their private area, they'll go to their OBGYN before their uh primary care. So I I if I had to focus on, and and if you want early diagnosis, it's not really the dermatologist. You really have to get to primary care, ER, urgent care ER, and OBGYN. Those would be the areas. And I remember when um AdaLumimab first came out, because it was the first to biologic. I remember telling the company that made it, I said, you you know, you have an average of seven years or more of diagnosis till the label is put on. You need to educate the people who see them. And um I think there's still room for improvement there. I'll leave it at that.

SPEAKER_00 32:16

So we're getting we're getting a little bit closer to the end uh uh we have a couple of other topics, but I I have one uh topic that I think comes up not terribly infrequently, and I maybe just ask if you have any clinical wisdom and clinical pearls, which is um there's a lot of overlapping features with IBD, with Crohn's in particular. And sometimes we see these patients with perire, you know, anal, perirectal lesions, uh, you know, or uh vulvo vaginal lesions. And the question is always wait, is this cutaneous Crohn's or is this HS? Any tips or tricks for folks who are sort of struggling with that in terms of diagnostic differences or or or pearls and making you think one way or the other?

SPEAKER_01 32:58

I'm not sure I have pearls except the obvious. And the obvious is it's here you have to biopsy. Don't it clean the you have to biopsy to try to uh may have to biopsy more than once if you're concerned that they have musculoskeletal complaints, as you've reported before in nice case reports, you know, get yourself an MRI of the sacroiliac joints if you're if they're if it's arthritic. You have to work with the gastroenterologist. I mean, um there's no way you can do it by yourself. Um I've had you know lesions, you know, kind of up in the shoulder and you know, weird places. I mean, and so um, so I think it's you know, work with the gastroenterologist. You may have to do GI imaging. If you're worried about a tract that's going to the surface, you're gonna have to get some GI imaging, and that's right, and uh and biopsies, and if they if they have low back pain, you have to ask about it. They're not gonna volunteer. Everything hurts down there. So they're gonna they're they're going to not volunteer that you have to kind of get it out of them and get and get then the rheumatologic imaging. But that that is not managed by dermalone.

SPEAKER_00 34:05

That's great. No, and uh, you know, we again that not an intentional plug, but you just jogged for me. We always have a gastroenterologist IBD expert as well come to master classes, uh, typically Dr. Ryan Stidam, who's an IBD guru, and he has shared with us some of the imaging protocols, right? The looking for a fistulogram, an MR, you know, MR fistulogram, you know, with contrast and such to try to distinguish Crohn's from you know from uh HS and such. And sometimes it's there, sometimes it's both, right? And there's overlap uh as well. But that's uh um uh excellent um uh insights. And I guess you know what we'll probably wrap up with is um the last topic is uh is you know a little bit about advocacy. I know Alice, you're very passionate about this. Um Alice has been a you know a staunch advocate for patients on with many of these diseases for decades, uh, for psoriasis, for psoriatic arthritis, and for HS. Um, we have uh a number of organizations in this space. You know, I know uh NPF in particular is a really a flagship banner organization for patient advocacy in the psoriasis arena, um, similar organizations in HS. Do you want to comment a little bit, maybe, Alice, about where you see some of the unmet need and where folks can advocate on multiple levels for their patients with uh with HS?

SPEAKER_01 35:28

Well, first of all, I'll I'll uh I mentioned Idium already the first time. And in uh Idium is the International Dermatology Outcome Measures Group. We have three of our board members are HS patients, and I and and so and we develop outcome measures that are useful in clinical practice, not just research. And you need to have good outcome measures because if you can't quantitate it, you can't really um say whether it's got significantly better. And uh and and so patients have a large impact there. The FDA comes to it, including healthcare providers, uh scientists from industry and uh and uh and nonprofits. So there's an area where the patient voice is heard, and I think that's important, and the patients uh are very grateful for that. And they've even said it's the only place where a patient voice is heard. There are other places that that uh uh there's uh uh HS Foundation and I'm sure there are internationally other groups. I do think it would be important um and I'm hoping I'm an incoming uh vice president elect. If I if anybody if if if I can volunteer it, I would like to volunteer that somehow maybe we can talk about bringing this up with the RUC committee to try to get reimbursement for surgical for procedure procedures for HS to increase because they are time consuming, especially when it's god-awful HS. It's it can be hours. And they they get they they get very little for that. And so if that if doctors got better reimbursed for it, maybe more doctors would do it.

SPEAKER_00 37:11

That's excellent. Thank you, thank you. No, it's wonderful. I mean, look, we we're trying to you know hit the disease on all fronts, and uh it's really important. We would be doing a disservice if we didn't talk about the advocacy piece as well. Um so maybe, you know, we've covered a lot. I mean, I'll just summarize and then I I'll you know um ask you if you have any closing remarks on the disease state as we look forward. But yeah, what I heard was a lot of hopeful uh commentary, right? So we talked a little bit about where the unmet needs are to start with, and that you know, many of those are addressable, some more than others, but at least from a depth of response standpoint, it's incredibly encouraging that we have drugs right now that are changing the face of HS, uh, that we have a whole pipeline of emerging therapeutics with very promising data that you shared with us that are coming, which is again incredibly encouraging. And then we talked a little bit outside the box about things like combination therapy and such, which is tremendous. Um, you covered the importance of medical and surgical and procedural uh interventions. You talked about early uh see, I've been listening. Uh, you've had your impact. Uh you talked about early intervention uh mattering, um, you know, and then multidisciplinary care with regard to comorbidities, among other things. So we covered a whole lot uh in a relatively short amount of time. So, and then even advocacy and where you know where we need to go there. So maybe for the last word, um, anything else we either didn't cover or you want to re-emphasize, uh, you know, moving 2026 even into 2027 uh for the care of our HS patients, and then we'll then we'll wrap up this uh this SML uh uh morning topic on HS.

SPEAKER_01 38:54

I think this is not novel, but I think it's always effective. Take the time to listen to your patients. They need to be listened to. They have a chronic illness that is that really impacts their life. So take the time to listen to them. Please uh don't make them feel dirty, don't make them feel that they have bad personal habits, and that's why they're in the position they're in. It sounds very elementary, but I can't tell you how many patients have been treated that way. I mean, sometimes they think they have that they've been told they have a venereal disease because the doctor thinks it's a venereal disease. And so there's I I think it's important. Give your patients hope and respect and listen to them. It's worth the time.

SPEAKER_00 39:38

That's perfect wrap-up. So with that, thank you, Alice. Uh we uh it's always a pleasure uh uh having you on Saturday morning live. Uh this time as a guest, even better. Uh uh so um and for everyone listening, stay right where you are. We have a fantastic lineup ahead this morning with conversations and insights that you will not want to miss. Uh Dr. Gottlieb and I are back together at 10 a.m. Eastern for our live QA session. Uh so be sure to stick around for that as well, and we'll see you soon.

SPEAKER_01 40:08

Thank you.