Optimizing Hidradenitis Suppurativa Care
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In this in-depth interview, Dr Alexandra Charrow shares practical insights on optimizing hidradenitis suppurativa (HS) care, from lifestyle modifications and comorbidity management to biologic selection and surgical coordination.
LIFESTYLE MODIFICATIONS
The Dermatologist: Your previous Dermatology Week session highlighted lifestyle modifications as a key component of HS management. Which lifestyle changes have you found to be most effective in reducing disease severity, and how do you approach these conversations with patients?
Dr Charrow: There are many different lifestyle modifications that can be helpful for patients. I try my best to highlight things that are easy to do when I first meet people. Then, as I get to know the patient better, we can discuss more comprehensive lifestyle changes, including smoking cessation and dietary adjustments.
Easier modifications include cutting the elastic off underwear, wearing looser clothing, and thinking about areas with chafing, rubbing, or friction. These are easier adjustments in the undergarment area, especially pants, compared to bras, which often must be tight but can still cause pain and lead to flaring. Shaving, plucking, or waxing should be avoided. This can be a bit more challenging, especially depending on the patient's long-term self-care practices. However, I tell patients trimming the area can be beneficial. Laser hair removal or electrolysis may be more effective than shaving, plucking, or waxing. Initiating the use of antimicrobial shampoos or soaps is another relatively easy and inexpensive lifestyle modification.
Smoking cessation and dietary modifications are more challenging. Smoking cessation is noted to have primary preventive benefits for patients with HS, but when you mention it to patients when you first meet them, many have tried to quit unsuccessfully. When discussing dietary modifications with patients, it becomes a larger conversation about foods that may trigger flares. In general, I avoid overly restrictive dietary recommendations because they can lead to disordered eating, especially in young women. I focus on less common but potentially impactful triggers. There is evidence from acne literature that whey protein can cause flaring, so I try to get patients to avoid it. Simple sugars can also be a trigger, so I often recommend minimizing those.
The evidence for smoking cessation recommendations, and similar sorts of challenging lifestyle changes, supports developing a relationship with patients, building up to the discussion, and determining what their barriers are.
The Dermatologist: Nicotine and hormonal influences play a role in HS progression. How do you counsel patients on smoking cessation and contraception choices to minimize HS flares?
Dr Charrow: Nicotine is extremely addictive, so I usually try to understand the patient’s interest in quitting. Many want to quit; others do not. That becomes a repeated discussion about smoking and HS. I do my best to determine the barriers patients face, such as family influences and stressors. I ask about activities they found helpful in past attempts to quit. Most have tried to quit before. What worked? What did not work? Most states have funded smoking cessation programs. I refer patients to those when appropriate. I try not to overly burden the primary care provider with this, although they often have cardiovascular, pulmonary, or wound healing reasons to help patients with smoking cessation.
Birth control is tricky. This population is primarily women of reproductive age, and for many who do not want to get pregnant, avoiding pregnancy should be our top priority. HS treatment options during pregnancy are limited. I think first about the most effective forms of contraception. Long-acting reversible contraceptives, such as hormonal intrauterine devices (IUD), implants, and injections, are key. But there is a hierarchy based on androgenicity. For example, Depo-Provera has high progesterone and may worsen HS in many patients, so I generally avoid it. Nexplanon also has high-dose progesterone, but it is effective. If someone already has it and likes it, I am not going to push them to switch. If a patient is starting from scratch and says, “My priority is to improve my HS,” then I might suggest a combined oral contraceptive pill with estrogen and a newer progestin, or similar. If their priority is avoiding pregnancy, a low-progesterone IUD is likely most effective and least harmful to HS.
BIOLOGIC THERAPIES AND SURGICAL INTERVENTION
The Dermatologist: Biologic therapies for HS have expanded. How do you determine whether to initiate treatment with a biologic, and what factors influence your decision-making process?
Dr Charrow: We have 3 US Food and Drug Administration-approved biologic treatments: bimekizumab, secukinumab, and adalimumab. And there are 6 more drugs in phase 3 trials. In 5 years, this conversation will look very different but right now, I base the decision on patient-specific factors, such as preferences, comorbidities, age, speed of onset, and durability.
Bimekizumab and secukinumab are IL-17 inhibitors; adalimumab is a tumor necrosis factor (TNF) inhibitor. First, I ask: Is there any reason the patient cannot be on one of these? If they have heart failure or active cancer, we probably avoid TNF inhibitors. If they have multiple sclerosis (MS), we definitely avoid TNFs. In those cases, we lean toward IL-17 inhibitors. If they have Crohn’s disease or ulcerative colitis, we probably avoid IL-17s and lean toward TNFs. Those decisions come first.
Then I assess how fast we need it to work. Some patients have severe, rapidly progressing disease, and they have traveled far to see me. I treat it like the only chance to intervene. If they need rapid control, I will choose a TNF inhibitor. If the disease is more low-level or slowly expanding, I might choose an IL-17 inhibitor, which tends to have longer-lasting efficacy and lower immunosuppressive risks.
The Dermatologist: Many patients with HS experience loss of response to biologic therapy over time. What strategies do you use to optimize biologic treatment, and when do you consider switching therapies?
Dr Charrow: We use therapeutic drug monitoring (TDM) regularly, especially with TNF inhibitors. The 2 TNFs I use most are adalimumab, which is FDA approved, and infliximab, which is not FDA approved for HS. Many HS specialists agree that infliximab is one of the most effective options, even if it is harder to prescribe due to the infusion requirement. It is inconvenient for patients and for private practices, but it works. Both adalimumab and infliximab can lead to loss of response over time; this happens more commonly with adalimumab. TDM helps determine why. We check drug levels and antibodies. If the drug level is low and there are no antibodies, we increase the dose. If the level is high and there is no response, we consider a different mechanism of action. If the level is low and antibodies are present, we switch therapies and consider using a strategy to prevent antibody development with the next drug.
When considering TDM, there are very little data from dermatology. There is great evidence from the Crohn’s disease and ulcerative colitis literature, which is probably the most analogous disease. We just have not had the opportunity to investigate it in HS as thoroughly. However, there are some excellent researchers looking into this. Stella Chen, for instance, recently received an HS Foundation Translational Research Award to study this question. Martina Porter, at Beth Israel Deaconess Medical Center, has spearheaded a lot of this research and worked extensively on this with Dr Chen, presenting new findings at national dermatology conferences. I hope more data will help us better understand how to implement TDM in practice—what is practical and what target drug levels we should aim for. That will be one of the most important outcomes, or we may find there is really no benefit to TDM in HS.
The Dermatologist: Surgical intervention is often necessary for advanced HS. How do you integrate medical and surgical management to achieve the best outcomes for patients with severe disease?
Dr Charrow: There are a few studies that have demonstrated that you should continue patients on their medication when they undergo surgery. There was a JAMA Surgery paper that suggested keeping people on adalimumab. If a patient is being sent to a plastic surgeon, I try very hard to have the surgeon keep them on the medication, and the plastic surgeon is usually in agreement with that. I have excellent plastic surgery colleagues who I am thankful to work with. If I am doing a deroofing, I always keep patients on their biologic. If someone is not on a biologic and they are getting a deroofing procedure with me, I will sometimes have a discussion with them about either starting a biologic beforehand, or alternatively placing them on antibiotics before, during, or after the procedure. It is not so much to prevent infection, which I am not especially worried about, but to promote healing and prevent further inflammation.
COMORBIDITY MANAGEMENT
The Dermatologist: HS has significant overlap with other inflammatory conditions, including inflammatory bowel disease (IBD). How does the presence of comorbidities influence your treatment selection, and what challenges arise when managing patients with both HS and IBD?
Dr Charrow: There are many comorbid conditions in HS, including IBD. A great review in JAAD outlined the evidence-based screening questions we should be asking. Beyond IBD, there is also inflammatory arthritis; somewhere between 2% and 20% of patients with HS have it. There is Crohn’s disease, ulcerative colitis, metabolic syndromes, and more. So, it is important to screen and, if needed, find a treatment that can address both conditions. For example, if a patient has metabolic syndrome and HS, initiating metformin could be helpful. If they have polycystic ovary syndrome, maybe consider spironolactone or a birth control pill. If they have inflammatory arthritis, you want a biologic that works for both arthritis and HS.
All 3 FDA-approved biologics for HS are also approved for various non-rheumatoid arthritis (RA) inflammatory arthritides. If a patient has RA or Crohn’s disease, they really can only get a TNF inhibitor if you want to treat both with one drug. Sometimes, though, the conditions need to be treated separately. For instance, in MS, it is unlikely you will find a treatment that works for both MS and HS. Or for a patient with RA who has already failed a TNF inhibitor, you may not have an FDA-approved option that treats both. In some cases, you are lucky and can get approval through the comorbid condition. Other times, you will need to treat them separately and think about how to safely combine biologics. This is a growing area of interest that we are just beginning to carefully explore.
FUTURE DEVELOPMENTS
The Dermatologist: With ongoing research into novel therapies for HS, what emerging treatments are you most excited about, and how do you see the treatment landscape evolving in the next 5 years?
Dr Charrow: I do not want to put too much weight on any one treatment, but I am very excited about novel mechanisms of action—ones that are not just repurposed from psoriasis medications. I am especially looking forward to small molecules that can achieve deeper tissue penetration. I am excited about broader immunosuppressants, and I am always interested in medications that have a dual focus or hit multiple targets. I think those kinds of agents could really shift the treatment landscape in the next 5 years. I am excited for the research the HS Foundation is supporting to help untangle the pathophysiology of this condition and make way for the most targeted treatments.
