Andrew Baker PA-C, MBA

This is a really important topic because so many times when people develop a new problem with their HS, some practitioners or offices are quick to refer them out. A good example is an abscess. One of these cysts turns into an abscess, it’s actively draining. I believe most people are comfortable with doing an incision and drainage. But many times people and clinicians are underutilizing intralesional injections. This is a quick procedure that can provide a lot of relief and less scarring for the patient. Obviously, there are limitations to that. But for some of the bigger areas that are more involved and resistant to I&Ding [incision and drainage] or intralesional injections, doing a deroofing procedure can provide a lot of benefit for patients. This is a way to keep the patient in your practice, have good continuity of care, and treat them effectively without referring them to a general surgeon. There are lots of resources available for that procedure, but that is something that I encourage everyone to get better at doing because it really provides a lot of relief for those patients with HS.

Ask your patients about HS. There is definitely a knowledge gap for practitioners across all specialties. And many times patients are not forthcoming with having this disease. And so when you’re seeing someone who comes in for acne, or you’re seeing someone who comes in and you’re draining an abscess, have the conversation and ask them, “Do you have these anywhere else? How many cysts have you had in your life?” Oftentimes, that opens up a good conversation, and patients will be more forthcoming with having this disease. Also, for the patients who have HS, talk to them about the benefit of early treatment. We’ve discussed this here, but a lot of people feel that biologic treatment is only necessary when they have severe disease or stage III Hurley disease, and that is not the case. Early intervention in this window of opportunity can provide people with an improved quality of life, less surgery, less sequelae from this disease, so that is really important. And also, develop a good multidisciplinary team. People in the medical community—some have very strong personalities. And it may take a little bit of time to find a group of individuals you trust to refer. Whether it’s a psychiatrist or a surgeon or whoever you’re working with for these patients, making sure that you’re on the same page about what it takes to truly treat this disease effectively is so important. And the last is to make sure you’re going to tell your patients that you’re going to follow them closely, you’re going to be seeing them frequently, you’re going to make sure that their medications are working for them. If they develop a hot spot or a draining abscess, make sure that you tell them that you’ll get them in quickly to manage this to prevent them from going to ERs [emergency rooms] and urgent care facilities. And just having polypharmacy, because so many times these patients are being bounced around. So just let them know that you care and that you’ll be there with them throughout this journey.

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An expert in dermatological conditions discusses office-based procedures that can benefit patients with HS and shares clinical pearls for the management of the disorder.

Clinical Pearls for the Management of HS

A multidisciplinary approach is needed for clinical management. Many clinicians are not on the same page about this disease or the treatment, so if you’re working with other specialists, there is a knowledge gap or an educational gap on this disease and how to effectively treat it. And that spills over to the patient, and they’re getting conflicting answers from different clinicians. And it can be very upsetting to the patient, and it can deter them from seeking treatment. So there is a real need for a call to action across all specialties. Also, given the somewhat limited improvements for some of these patients on TNF-⍺ [tumor necrosis factor-⍺] therapy, there is definitely a need for novel systemic treatment as well.

The formation of the inflammatory nodules, abscesses, and sinus tracts and fistulas is characterized by this large influx of key proinflammatory mediators, such as TNF-⍺, IL-1, IL-17, IL-12, and IL-23. And now some of these new therapies are looking to target some of these other inflammatory mediators to try to stop the disease progression. A good example is IL-17.

The upcoming expected approval of secukinumab is definitely on a lot of our minds at this time. This medicine has been used frequently off-label for patients with HS [hidradenitis suppurativa] or patients who have a concomitant HS with psoriasis. And there’s been a lot of benefit to those patients. And the reason we think this medicine is going to work is that it does bind and interferes with the IL-17 cytokine, which has been known to reduce inflammation, and alters the immune response of this cascade.

Andrew Baker PA-C, MBA, reviews unmet needs for the clinical management of moderate-to-severe HS and shares insight on novel and emerging therapies in the pipeline.

Unmet Needs and Emerging Therapies in HS

Early diagnosis and treatment of this [hidradenitis suppurativa (HS)] has been shown to improve patient outcomes. Less recurrence of these lesions also increases overall quality of life. So I think that one thing that we’re all trying to do is find this window of opportunity to treat these patients for optimal results. So that can look very different for many different people. If we’re meeting somebody who has Hurley stage I, we’re just trying to intervene and let them know about the disease and how we’re going to need to follow them very closely. And sometimes you can get by with just using topical treatments, antibiotics, or small procedures to help limit advancement of this disease. But many times, there are other people who come in, and your window of opportunity to treat them is already running out. And at that time, you need to be more aggressive with your treatment regimen and start more with biologic treatment early on in the disease.

TNF-⍺ [tumor necrosis factor-⍺]inhibitors are the only FDA [Food and Drug Administration] treatment available for patients with HS at this time. However, the long-term effectiveness of these medications has been shown to be highly variable. An example of that: Many patients who you’ve started on one of these medications seems to have a really great response initially, but over time, you’ve plateaued in the sense that their lesions keep recurring, they’re having more flares that need to have I&D [incision and drainage], or they need to have other procedures performed. They’re needing to be on more chronic antibiotics than they were when they were on. And it just seems like it’s not the best fit for the long-term treatment of the patient. And for this reason, there are multiple other clinical trials ongoing, and I know that clinicians are very closely watching these for other available future treatments for HS.

A physician assistant expert in dermatological conditions comments on the use of biological therapy to manage moderate-to-severe HS in adults and adolescents and the long-term effectiveness of these agents.

Role of TNF-α Inhibitors in Moderate-to-Severe HS Treatment

Hidradenitis suppurativa, which I’m going to refer to as HS, is an inflammatory disorder that is characterized by chronic deep-seated nodules, abscesses, fistulas, sinus tracts, and scars in the axilla, inguinal region, inframammary folds, and the perianal area. HS can be accompanied by a lot of pain and embarrassment and can significantly decrease the overall quality of someone’s life.

The pathogenesis of HS is multifactorial, with genetic, environmental, and immunological factors included in both the onset and the maintenance of the condition. More specifically, genetics—we believe that up to about 42% of patients with HS do report a family history of the condition. Also, there are environmental factors such as mechanical stress, metabolic syndrome, obesity, diabetes, diet, smoking, the skin microbiome, and hormonal factors all involved, as well as in the development and the maintenance of HS. And it’s because of the effects of HS on the overall well-being of patients that they have pain, self-esteem problems, sleep disturbances, sexual dysfunction, that clinicians should be aware of the possible development of depression and/or suicidal thoughts in these patients. And then lastly, immunological, this cascade does start with the follicular occlusion that happens. This results from hyperkeratosis of the follicular epithelium. This accumulates cellular debris, and the formation of a keratin plug happens at that time. And the second event is in the rupture of the dilated follicle, which then disperses the keratin fibers, bacteria, and other pathogens, and associated damage with the dermis as well. The follicular rupture then triggers an acute and severe immunological response. This definitely is the main driver of the cytokine, chronic inflammation, and sinus tract formation.

There are many comorbidities with HS, but specifically obesity, metabolic syndrome, inflammatory bowel disease, depression, PCOS [polycystic ovarian syndrome], and tobacco dependence are common with most patients who have HS.

Everyone presents differently, but nothing replaces a thorough history and physical to diagnose HS. There is no specific diagnostic test available to us at this time to diagnose HS. So it’s really just getting to know your patients, developing a rapport with them, and doing a thorough physical exam to find certain areas that are consistent with HS. And as far as staging HS, typically speaking, we use what’s called a Hurley staging. And Hurley staging is divided into stage I, stage II, and stage III. So stage I is a single abscess or multiple isolated abscesses without scar or sinus tract formation. Stage II is recurrent abscesses with either single or multiple scars and/or sinus tract, with widely separated lesions. And then stage III is multiple lesions with extensive scarring and sinus tract formation involving an entire region that is all interconnected.

Why is early treatment important? It is imperative because once these patients have had sinus tract formation, scarring, or surgical intervention, it is so hard to get them to a better baseline. So it’s really important to begin earlier rather than later so it can increase their overall quality of life prior to having some of those irreversible procedures and scarring with sinus tracts.

Andrew Baker PA-C, MBA, provides an overview of hidradenitis suppurativa (HS), including the pathogenesis, comorbidities, and diagnosis of this inflammatory disorder.

Andrew Baker PA-C, MBA

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