Gina Mangin, MPAS, PA-C

 The clinical pearl that I’d love to share with my colleagues about treating patients with HS [hidradenitis suppurativa]—and I’ll be honest with you, I’m borrowing this from a colleague who shared this at the podium at a recent conference—is listen to your patients. Take the time to sit down in the exam room and just listen to your patient. These patients have been experiencing this disease on average for 7 to 10 years without having any relief of their symptoms. There are times our patients just need to vent, and they need a listening ear. If you can offer that listening ear to your patient, you’re going to build trust and that’s going to lead to a long-term relationship and, in the end, better patient care.

It’s such an exciting time to be practicing dermatology because with some of these challenging diagnoses that we take care of on a daily basis, I feel now in 2023 that we’re actually able to prescribe medications that can help our patients. As medical professionals, I feel that all of us went into medicine to help patients, and when we have a diagnosis where we’re helping them just a little bit but they’re not completely resolved, we feel like failures inside because that’s our goal. We want to help patients and we want to get them better. Now that we’re in the era of these biologics and in the era of this research that’s going into some of the most challenging diagnoses—like HS, alopecia areata, psoriasis, atopic dermatitis, and vitiligo—we’re finally getting tools in our toolbox that are effective but also safe. It’s just such an exciting time to be practicing dermatology and having the ability to help these patients.

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Gina Mangin, MPAS, PA-C, shares take-home pearls with fellow healthcare providers, highlighting the importance of listening to the patient.

Clinical Pearls for Providers Treating HS

 What biologics are available for our patients with HS and what biologics are in the future? I mentioned earlier that the only FDA-approved medication and biologic that is available for our patients is adalimumab, which is a TNF [tumor necrosis factor] inhibitor, but it is promising and encouraging because we have new ones that are going to be hitting the market very soon. One of those, which is secukinumab, is going to target IL-17. Another that has completed phase 3 trials and hopefully will be hitting the market soon, which also targets IL-17…is ixekizumab…. Not only are we having newer biologics and injectables that are under investigation, but there are also oral JAK inhibitors that are under investigation. So, the future is bright for our patients with HS and it’s exciting that we’re going to hopefully have more options for our patients to get them better.

My experience with treating patients with biologics has been very positive. I use biologics in patients with psoriasis and atopic dermatitis, and in patients with HS. I have had and do have patients who are currently on adalimumab, are experiencing HS, and doing well. I also have some patients who are better but not completely there. That’s why I’m excited that we’re going to have some newer biologics that are available. Often when I’m using biologics, I have found it has been an easy conversation with my patients because it’s medications that are targeted therapies, and being targeted, it helps me explain to them that the adverse effects may be less as compared with something like oral prednisone or our oral immunosuppressive medications. That tends to put my patients at ease when we’re talking about these medications, especially because we now have so much data over the past 15 years with the use of these biologics. I feel as if the data and the safety of these medications are improving as we use these over time.

The clinical impact that these neurobiologics are going to have for our patients with HS is that they are going to improve patient care, meaning…better long-term results. And if we have better long-term results, I think our patients are going to be far more adherent. I feel as though our patients are not going to be hopping from one clinic to another looking for that magic cure. My hope is that we’re going to have better long-term control, and that’s going to lead to better patient adherence and better patient improvement overall.

An expert in dermatological conditions discusses new treatments in the pipeline for HS, commenting on her experience with biologic treatment.

Emerging Therapy for Patients With HS

 The treatment options that we have for HS [hidradenitis suppurativa] are extensive. We know that HS is this chronic, recurrent, inflammatory disease that’s involving the hair follicle. The only FDA-approved medication that we have for HS is adalimumab, which is an injection that patients administer themselves, but there are other things that we use that aren’t necessarily FDA approved. There are tons of medical literature out there supporting the use of these medications, which include oral antibiotics, intralesional steroid injections, and oral immunosuppressive medications. Other things we will use are medications that may affect the hormone imbalances, meaning oral birth control pills, or oral spironolactone. We will also use topical antibiotics, topical resorcinol. So, the list is large in terms of the treatment options that we have out there.

The next question is, how do we treat these patients and how do we decide which treatment modalities to use? The first question is, is their disease mild or is it more moderate and severe? If it’s mild, then we can probably just use some topical antibiotics. If they have a flare, then we can use intralesional cortisone injection. But if they’re having a flare, the key is that we must calm that inflammation down. Often when we’re going to start with oral anti-inflammatory antibiotics, if we see that these flares are continually progressing and we’re seeing that they have scarring along with the tunnels and the tracks forming, then many times we’re going to combine medications such as adalimumab and oral antibiotics but also…surgical treatments as well. I failed to mention earlier that those are treatments too—surgical treatments, removing those cysts or deroofing those cysts. When your patients’ symptoms are severe, they’re going to need both medical and surgical intervention.

Gina Mangin, MPAS, PA-C, reviews current treatment options for patients with HS, highlighting adalimumab as well as non-FDA approved therapies.

Treatment Options for HS

 HS [hidradenitis suppurativa] is diagnosed by a clinical diagnosis, so patients will be evaluated by a physician, a PA [physician assistant], or a nurse practitioner, and on evaluation you will notice nodules, abscess, tombstone comedones—these are pairs of comedones adjacent to each other—and you can have hypertrophic or fibrous scarring. It’s a clinical diagnosis. When these patients present with 2 or more recurrent lesions within a 6-month span, that’s when you start thinking HS.

So, many times HS is diagnosed, or I should say there’s a delay in diagnosis, and the delay can range somewhere from 7 to 10 years. Now, the question is, why is there such a delay in diagnosis? Part of the problem is these patients are given wrong diagnoses as having plain abscesses, cellulitis, or folliculitis. Often, these patients, on average, have seen 5 medical providers before the correct diagnosis is made. Also playing a role is that 75% of the time, these patients think that this disease or these symptoms they’re having will go away on their own, and that may delay them coming in to be evaluated. Now, how can we improve on the delay of the diagnosis for these individuals? Education is key; educating our colleagues and patients about the signs and symptoms of HS. I feel in the past 2 years there has been a little bit more buzz about HS, and I have been seeing more patients come into my office knowing or thinking that they have this diagnosis because they’ve already seen some information on the internet or they’ve heard some information from friends and family. The buzz is starting, but we must continue that momentum.

An expert physician assistant in dermatology provides an overview of how HS is diagnosed, and how the diagnosis is often delayed.

Gina Mangin, MPAS, PA-C

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