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Mital Patel-Cohen, MD, on Managing Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic disease with insidious onset characterized by recurrent abscesses, sinus tract formation, and scarring. Unfortunately, there is no laboratory testing for HS, so the diagnosis must be made clinically, said Mital Patel-Cohen, MD, director of complex medical dermatology at Summit Medical Group (New Jersey), during her presentation at the virtual Interdisciplinary Autoimmune Summit 2020.

In her presentation, Dr Patel-Cohen reviewed the presentation, common complications, and pathogenesis of HS. She discussed the management of HS, specifically the need for a multimodal approach for treating patients. “For most of my patients, I am using combination medical and procedural therapies to achieve the best results,” she said.

She shared some clinical pearls for optimizing therapies. For example, she has not found using oral zinc gluconate and antibacterial wash alone to be helpful for patients with active moderate or severe disease. “I think it is helpful for maintenance or for patients with mild disease or as an adjuvant therapy,” she explained.
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The literature shows varying responses to colchicine for the treatment of HS, but Dr Patel-Cohen noted she found it effective when added to other treatment regimens such as antibiotics. This option is good for patients who may respond to treatment, but would like an “additional boost,” she added. Dapsone is another option that works well for mild disease or as an adjunct to other therapies, including biologics.

Another pearl Dr Patel-Cohen shared was the use of extended-release formulations of metformin to mitigate gastrointestinal adverse effects. In HS, metformin requires higher dosing than what is traditionally used to treat diabetes. This causes significant gastrointestinal adverse effects, which can be challenging for patients, she explained. She noted that this therapy is helpful for patients who are overweight or who have HS flares associated with hormonal fluctuation.

Combination therapy with clindamycin and rifampicin can be effective for patients, especially those with significant drainage, odor, and inflammation. Dr Patel-Cohen explained that she also adds metronidazole to this treatment regimen. She reviewed a study that added moxifloxacin to both antibiotics that showed significant improvement and remission with this triple therapy. However, the treatment period is 6 to 12 months for severe patients, she added.

Another antibiotic Dr Patel-Cohen discussed was ertapenem, which can lead to improvement among patients with severe disease refractory to other treatments. This is not a quick fix and patients do experience relapses and recurrence, she noted. “If you do use this option, make sure to use antibiotic therapy afterwards,” she stated.

In addition, Dr Patel-Cohen discussed the role of onabotulinumtoxinA injection for patients who believe sweating is causing their HS flares; brachytherapy for patients who cannot take or were refractory to other systemic therapies; and several biologic therapies, including adalimumab, infliximab, anakinra, ustekinumab, brodalumab, and IFX-1. She noted that many of the biologics approved for psoriasis will require higher dosing to effectively treat patients with HS.

Dr Patel-Cohen noted that one of the most common questions she receives is whether she refers patients with HS for surgery. She stressed the importance of working with a general or plastic surgeon for treating these patients. “If you send a patient to receive surgery, try to medically manage them first prior to surgery because they heal better and have better outcomes,” she said. Following surgery, Dr Patel-Cohen prescribes a maintenance therapy to prevent recurrence. 

She showed images of a patient treated with infliximab, dapsone, and triple antibiotic therapy who experienced some improvement but still had active lesions. She noted that although treating HS can be difficult because patients do not achieve the same level of clearance as patients with psoriasis, it is still important to remember that treatment significantly improves their quality of life and pain, even with active lesions.

Reference

Patel-Cohen M. Hidradenitis suppurativa: clinical pearls and management updates. Presented at: Interdisciplinary Autoimmune Summit 2020; July 10-12, 2020.

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