Joslyn Kirby, MD, associate professor and vice chair for education in the department of dermatology at the Pennsylvania State University College of Medicine, presented on new and future treatment options for hidradenitis suppurativa (HS) at the 2019 Fall Clinical Dermatology Conference.
“While the goal of my talk is to acknowledge the many exciting new developments in HS, I do not want to forget the tools we already have,” said Dr Kirby.
She discussed the importance of telling patients that HS is an inflammatory disease. According to her, patients can feel as though they are defective and that their immune system does not work. Telling them that they have HS because their immune system works too well helps them understand their disease and feel like they are able to take control, she noted. In addition, she added that the word “infection” should be removed from “our vocabulary” because most sources of boils in patients with HS are not associated with infections.
HS takes a toll on patients, said Dr Kirby, and they often describe their disease as a roller coaster with explosions of pain and periods of relatively quiet disease. She recommended asking patients what “their rollercoaster” is like and if they ever have periods of no pain or skin symptoms. Along with genetic risk factors, microbiome changes, smoking, and body weight can trigger HS. However, Dr Kirby noted that she never discussed lifestyle changes at the first appointment. “When you walk into a room, visit 1 is not the time to direct them to stop smoking or go on a diet,” she said. This conversation occurs after setting up a rapport with the patient and when discussing long-term treatment plans.
Dermatologists, said Dr Kibry, need to approach HS treatment “like a boss” and bring their hope and optimism into the room when meeting patients.
In her opinion, dermatologists should be the ones treating HS because they know the medicines and can perform the surgeries. “If you can do a punch biopsy you can do HS surgeries,” she said. However, she recommended collaborating with primary care physicians, plastic surgeons who know HS, psychologists, and pain specialists to ensure all aspects of HS are treated.
According to Dr Kirby, clinical trials are exploding in the field of HS, particularly in the last few years. She said her first line of treatment for patients with severe disease is enrolling them in a trial. Many trials are targeting IL-17 and IL-23, she noted, with some data suggesting these targets work for HS.
In addition, she recommended a step approach to treatment based on a patient’s HS stage. For example, she suggested using topicals for a patient with stage 1 HS, as well as using spironolactone to help manage the disease. “For more severe disease, use systemics right away and think about surgery,” said Dr Kirby. She recommended adalimumab (Humira) for patients with moderate to severe HS. Intralesional steroids can be used for acute treatment of lesions, as well as punch de-roofing, she added. In addition, she suggested topical resorcinol, which can be compounded, for painful nodules.
Tunnels will not go away with medication and will require surgery, she said. After opening the tunnel, “what is important is scraping 360 degrees,” said Dr Kirby. This removes all of the gelatinous, almost egg-white material, which is the HS, and helps the tunnel heal well, she added.
“Do stage-based treatment and don’t wait to start effective therapies,” concluded Dr Kirby, adding that patients and providers need to manage this disease “like a boss.”
Kirby JS. New and future treatments for hidradenitis suppurativa. Presented at: Presented at: 2019 Fall Clinical Dermatology Conference; Oct 18, 2019; Las Vegas.