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The Who and When of Intralesional Injections for HS Treatment

Steven R. Cohen, MD, MPH, is Chief Emeritus of Dermatology and Professor of Medicine (Dermatology) at the Albert Einstein College of Medicine in the Bronx in New York City, NY. He is also Director of the Hidradenitis Suppurativa (HS) Center and a recognized authority in the fields of complex medical dermatology, as well as psoriasis and HS. Dr. Cohen met with The Dermatologist to discuss the efficacy of high‑dose intralesional triamcinolone (ILTAC) for HS.

Cohen_HSBased on the August 2020 study,1 what types of patients may be good candidates for the high‑dose ILTAC treatment?
We wrote this article to examine our experience with intralesional corticosteroid therapy in HS, using a range of dosing regimens for inflamed nodules, abscesses and sinus tracts. We asked patients whether they got better, whether they thought this was an effective therapy, whether it reduced their pain, whether it sustained their remission, and so forth. Based on that feedback, plus my own clinical observations, intralesional therapy is most suitable for acute or chronic inflammation. In other words, the ideal candidates for intralesional therapy present with redness, heat, pain, and swelling, of HS lesions.

However, many patients have painless sinus tracts. The tracts are not inflamed, but they often drain and smell when colonized with odiferous bacteria. Although these non inflamed tracts (or “tunnels”) are terribly disabling, the patients with these lesions are not good candidates for intralesional steroids. Ulcers, even when painful and inflamed, are typically unresponsive to intralesional steroids. The injections may aggravate ulcerated lesions.

One of the outcomes experienced by almost all patients with advanced HS is scarring. We do not use intralesional therapy for scars unless the patient has a tendency to form keloids.

This is a long answer, but it is difficult to define the ideal candidate for intralesional therapy. The simple answer is to say, "Oh, well, anybody with inflammation and pain would be a good candidate for this approach." However, if you are not an HS specialist or you do not have a good feeling for the range of morphologies in this disease, then I would urge caution before using high-dose intralesional steroids. Consultation with a more experienced physician is advisable.

I counsel my students and colleagues to be selective when using intralesional therapy. Restrict treatment with high concentrations of corticosteroids (ie, 20-40 mg/mL) to inflamed areas. Avoid sites that are not inflamed, draining, and painful.

HS is a debilitating condition that results in a poor quality of life due to high disease burden. In what ways can ILTAC modify patients’ quality of life?
Many patients with HS have focal areas of involvement affecting the underarms, inframammary skin, groin and buttocks. It is noteworthy that more than 50% of patients have groin lesions.2 These inflamed and painful areas are incredibly disabling. Active lesions may drain onto the clothes and cause a foul odor. Individuals with HS often do not want to go out, and experience a profoundly restricted social life. When HS involves many anatomic areas with large numbers of inflamed, draining, and painful lesions, the use of intralesional therapy may be impractical.

Ideally, a patient with one to six lesions is someone I am likely to treat with high-dose intralesional therapy. With the superior efficacy of high-dose therapy, the patient is most likely to see an improvement in quality of life.

Alternatively, when there are multiple areas of involvement (ie, under each arm and under each breast) and more than 6 actively inflamed and draining lesions, what is the approach? When the intralesional steroid dose exceeds 120 mg, this approach becomes increasingly impractical. I would not encourage injecting a very high volume of steroids because patients get this systemically, as well.

Additionally, these injections are not painless; however, we do not administer anesthesia for an injection(s). Fortunately, and somewhat ironically, the injections are often far less painful than HS-related discomfort. I am inclined to inject these patients, because intralesional therapy relieves their pain acutely.

Another problem is “needle phobia.” I have a conversation with the patient to explain that the needle we use is very tiny, and that they will likely not even feel the physical insertion of the needle. Patients will feel the medication going into the tissues; this will burn a little bit, but it is nothing like what they are experiencing with HS.

What limitations are there to ILTAC?
We try to schedule an emergency appointment for any patient with an acutely inflamed, painful HS lesion. A limitation certainly is how much are we going to inject, and that can be very operator dependent. In addition, treating HS lesions often causes the patient to lose a half-day of work, school, child care, and so forth. In an area like New York City, you may be able to have a patient come in and out of the office relatively quickly but treatment may require multiple visits rather than trying to treat everything in one session.

The same principles that I previously suggested about the most ideal lesion(s) for intralesional steroids holds for what we can do in terms of relieving discomfort. However, injecting large numbers of sites often means the patient will get a systemic effect. Therefore, we focus on acute areas of inflammation. Lesions that have not been previously injected tend to be the most responsive to high-dose intralesional therapy. When lesions are fluctuant from the buildup of pus, incision and drainage is often combined with corticosteroid injections.

In regard to HS treatment, what key takeaways do you want to share with other dermatologists?
To start, when we have a great treatment, we say to patients, "I'm going to put you on this therapy and the end is in sight. We're going to get your disease under control, and it's going to be great." For those of us who take care of patients with HS, we cannot say that, because the ideal treatment algorithm has not been defined.

For example, we usually spend an hour on the first visit to educate a patient (and family) about their disease. We have a video that describes our understanding and approach to the disease in lay language including combining antibiotics, hormonal (anti-androgen) therapy, and anti‑inflammatory agents. Then, when we explain to patients why we are using this approach, it gives them some measure of hopefulness. We often hear the patients say, "Wow, I never heard this explanation. You really know what you're doing." It took us years to figure out what we are doing, but it has helped considerably. [You can view the video here]

Also, I want to advise my colleagues to try and encourage the patients to stay with the basic approaches to therapy. Some of them are primitive, such as the use of an antibacterial soap, applying topical antibiotics onto the skin, and performing hot compresses. These may sound like insignificant remedies, but they are really, really helpful. In addition, try to see patients with HS at close intervals so that they feel emotionally and medically supported.

There are so many diseases in dermatology for which we have highly effective treatments, such as psoriasis, atopic dermatitis, and acne, where we can shut the disease process down. Similarly, HS is now moving into this new era where we have biologics to combine with the older treatment approaches. I want to encourage my colleagues to reach into their bag of tricks. High-dose intralesional therapy, adalimumab and infliximab reflect advances that are very helpful, but partnering with the patient is critical. It takes a lot of time in the office: obtaining history, thorough examination, patient education, comorbidity assessment, laboratory evaluations following metrics of inflammation, microbial cultures and a lot of thought about optimizing the approach to treatment. If you do not have a great deal of experience or do not have the time to devote to patients with HS, I suggest reaching out to colleagues who are interested in taking care of these HS patients, or may be willing to offer guidance.

Most importantly, I want to advise my colleagues to caution their patients to AVOID the emergency room (ER). This is a huge problem in caring for those with HS. When patients experience a lot of pain, and they cannot get an appointment with the dermatologist, their first instinct is a visit to the emergency room. In the ER, our patients are often sent to the surgeon, resulting in large incision and drainage procedures, packing, and healing by secondary intention that results in a large draining wound for weeks to months afterward.

In short, if you are caring for a patient with HS, you want to explore the entire pharmacologic armamentarium—oral and topical antibiotics, hormonal therapy, and anti-inflammatory agents that include high-dose intralesional steroids, and biologics.

Is there anything else notable about injection or HS that you would like to share with your colleagues as well?
HS is a rapidly changing field. There are many new ideas and new treatment protocols that repurpose older therapies, which is exactly what we did with the recent study our group performed.1 The use intralesional steroids is not very effective with traditional doses of 5 and 10 mg/mL. With 40 mg/mL, you can shut down inflamed, draining and painful HS lesions.

For the future, I have a lot of optimism. We are investigating a number of new effective therapeutic approaches. People should keep their eye on the literature and know that we are moving into a new era for HS. Currently, we are in the anti‑TNF treatment realm exclusively. Some of the newer biologics are likely to provide even better results for our patients. For example, introducing new interleukin blockers may prove more effective than the anti‑TNF inhibitors.3-5 Additionally, some of the pharmaceutical companies, including the manufacturers of secukinumab, risankizumab, and brodalumab, are pursuing an HS application for these newer biologics.

I believe we are going to see a wide spectrum of new ideas coming forward within the next few years that will transform the therapeutic landscape of HS.

1. Garelik J, Babbush K, Ghias M, Cohen SR. Efficacy of high-dose intralesional triamcinolone for hidradenitis suppurativa. Int J Dermatol. 2021;60(2):217-221. doi:10.1111/ijd.15124

2. Calao M, Wilson JL, Spelman L, et al. Hidradenitis suppurativa (HS) prevalence, demographics and management pathways in Australia: a population-based cross-sectional study. PLoS One. 2018;13(7):e0200683. doi:10.1371/journal.pone.0200683

 3. Gottlieb A, Natsis NE, Kerdel F, et al. A phase ii open-label study of bermekimab in patients with hidradenitis suppurativa shows resolution of inflammatory lesions and pain. J Invest Dermatol. 2020;140(8):1538-1545.e2. doi:10.1016/j.jid.2019.10.024

 4. Casseres RG, Prussick L, Zancanaro P, et al. Secukinumab in the treatment of moderate to severe hidradenitis suppurativa: Results of an open-label trial. J Am Acad Dermatol. 2020;82(6):1524-1526. doi:10.1016/j.jaad.2020.02.005

5. Ghias MH, Johnston AD, Kutner AJ, Micheletti RG, Hosgood HD, Cohern SR. High-dose, high-frequency infliximab: A novel treatment paradigm for hidradenitis suppurativa. J Am Acad Dermatol. 2020;82(5):1094-1101. doi:10.1016/j.jaad.2019.09.071

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