Management of HS Requires Both Coordination, Communication Between Patients and Providers

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A session held at the American Academy of Dermatology 2024 Conference on March 8 focused on how providers can help treat patients with hidradenitis suppurativa (HS) who live in socioeconomically underserved areas, primarily through communication with the patients about treatment options and by collaborating with other clinicians to give a full picture of the condition to all patients.

Hidradenitis suppurativa | Image credit: Kristina Blokhin - stock.adobe.com

Adults With HS Need to Be Treated With Patient-Centered Approach

Gregory M. Orlowski, MD, PhD, FAAD, assistant professor of dermatology at Boston University, focused primarily on treating adult patients with HS. HS, he explained, is a “chronic progressive autoinflammatory skin condition where blocked hair follicles in skin lead to episodic pain, swelling, and drainage.” This drainage eventually becomes a scar or an abnormal tunnel called a sinus tract. Doctors can diagnose this by observing characteristic lesions, predilection for flexural sites, and lesion recurrence.

Orlowski pointed out that many spell the condition as “hydradenitis,” which is incorrect but, he said, correctly depicts the way that HS should be visualized as the monster in Greek myth. “I think this nicely depicts or illustrates the multifaced, relentless beast that is HS, including depicting the tunnels that form in this condition and how they almost seem immortal,” he said.

HS has a prevalence of about 1%, with a disproportionate number of patients being young Black women and those of lower socioeconomic status. Patients of lower socioeconomic status make up approximately 45% of all HS patients in the Netherlands, according to the results of a study in the Journal of the American Academy of Dermatology from 2016.¹ According to Orlowski, sinus tracts are the key clinical markers of the severity of HS.

Management of this disease, said Orlowski, is reliant on getting the patient to trust the doctor prescribing it. “The least effective treatment is the treatment your patient doesn’t use,” he said, “So we need to focus on the patient as well and we need to get them to those treatments. They have to trust you understand their treatment and buy into the plan you develop together with them.”

Clinical trials of various biologics to treat HS have been conducted and have had good results overall. But often these treatments aren’t enough by themselves. The biologic treatment can often be short-lived, with the median time to discontinuation being 9 months in adalimumab, 7.25 months in infliximab, and 6.5 months in ustekinumab. Patients often discontinue due to a loss of efficacy, whether it’s real or simply perceived, as well as for adverse events, nonadherence, or loss of coverage. Anti-drug antibodies have been a problem in this area, as medications that worked previously may simply stop working altogether.

“This is promoted by treatment interruption, and this is a problem in our patient population because of noncompliance, which is more prevalent in this population,” said Orlowski.

Biologics also fall short in HS because of the more complex pathology compared with other skin diseases that are effectively treated with biologics, such as psoriasis. The structural pathology in HS is unique and makes it difficult to properly treat with biologics alone due to the increased inflammation. This also extends to how much the biologics can reduce the severity of HS.

“Patients suffer even with a 50% reduction in draining abscesses.… Studies have shown that when compared to many different skin conditions, especially psoriasis, HS was the most impairing.… It takes 1 bad abscess in your armpit to ruin your weekend,” said Orlowski.

Orlowski went on to say that identifying HS and recognizing when surgery is needed is key to getting as much efficacy as possible out of treatment, as the longer the physician waits, the worse the outcomes get. Surgery can be a legitimate option for many patients, as the recurrence rate is 13% in wide excisions, 22% in local excisions, and 27% in deroofing surgeries, according to a study published in the Journal of the American Academy of Dermatology in 2015.² Surgery has had the best quality of life benefits in HS but making sure to continue treatment with the patient is critical to their long-term health.

All of this, he said, goes back to the socioeconomically underserved. There are barriers that affect patients with HS all the time, he said, but patients who are socioeconomically underserved have other barriers on top of those initial ones. “In these patients, this is the perfect setup for a failed therapeutic relationship. All these different issues are disease exacerbators as they worsen these disease effects and then there are other some amplified exacerbators here that then further worsen these disease effects. And these are major initial barriers to treatment,” said Orlowski.

Orlowski suggests that helping these patients who have systemic barriers to treatment should start with showing an understanding to the patient, earning their trust, educating them, and giving them hope while also giving clear expectations of how the disease will be treated. Then, he said, create a medical regimen and advocate for the patient to access medication by seeking assistance from a pharmacy and modifying the treatment until results are found. Lastly, build relationships with surgical collaborators who could make surgery more accessible for patients of lower socioeconomic status.

“[HS is] a different kind of beast altogether.… It’s going to take you, it’s going to take all of you, and it’s going to take a multidisciplinary team,” said Orlowski.

Pediatric HS Approached Differently Than in Adult Patients

Lisa Shen, MD, FAAD, assistant professor of dermatology and pediatrics at Boston University, talked about how approaching HS in children is different than in adults.

“Kids,” she said, “are not just little adults and there are some unique considerations you have to keep in mind.”

Approximately 25% of patients with HS report an onset of the disease before the age of 18 years. Most of the time, earlier onset occurs in female patients and is related to genetic susceptibility. Diagnosing HS in younger patients can also be different for doctors.

“Many patients come in telling you that all their childhood [and] teenage years, they just thought that they had occasional boils or recurrent razor bumps,” said Shen. “So when those are occurring recurrently over the long course of time, at least 6 months, really you should be thinking about this diagnosis.”

A family history of HS and double-headed comedones in intertriginous areas are also indicators of early-onset HS in children. Comorbidities can include acne vulgaris, acne conglobate, obesity, and anxiety. A previous study of Shen’s found that the mean age of symptom onset in a cohort of 304 pediatric patients was 13 years and the mean age of diagnosis was 15 years, with 35.8% reporting a family history of HS.³ This same cohort reported obesity as the top comorbidity at 64.1%. This cohort was disproportionally Black and female.

HS can have a profound effect on children’s psychosocial life, including in social isolation, mental health, and in school attendance. These things, Shen said, can be treated individually. Wound care to minimize drainage can be paramount to decreasing stigmatization and social isolation in this group. She also said support groups can be beneficial: “I think one of the biggest problems is that this is a condition that can be hidden to a certain degree, but they also feel very alone. So when they meet other patients with HS or at least have the resources that some of these support groups can provide, it can be really helpful in terms of what to do about school absenteeism.”

Shen said that communicating with schools about the condition can help to make small lifestyle changes for the child to be able to comfortably participate in school. Lastly, treating depression and anxiety is critical to improving outcomes.

Families can help by making lifestyle changes alongside the child, such as weight management, reducing friction in clothing, changing their hair removal practices, and practicing wound care. Youth should be encouraged to quit smoking if they do so.

Medical treatments for children are slightly differen and can include ttopicals, antibiotics, and biologics. Antiobiotics such as doxycycline, clindamycin/rifampin, and augmentin are some that can be used for HS. Sprionolactone can be used but menstrual irregularities and dehydration should be monitored. Metformin can help with insulin sensitivity in this group as well as with androgen inhibition but should only be used in patients 10 years and older.

Biologics are a form of treatment that has a lot of uses, specifically adalimumab, infliximab, ustekinumab, secukinumab, and ixekizumab. “Of course, adalimumab is the only that we have approved, but we do use a lot of biologics off label, and oftentimes are most successful at getting biologics that are approved for other indications,” Shen said. “I would recommend if you’re not sure where to go start with the ones that are already FDA approved for other indications.”

The effect that Janus kinase inhibitors can have on acne, growth, and weight gain are currently being looked into in the pediatric population. Shen also recommended partnering with pediatric surgeons so that any children needing surgery can get it with a trusted surgeon.

Shen concluded by saying that behavioral health support, lifestyle modifications, medical treatments, and surgical treatments are all vital in treating children with HS. Early interventions for this treatment can make the treatment of HS easier and more effective.

References

1. Deckers IE, Janse IC, van der Zee HH, et al. Hidradenitis suppurativa (HS) is associated with low socioeconomic status (SES): a cross-sectional reference study. J Am Acad Dermatol. 2016;75(4):755-759.e1. doi:10.1016/j.jaad.2016.04.067

2. Mehdizadeh A, Hazen PG, Bechara FG, et al. Recurrence of hidradenitis suppurativa after surgical management: a systematic review and meta-analysis. J Am Acad Dermatol. 2015;73(5 suppl 1):S70-S77. doi:10.1016/j.jaad.2015.07.044

3. Sanchez S, Mumber H, Shen L. Characterizing hidradenitis suppurativa in the pediatric population. Abstract presented at: Society for Pediatric Dermatology 47th Annual Meeting; July 7-10, 2022; Indianapolis, IN.