Hidradenitis suppurativa treatment should be 'layered,' address psychosocial impacts
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Providers should avoid monotherapy when treating hidradenitis suppurativa, and instead use a “layered and rotated” approach that also addresses the isolating psychosocial aspects of the disease, noted a speaker here.
“[Hidradenitis suppurativa (HS)] is basically an inflammatory disorder of the hair follicle — it used to be considered a sweat-gland disease, but we now know that the sweat gland is involved secondarily,” Ginette Okoye, MD, FAAD, a professor and chair of dermatology at the Howard University College of Medicine, told attendees at the 2021 Association of Women in Rheumatology Annual Conference. “The primary issue is the hair follicle in intertriginous areas of the body.
“Its prevalence seems to be increasing — it’s estimated to be about 0.1% in the United States — but we know that this disease is under-recognized and underdiagnosed,” she added. “It is three times more common in women, and it is more common in people of African ancestry and in people of lower socioeconomic status backgrounds. We also know that people with African ancestry are more likely to be hospitalized for their HS. And smoking and obesity are known to potentiate the severity of the disease, but we don’t fully understand why.”
Pathogenesis and diagnosis
According to Okoye, the difficulty in treating HS is partially due to its multifactorial pathogenesis. Various aspects of the disease’s pathogenesis are “at play” in different ways in different patients, she said. However, the one primary issue that experts believe is true across most patients with HS is follicular occlusion. Patients develop this occlusive plaque in the top layer of the hair follicle, and below that occlusion the follicle begins to dilate, eventually to the point of rupture. It then spills its inflammatory contents into the dermis.
Although this is similar to acne, HS distinguishes itself in that patients with the disease cannot “reel that inflammatory cascade back in,” Okoye said. The inflammation continues to grow, recruiting neutrophils that cause tissue damage. Ultimately, many follicles follow this process until they connect to each other under the skin, forming a sinus tract.
“The basic science of HS is in its infancy — this is almost as much as we know at this point,” Okoye said.
To diagnose HS, providers can rely on three primary diagnostic criteria that must be met. First, typical lesions, which include deep-seated, painful nodule in early lesions or abscesses, draining sinuses, bridged scars and “double open comedones” in more developed cases. Second, the typical locations of these lesions are in the axillae, groin perineal and perianal regions, the buttocks, the intra- and inter-mammary folds and the abdomen. Third, diagnosis requires chronic disease and recurrences in the same areas.
“Regarding these double open comedones — those are two blackheads side-by-side — if you see that, it’s HS,” Okoye said. “It doesn’t really occur in any other dermatologic disease that we know of. What it represents is basically a tiny sinus tract. So, if you see that, they have HS.”
Comorbidities: IBD, axial SpA, depression
According to Okoye, the comorbidities of HS can include metabolic syndrome, cardiovascular disease, inflammatory bowel disease, axial spondyloarthritis, autoinflammatory syndromes, and depression, anxiety and suicidality.
“These can also include job loss, dropping out of school, divorce, et cetera,” she added. “It’s a really horrible disease. If the photos didn’t show you that, you just have to meet your first patient, and you’ll see that it’s really a difficult disease to live with.”
Although research on the disease has been scarce, Okoye cited a 2020 study published in JAMA Dermatology that found that patients with HS demonstrated an increased risk for ankylosing spondylitis (HR = 1.65), psoriatic arthritis (HR = 1.44) and rheumatoid arthritis (HR = 1.16).
In addition, a 2019 study published in Seminars in Arthritis and Rheumatism fond that the prevalence of HS was higher among patients with SpA compared with the general population, she said.
A layered, rotated treatment
According to Okoye, the most important factor in treating HS is developing a multitiered approach that addresses the medical, surgical and psychosocial needs of the patient.
“I used to think of my treatment of HS like a pyramid or a ladder, where I would start with antimicrobials and work my way up through hormonal treatments and biologics, all the way to surgery,” Okoye said. “However, I now know that we really have to treat HS a little bit differently. We can’t use monotherapy, so it’s no longer a stepwise fashion where we try one thing and then another. You have to layer therapies one on top of the other.
“And it’s more than just the medical or the surgical management,” she added. “We have to help patients figure out some psychosocial resources. “We have to help them with lifestyle modifications, like smoking cessation. And some of them need help with wound care, because managing these chronic wounds with lots of drainage and malodor, for example, really affects their quality of life.”
First-line treatment is generally antimicrobial therapy, which can be layered over other treatments, and can include antiseptic washes. Options include a zinc pyrithione shampoo, a 4-10% benzoyl peroxide wash and even a “bleach bath,” or a quarter cup of bleach mixed with a full bathtub of water.
“It’s like a swimming pool, is what I say to my patients because they look at me like I’m crazy when I say put bleach in your water,” Okoye said. “It really helps with odor, which is really important for patients with HS.”
According to Okoye, the mainstay of treatment for HS includes oral antibiotics, administered twice daily for 2-3 months. Options include doxycycline or minocycline 100 mg, with the addition of rifampin 300 mg as possible combination therapy for either. Clindamycin 300 mg — alongside rifampin or alone — is also used. A third option is triple therapy with moxifloxacin, metronidazole and rifampin for 2-3 months, with the metronidazole stopped at week 6. However, this strategy is often not well tolerated in patients, Okoye said.
Meanwhile, daily hormonal therapies can include finasteride 5mg, spironolactone up to 200 mg and metformin 500-200 mg.
“Again, these are not slam dunks by themselves,” Okoye added. “These are medications I would layer on top of a biologic or an antibiotic.”
Biologics should be considered in patients with severe disease, those with an inadequate response to antibiotics, and those with comorbid Crohn’s disease, pyoderma gangrenosum or psoriasis.
In addition, although adalimumab (Humira, AbbVie), ustekinumab (Stelara, Janssen), infliximab (Remicade, Janssen) and anakinra (Kineret, SOBI) have been shown to improve the disease, only Humira is approved for moderate-to-severe HS.
According to Okoye, treatment with adalimumab involves 160 mg — double the dose for psoriasis — at week 0, 80 mg at week 2, and then 40 mg weekly.
However, only about half of patients typically receive a benefit from this treatment, and, among those patients, “it’s only about a 50% benefit,” Okoye said. Indeed, if the sinus tracts under the skin remain, so will the disease.
“Again, medical management should be layered, and even rotated, otherwise you’ll hit a plateau and it tends to stop working,” she added. “In addition, surgical management is absolutely a part of the treatment algorithm here, so we can remove those sinus tracts and chronic lesions, to help prevent progression.”
Psychosocial and lifestyle aspects of HS
According to Okoye, a multidisciplinary approach is needed to fully address the quality of life issues that arise from HS, which can include depression, loss of intimate relationships, sexual dysfunction, pain and embarrassment. Multidisciplinary teams can include a primary care physician, a dermatologist and a rheumatologist, as well as a therapist, psychologist or a psychiatrist. Support groups, family members and significant others can also help in this regard.
“There is a really huge online community now with patients with HS, and a lot of patients get a benefit from that,” Okoye said.
Lastly, lifestyle modifications to help treat HS can include weight loss, nutritional counseling, referral for bariatric surgery if indicated, anti-inflammatory diet and smoking cessation.
“Lifestyle modifications cannot be understated,” she added. “We talk about smoking cessation at every visit, if they are still smoking. We talk about the cardiovascular risks, we check their vitals and we check their weight. Weight loss doesn’t always help, but it can, because of that skin-on-skin friction component. All of these can be important aspects of management.”
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Okoye G. Hidradenitis Suppurativa: Diagnosis, Management and Comorbidities. Presented at: Association of Women in Rheumatology Annual Conference; August 12-15, 2021, Hilton Head Island, South Carolina (hybrid meeting).
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