Advancing Hidradenitis Suppurativa Care - Early Diagnosis, Biologic Therapies, and Multidisciplinary Approaches: Part 3

Conversation continued from part 2.

Surgical Innovations in HS Management

Surgery remains an underused but valuable component of HS treatment. Hamzavi highlighted key findings from recent studies, particularly regarding surgical outcomes in patients with skin of color. Contrary to common concerns, excising HS lesions does not increase keloid formation risk in patients without a history of keloids. These data highlight the importance of offering surgical options to all patient populations.

According to Hamzavi, advancements in surgical techniques, such as the use of tumescent anesthesia, have improved the accessibility and tolerability of procedures. Additionally, emerging evidence suggests that surgical excision of inflamed sinus tracts may reduce systemic inflammation and lead to improvements in lesions at distant sites. This systemic effect positions surgery as a complementary treatment to biologics.

Postoperative Care and Wound Healing

Innovations in postoperative wound care are also improving outcomes for patients with HS. Hamzavi referenced new tools such as HidraWear, a dressing system designed by a patient with HS. This product facilitates wound healing and patient comfort, transforming the recovery process into a manageable experience. Postoperative pain typically resolves within a few days, followed by weeks of progressive healing.

Holistic Patient Care

Both clinicians stressed the importance of adopting a holistic approach to HS management. Beyond medical and surgical interventions, addressing nutritional factors and counseling patients about the disease’s burden are crucial. Elias urged dermatology clinicians to allocate time for meaningful discussions with their patients. This engagement not only enhances trust but may also profoundly affect patients’ mental and emotional well-being.

“I think that’s important to think about the entire toolbox and the entire armamentarium treatment that we have available to these patients. And not to forget—I’m going to keep repeating it—not to forget to spend time with these patients,” Elias concluded.

The Rise in HS Awareness

Hsiao, a board-certified dermatologist and associate professor of clinical dermatology at Keck Medicine of the University of Southern California and director of the Hidradenitis Suppurativa Specialty Clinic, both in Los Angeles, and Cooper, a board-certified dermatologist at Memorial Hermann Health System in Katy, Texas, emphasized that HS is no longer perceived as a rare condition. Cooper mentioned that in her practice in suburban Houston, Texas, she encounters at least 1 patient with HS daily, with many more having been diagnosed in recent years. This shift in perception is partly due to increased awareness among both patients and clinicians. Hsiao noted that many patients are now self-referring to dermatology clinics after learning about the condition through media or educational campaigns, further highlighting the importance of early recognition and intervention.

Both Hsiao and Cooper agreed that increasing HS awareness is crucial. Cooper emphasized the need for dermatology clinicians to be vigilant during routine skin checks, particularly when patients present with cysts, scarring, or abscesses in the inguinal area or axilla.

“If you see cysts or scarring in the inguinal area or axilla, ask about it. Don’t just go through your skin examination because it’s not skin cancer, but ask questions about how long it’s been going on and when was their last flare to get an idea of how impactful this is on their life,” Cooper said.

In addition to skin checks, the pair recommended that health care providers consider HS in young patients with acne, especially young women who may also present with cysts in the chest or underarms. Early identification, they argued, allows for earlier intervention, reducing the likelihood of long-term scarring and other complications.

A Lack of Options

According to Cooper, treatment options for HS have been historically limited and often focused on symptom management. Cooper recalled that when she started her practice 17 years ago, antibiotics, retinoids, surgery, and metabolic management were the mainstays of therapy. The lack of effective treatments for HS often led to frustration for both patients and clinicians as the condition progressed, causing irreversible damage to the skin.

In recent years, however, the availability of biologic therapies has dramatically changed the treatment landscape. As Cooper noted, the introduction of biologics such as adalimumab (a TNF-α inhibitor) has provided a significant breakthrough. These agents target the underlying inflammatory process of HS, offering patients relief from painful flare-ups and preventing further scarring. Secukinumab, an IL-17A inhibitor, has also recently been approved, offering additional therapeutic options. Additionally, the recent approval of bimekizumab, an IL-17A and IL-17F inhibitor, has further expanded treatment choices, bringing hope to those with more severe or treatment-resistant disease.

Setting Realistic Treatment Expectations

One of the key challenges in managing HS with biologics is setting appropriate treatment expectations with patients. Cooper emphasized that although biologics can significantly improve disease outcomes, they are not a cure for HS. Many patients have already developed scarring, fistulas, and abscesses by the time they begin biologic therapy. Therefore, treatment goals should focus on reducing inflammation, preventing new flares, and improving quality of life rather than expecting complete resolution of the condition.

Hsiao and Cooper emphasized the importance of open communication with patients regarding the realistic outcomes of biologic therapy. The goal is often to achieve at least a 50% improvement in disease symptoms (HiSCR 50), although higher response rates, such as HiSCR 75 or even HiSCR 100, are desirable.

Hsiao cited the promising data from bimekizumab’s phase 3 trials, BE HEARD I (NCT04242446) and BE HEARD II (NCT04242498), which showed that nearly 45% of patients achieved HiSCR 100 after 2 years of treatment. Such outcomes are a significant improvement compared with previous treatments, and this sets a new benchmark for patient care.

Patients who completed week 48 in BE HEARD I and BE HEARD II could enroll in the open-label extension study and received bimekizumab every 2 weeks or every 4 weeks (Table).

“I was impressed by the fact that we’ve now had data out through 2 years that have been showcased at the EADV [European Academy of Dermatology & Venereology] conference showing some good numbers for HiSCR 50, 75, 90, and 100 even. Their data showed that if we looked at a pooled group of patients taking bimekizumab, almost 45% at 2 years were hitting that HiSCR 100, which is 100% clear of abscess and inflammatory nodules,” Hsiao said.

Cooper further stressed that biologics are not a one-size-fits-all solution. Although both adalimumab and secukinumab have shown effectiveness in treating HS, some patients may respond better to one agent over the other. As the treatment landscape evolves with newer biologics such as bimekizumab, clinicians will need to stay informed about the data to tailor therapies to individual patients.

Table

The Role of Combination Therapy

In the treatment of HS, biologics are often used in conjunction with other therapeutic agents to enhance outcomes. Cooper explained that she frequently prescribes spironolactone and, in some cases, metformin to women with HS, especially if they have underlying hormonal imbalances or metabolic concerns. Antibiotics may also be used to manage acute flares, and surgical interventions such as incision and drainage are sometimes required for abscesses. By combining these approaches, clinicians can provide comprehensive care that addresses both the inflammatory and structural aspects of the disease.

Hsiao agreed with Cooper’s approach, highlighting the importance of maintaining a multifaceted treatment plan. She also discussed how biologics are typically prescribed as monotherapy in clinical trials but that in real-world practice, combination therapy is often necessary. This is especially true for patients with extensive scarring or advanced disease. By combining biologics with other treatments, dermatology clinicians can optimize disease management and help patients achieve better outcomes.

The Impact of Early Intervention

A key takeaway from the discussion is the importance of early intervention in preventing disease progression. Both Hsiao and Cooper are hopeful that with earlier diagnosis and the use of biologics before significant scarring occurs, patients will experience better long-term outcomes. Hsiao made an analogy between HS and acne, noting that just as isotretinoin is used early to prevent scarring in acne, similar strategies should be employed in HS. By treating patients earlier, before they develop extensive scarring and sinus tracts, it may be possible to halt the progression of the disease and preserve the skin’s integrity.

Cooper added that early intervention is especially crucial given that the current treatment options are effective at reducing inflammation and preventing scarring. In the past, patients were often not referred to dermatology clinicians until their disease had progressed significantly, leaving little room for intervention. With the advent of biologics, dermatology clinicians can now work to prevent the development of severe disease and improve patients’ quality of life by addressing HS earlier.

Overcoming Barriers to Access and Adherence

Despite the advances in HS treatment, several barriers still exist in terms of access to care and treatment adherence. Cooper noted that some patients are hesitant to switch biologics, even when there is evidence that a different therapeutic may offer better results. This reluctance often stems from fear of relapse or worsening symptoms, which underscore the importance of setting clear expectations from the outset and educating patients about the potential benefits and risks of switching therapies.

Insurance coverage and access to biologics are also common challenges in the real world. Hsiao pointed out that insurance providers often dictate which therapies patients can access, which can delay the initiation of the most appropriate treatment. Additionally, patients may be reluctant to stop their current biologic until they have a new one in hand, as discontinuing therapy prematurely may lead to flare-ups and exacerbate their symptoms. She stresses the importance of overlapping biologic treatments to avoid gaps in care.

Both clinicians are optimistic that as awareness of HS continues to grow, more health care providers—including primary care physicians, urgent care clinicians, and even specialists in surgery—will recognize the condition and refer patients to dermatology clinicians sooner. This earlier referral will allow dermatology clinicians to intervene at a stage when biologic therapies can be most effective, reducing the need for surgical interventions and minimizing the long-term impact of the disease.