Raj Chovatiya, MD, PhD: Hidradenitis Suppurativa Is the ‘Definition of Unmet Need’

Hidradenitis suppurativa (HS) is a complex, burdensome, and often misunderstood condition. Luckily, the pipeline is bustling with activity and dermatology providers will soon have multiple options available for their patients.

At Maui Derm NP+PA Fall 2024, Raj Chovatiya, MD, PhD, associate professor at the Rosalind Franklin University Chicago Medical School and founder and director of the Center for Medical Dermatology and Immunology Research in Chicago, delivered an in-depth session recapping current treatment options, what challenges exist in the management of HS, and what agents are in development.

This transcript has been edited for clarity.

Dermatology Times: Tell us about your session on hidradenitis suppurativa presented at Maui Derm NP+PA Fall, and why it’s important to provide this education to an audience of advanced practice providers.

Raj Chovatiya, MD, PhD: Believe it or not, no matter where you practice, you're always going to see hidradenitis suppurativa in your dermatology clinic so it's really important to understand the basics of the disease, how we think about its pathogenesis, how we approach treatment and, most importantly, what is the amazing stuff coming that's going to change the way we view what's possible with this disease.

In my session, we accomplished each one of those objectives. We talked a little about exactly why hidradenitis suppurativa is named as such, why it's such a burdensome condition, why the pathophysiology is a little bit confusing and has stunted some of our actual therapeutic development, and then we talked a little bit about some of the targeted therapies we have in this space. That conversation, of course, began with adalimumab. We talked a little bit about the recent approval of secukinumab, and then we focused in on some of the updates from IL-17 and JAK inhibitor medications that are poised to be approved over the next few years. Finally, we touched on some of the emerging therapies that are way earlier in trials, phase 1 and phase 2, that really show that hope is on the horizon when it comes to thinking about high level improvement in this disease.

HS can seem daunting and somewhat confusing if you're not really experienced with No. 1, how to make the diagnosis. And 2, how exactly you start therapy, both for milder cases and more severe cases. HS is critical to diagnose correctly and treat because patients usually face a multiyear delay in terms of making their diagnosis. They also oftentimes face undertreatment for their disease, and HS is one of those conditions that actually has progressive features, meaning that if you don't treat it aggressively enough, individuals can actually get worse over time. So really, it's important to understand the signs and the body areas where you would typically expect HS to be able to add a name to the disease itself, and then to really be aggressive with the right treatment option to make sure you're preventing some of the long-term sequela we think about with this condition, including scarring and sinus tracts.

DT: What is the pathophysiology of HS and have we learned anything new about it?

RC: HS is largely based in the follicle unit of the skin, meaning that most of the inflammatory process is centered around an occlusion event that leads to dilation of the follicle unit, a whole bunch of cytokine production, and then rupture and formation of these scarred tracts underneath the skin. That's the easy version of talking about it. On a complicated level, we don't actually really know, because there are so many different signals and cytokines and chemokines that are important to this disease, and none of our therapies has looked like a magic bullet. It's the reason why we sort of have to take an exclusionary approach and go down the list of possible targets to find what might work.

What we do know is that TNF-alpha does seem to be a top-level organizing cytokine that support the innate and adaptive features in this disease. Recent data has suggested IL-17, particularly really [a] full blockade of IL-17, can yield really good benefit and can actually even potentially prevent the formation of draining tunnels and sinus tracts.

JAK inhibition also is an appropriately broad strategy that seems to be able to treat multiple nodes of the disease itself. Some of the more emerging data suggest that targets like…tyrosine kinase, IL-1, various types of complement factors…even other cytokines that we think about more associated with the innate immune system, all are potential nodes. My guess, long run, we're never going to find 1 magic cytokine, but rather, probably a blanket approach that can allow us to treat the disease effectively.

DT: Can you talk a little about the multimodal approach to HS treatment?

RC: HS is one of those conditions where we usually think about lifestyle changes; easy, topical solutions; and potentially systemic options, and we usually do that all together. From a lifestyle standpoint, we really want to make sure our patients are living their best life possible, and that means really trying to curb potential smoking or tobacco use, doing a real good job of diet and exercise. There are interesting associations between tobacco use and obesity and this disease. They're not necessarily causatory. We don't have that data, but we do know these do seem to be associated with more severe conditions.

Then we want to optimize the use of cleansers in the areas of involvement. Antimicrobial cleansers like chlorhexidine gluconate, benzoyl peroxide…these have natural anti-inflammatory activity. They can be really helpful. Topically, we also think about the use of antibiotics, which oftentimes have anti-inflammatory activity. And then from a systemic standpoint, we'll oftentimes start also systemically with antibiotics, potentially medications that work on hormonal aspects of the disease, ones that actually are more traditionally reserved for diabetes, like metformin. Then at the next step, biologic therapies like adalimumab or secukinimab.

DT: What does the pipeline for HS look like currently?

RC: I think the big thing to be aware of with HS is that, while we've had very limited options historically, the 1 approval we've had the past year is just 1 of many that are to come, and you're going to be seeing probably something new happening almost every year. It behooves you to pay really close attention to what's happening at the podium when you're following along with some of the experts, because this is going to get very complicated very quickly. I think that once we understand how these drugs work, we’ll really have a better educated guess on what is the right drug for each patient. Additionally, I think that the more we pay attention to what's happening, the more comfortable we're overall going to feel with the use of any of these medications in our patients with HS.

DT: What are the areas of unmet need that still exist in HS?

RC: Hidradenitis suppurativa is literally the definition of unmet need as far as diseases go. We know that we don't diagnose the disease often enough. We know we don't treat early [or] aggressively enough. We know that we lack a lot of really good treatments that provide longitudinal control, and we know that many of our patients have a lot of extrinsic factors, various aspects of social and structural determinants of health, that make even getting them connected to health care a huge challenge. Efforts in the future are probably going to be addressing all of those to really get our patients to a place that we managed to get some of our other chronic diseases.

Reference:

Chovatiya R. Hidradenitis suppuritiva update 2024. Presented at: Maui Derm NP+PA Fall; September 15-18, 2024; Nashville, Tennessee.