Recognizing and Treating Hidradenitis Suppurativa With Joslyn Kirby, MD

Joslyn Kirby, MD, is an associate professor of dermatology at Penn State Health. At the 2023 Society of Dermatology Physician Assistants (SDPA) Annual Summer Dermatology Conference, Kirby spoke at a session on hidradenitis suppurativa (HS).

Kirby spoke with Dermatology Times® to discuss the highlights of her session, as well as the importance of recognizing and treating HS, including awareness efforts for the condition.

Joslyn Kirby, MD: I'm Joslyn Kirby. I'm an associate professor at Penn State Health in the Department of Dermatology.

Dermatology Times: What are key highlights and takeaways from your session, "Hidradenitis Suppurativa?"

Kirby: One of the biggest points I hope people walk away with is that HS is a much more complex immune system condition than, say, other chronic inflammatory skin conditions, thinking about eczema, thinking about psoriasis. So there are more components of the immune system contributing to the trouble that we see on the skin, and that can be frustrating. But it also presents a lot more opportunities to intervene; there's a lot more targets to try and treat. So I think it's both a frustration, but an opportunity.

We're always learning more about exactly why HS happens. I think that, aligned with that it's really important for us to help our patients understand that HS is not an infection, and that word gets thrown around a lot. And I think it's just really important for us and for them to use the word inflammation rather than infection, because I think that really helps them understand this is the power of their immune system, this overactive immune system. And that sets the stage for then talking about treatments, which are kind of a mixture of removing the triggers that set off that overactive immune system, or treatments that just helped to level set that overactive immune system. Because if we go into the room, and they don't understand, that they may have walked in with the conclusion that because they keep getting infections, that their immune system is underactive, or defective. And then if we go in and talk about a biologic or immunomodulator, they're not going to understand why that makes sense, because we didn't help them understand what this condition really is, which is an overactivity of the immune system where bacteria play more of a secondary role.

Dermatology Times: What is the significance and importance of HS awareness and recognition?

Kirby: I think the opportunity leading off from HS awareness week last week [June 5-11], is to help us keep in mind, where can we find those patients who maybe don't even realize they have HS? And sometimes, they're right there in the office. So it's the patient who comes in with really bad acne, because maybe they have HS that they just weren't ready to maybe share or disclose with us. It might be the patient with dissecting scalp cellulitis, who comes in and might also have HS, but again, wasn't necessarily going to lead with that. They were going to talk about their scalp, and they were going to try and figure out if they could talk to us about these painful bumps that were happening on more private areas of their body.

So rather than delay that conversation, can we ask those patients, 'Hey, have you ever got a painful bump? Or boil or nodule in your underarm or on your inside of your leg or on your buttock?' And if the answer is yes: 'Has that happened? How many times in the last 6 months? And if the answer is that they've had 2 or more episodes in the last 6 months, then that is somebody who is screening positive for HS, and it's a chance to say, 'Hey maybe you didn't get an a gown today. Can I ask that we take a look, because maybe there's something else I can help you with today?'

So from HS Awareness Week, it's: Let's find that HS even before people necessarily have a name for it; let's help them have a name for it. And let's find those patients on a good day, because sometimes patients come in to us, they of course, don't have the painful bumps on the day that they're in front of us in the office. So even on the good days, when somebody does come in for HS, we can help put in a name on it by asking those questions and also looking for the blackheads, that if they're under the arm or on the thigh, that is HS until proven otherwise, seeing the scarring from prior lesions. So even when they don't have the big boils, can we still diagnose and take active steps to manage the disease with them?

Dermatology Times: Why is it so important to address HS in stage-based treatment approaches?

Kirby: I find that some of my patients affected by HS are more cautious, that they really want to understand the safety of a treatment that we are maybe talking to them about. And I think that a thing that I'm balancing in my mind with any given patient is, I don't want the side effects of my treatment to be worse than what you're dealing with from your HS. But I also don't want the opposite. I don't want your HS to be causing so many impacts, side effects, on your life, and the treatments I'm giving you are kind of dinky, and don't come with a lot of side effects, but also usually don't come with a lot of effects. And that also rolls into when we're talking with patients, and talking to them about the side effects of treatments, helping them realize that we're not really making a decision between: 'Are we accepting of this side effect? Yes or no? Will I take the treatment? Yes or no?'

The choice is really: 'Am I willing to consider, take on the risk, of those side effects, and maybe the improvement that comes in my HS versus the impact of my HS right now? So which one do I want to deal with?' Because if we allow people to think about, 'I don't want to take that treatment,' and they walk out without it, or without anything, they still have that uncontrolled HS, and it has impacts, and it has side effects. So which one is the lesser of 2 evils?

At least for right now, HS is still a condition where we get the best improvement by thinking about both medicines and procedures in the management of a patient. And so we generally want to start with medicines and see how much improvement we can get. But if a person comes in and isn't totally clear, and if they find they have spots that keep coming back over and over in the same exact spot, or just have been persistently active in that same spot, but it's not a failure of the medicine, there are just some deeper lesions and pockets of inflammation that medicine can't get into, if there are those kind of fixed and persistent pockets of inflammation. We keep going with medicine, but we add in procedures. To change from medicine to medicine, for those fixed and persistent lesions, it's just going to expose the person to more medication side effects, which might be cost, when the medicine was doing what it could and what we could expect from it; we just had to add something complementary to it.

[Transcript edited for clarity]