Rapid HS Pearls: Drug Data and Wound Care

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Managing hidradenitis suppurativa (HS) requires a multifaceted approach with medical surgical, and social interventions to serve patients, and 4 leaders in HS research and treatment showcased the latest drugs and treatment strategies at the 2024 Fall Clinical Dermatology Conference for Physician Assistants and Nurse Practitioners in Scottsdale, Arizona. The workshop titled “A Clinician’s Guide to Managing HS” was led by Hadar Lev-Tov, MD, MAS, associate professor at the University of Miami Miller School of Medicine in Miami, Florida; Jennifer Hsiao, MD, associate professor at the Keck School of Medicine at the University of Southern California in Los Angeles, California; TJ Chao, MPAS, PA-C, advanced practitioner at Atlanta North Dermatology in Atlanta, Georgia; and Athena Gierbolini, HS Foundation board member, Hope for HS president.¹

The Diagnostic Journey

Session leaders took a moment to pause for perspective on diagnosing HS. They remind clinicians of the 2-2-6 Rule: 2 episodes of 2 or more abscesses in 6 months. Comorbidities that are level II evidence for HSto screen for include acne, pilonidal disease, depression, suicidality, anxiety, sexual dysfunction tobacco or substance use, dyslipidemia T2D, HTN, obesity, PCOS, inflammatory bowel disease, and spondyloarthirits.² Multidisciplinary care in HS involves having connections, communication, and referrals ready for treatment in psychiatry and psychology, infectious disease, general and plastic surgery, nutrition and dietetics, primary care, gastroenterology, rheumatology, and obstetrics/gynecology.³

Research and Trials for HS Treatment

The current HS treatment armamentarium is growing and evolving. The current pharmaceutical landscape for the condition includes:

• Adalimumab (Humira; AbbVie), a TNF inhibitor, is widely used for HS. According to data from 2 phase 3 trials, approximately 40-60% of patients respond to adalimumab.However, around 40-50% of patients lose their response by 9 months.Factors that increase the risk of treatment failure include advanced disease (Hurley Stage III), presence of draining tunnels, obesity, and tobacco use. Despite these challenges, adalimumab is safe to use perioperatively, and dose escalation might be beneficial, although data is limited in this regard.^4-5
• Secukinumab (Cosentyx; Novartis), an IL-17A inhibitor, shows promise for patients who have not responded to TNF inhibitors. The recommended dosing is:300 mg subcutaneously weekly for 5 weeks, followed by 300 mg every 4 or 2 weeks. Women and patients with a lower BMI tend to respond better. Notably, approximately 60% of TNF inhibitor failures respond by 16 weeks. Session leaders noted that secukinumab is particularly useful for patients with a history of demyelinating disease, heart failure, or malignancy.^6-7
• Bimekizumab (Bimzelx; UCB), targets both IL-17A and IL-17F, proving efficacy. In trials, the BE HEARD HiSCR50 Response was around 55% to 60% at 16 weeks and 70% at 48 weeks at the highest dose.This dual inhibition strategy offers hope for patients with more severe or refractory HS.⁸
• Povorcitinib (INCB54707; Incyte), a JAK1 inhibitor, shows potential in phase II trials with HiSCR₅₀ score demonstrating approximately 60% at the highest dose by 12 weeks and HiSCR₉₀ score demonstrating around 20% at the highest dose by 12 weeks.Its mechanism involves downregulating TNF-α and TGF-β pathways, indicating a novel therapeutic avenue for HS management.⁹

Comprehensive Wound Care: Pre- and Post-Operative Strategies

Effective wound care is essential for managing HS. Here are some recommendations discussed in the workshop:

Pre-Operative Care

For comfort measures in pre-o, session leaders recommended the use of lorazepam (0.5-1 mg) for anxiety, music, and comfortable positioning. Recommended anesthesia includes lidocaine 0.5% with 1:200,000 epinephrine as a ring block; lidocaine 0.2% in 10cc syringes for tumescent anesthesia.¹

Post-Operative Care

Pain management can include bupivacaine 0.25% as a ring block, tranexamic acid dripped onto the surface, and toradol10 mg as needed.Absorptive dressings such as foams, calcium alginate, and superabsorbent dressings are recommended for heavily draining wounds. The choice of dressing should be dynamic, based on the lesion’s requirements and patient factors (e.g., allergies, friction areas).1

Routine Wound Care

Session leaders said there is no definitive evidence that any one cleanser is superior for HS wounds. Here are key points to consider:

• Dynamic Needs: Different lesions may require different dressing types throughout the disease course.
• Absorptive Dressings: These are crucial for managing heavily draining wounds.
• Atraumatic Materials: Dressings should be kept in place using materials that minimize trauma to the skin.

Regular re-evaluation and optimization of dressing choices are essential, considering patient factors (allergies, skin friction) and wound-related factors (exudate amount, colonization).¹⁰

References

1. Lev-Tov H, Hsiao J, Chao TJ, Gierbolini A. A clinician’s guide to managing hidradenitis suppurativa: an in-depth workshop. Presented at: 2024 Fall Clinical Dermatology Conference for PAs and NPs; May 31-June 2, 2024; Scottsdale, AZ
2. Garg A, Malviya N, Strunk A, et al. Comorbidity screening in hidradenitis suppurativa: Evidence-based recommendations from the US and Canadian Hidradenitis Suppurativa Foundations. J Am Acad Dermatol. 2022;86(5):1092-1101. doi:10.1016/j.jaad.2021.01.059
3. Narla S, Lyons AB, Hamzavi IH. The most recent advances in understanding and managing hidradenitis suppurativa. F1000Res. 2020;9:F1000 Faculty Rev-1049. Published 2020 Aug 26. doi:10.12688/f1000research.26083.1
4. Bechara FG, Podda M, Prens EP, et al. Efficacy and safety of adalimumab in conjunction with surgery in moderate to severe hidradenitis suppurativa: the SHARPS randomized clinical trial. JAMA Surg. 2021;156(11):1001-1009. doi:10.1001/jamasurg.2021.3655
5. Kimball AB, Okun MM, Williams DA, et al. Two phase 3 trials of adalimumab for hidradenitis suppurativa. N Engl J Med. 2016;375(5):422-434. doi:10.1056/NEJMoa1504370
6. Fernandez-Crehuet P, Haselgruber S, Padial-Gomez A, et al. short-term effectiveness, safety, and potential predictors of response of secukinumab in patients with severe hidradenitis suppurativa refractory to biologic therapy: a multicenter observational retrospective study. Dermatol Ther (Heidelb). 2023;13(4):1029-1038. doi:10.1007/s13555-023-00906-2
7. Kimball AB, Jemec GBE, Alavi A, et al. Secukinumab in moderate-to-severe hidradenitis suppurativa (SUNSHINE and SUNRISE): week 16 and week 52 results of two identical, multicentre, randomised, placebo-controlled, double-blind phase 3 trials [published correction appears in Lancet. 2024 Feb 17;403(10427):618]. Lancet. 2023;401(10378):747-761. doi:10.1016/S0140-6736(23)00022-3
8. Kimball AB, Zouboulis CC, Sayed C, et al. Bimekizumab in patients with moderate-to-severe hidradenitis suppurativa: 48-week efficacy and safety from BE HEARD I & II, two phase 3, randomized, double-blind, placebo controlled, multicenter studies. Presented at Late-breaking Research Session 1 of the Annual Academy of Dermatology Annual Meeting. March 17-21, 2023; New Orleans, LA.
9. Kirby JS, Okun MM, Alavi A, et al. Efficacy and safety of the oral Janus kinase 1 inhibitor povorcitinib (INCB054707) in patients with hidradenitis suppurativa in a phase 2, randomized, double-blind, dose-ranging, placebo-controlled study. J Am Acad Dermatol. 2024;90(3):521-529. doi:10.1016/j.jaad.2023.10.034
10. Chopra D, Anand N, Brito S, et al. Wound care for patients with hidradenitis suppurativa: Recommendations of an international panel of experts. J Am Acad Dermatol. 2023;89(6):1289-1292. doi:10.1016/j.jaad.2023.07.1037