Treatment Guidelines and the Role of Biologics in the Treatment of Hidradenitis Suppurativa

EP: 1.Hidradenitis Suppurativa: Practical Tips and Considerations Regarding Diagnosis, Treatment, and Patient Communication

EP: 2.Hidradenitis Suppurativa: Overview, Patient Burden, and Challenges to Diagnosis

EP: 3.Disease Severity and the Role of Progression in Hidradenitis Suppurativa

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EP: 4.Treatment Guidelines and the Role of Biologics in the Treatment of Hidradenitis Suppurativa

EP: 5.Navigating Hidradenitis Suppurativa Chronicles

Hi, and welcome to this Dermatology Times Partner Perspective video series. I’m Tiffany Mayo, associate professor, vice chair of diversity and inclusion, and director of the clinical research unit at the Heersink School of Medicine department of dermatology at the University of Alabama at Birmingham. In the first video, we discussed the clinical features, patient burden, and challenges of diagnosis of hidradenitis suppurativa, or HS. In this video, I will be discussing the standard treatment approach for moderate to severe HS, with a focus on systemic treatment. I will also discuss the emerging role of biologics in the treatment of this disease. Of note, there is an ongoing need for further research to develop stronger evidence-based recommendations.

This episode is sponsored by Novartis, and I have been compensated for my time.

Management of HS can be complex, with a need to address symptoms, associated pain, and psychiatric and medical comorbidities.¹ As I discussed in an earlier video, disease progression can involve inflamed nodules, abscesses, and eventual scarring, and can strongly impact patient quality of life.² Pain is particularly intense during flares and abscess formation.³ Aims of treatment should be not only to address present symptoms but also to prevent progression.⁴

Treatment selection is influenced by the stage, or severity, of HS, which is determined by the clinical presentation and imaging results as well as patient perception of symptoms.^3,5 Ultimately, treatment and management of HS is guided by the clinician and patient, with an emphasis on factors unique to individual patients and their specific preferences.^4,6

It’s important to understand that patients may feel as if they have already tried the recommended treatments or have hesitancy toward some treatments. Clinicians should still try to educate patients on the overall treatment plan and review the risk and benefits of treatment in the context of discussing HS and its overall impact on the patient. This allows patients to make a well-informed decision regarding their health.^7,8

Now, let’s transition to review the standard approaches and suggestions for care, including the 2019 guidelines from the United States and Canadian HS Foundations. Interventions commonly used for HS include topicals; lasers; surgical procedures, such as excisions and deroofing; and systemics. As I mentioned in an earlier video, due to diagnostic challenges in the early stages, patients often receive initial diagnosis of moderate to severe HS. Treatment for these advanced stages typically includes systemic therapies.^4,7

Standard systemic agents have been associated with varying levels of success in treating moderate to severe HS, which highlights the need for therapies with improved efficacy and safety profiles. There are many efficacy and safety factors to consider when choosing treatments for HS.¹

Antibiotics have historically been used as a mainstay treatment for HS. They may be administered as monotherapy in mild cases and as adjunctive treatment in advanced disease. However, they are associated with poor response, recurrence following cessation, and risk of antibiotic resistance. With these considerations, antibiotics should be used only as adjunctive therapy in severe cases, and clinicians must monitor duration and frequency of use to reduce risk of resistance.¹

Hormone therapies are used frequently, particularly in women, but also in children and occasionally in men. Use is based on limited evidence that is primarily anecdotal. Notably, progesterone can exacerbate HS among some patients.¹ Hormone therapies are most appropriate for mild to moderate HS and may also be used as adjunctive treatment in severe cases.¹

Retinoids have also been used historically, although results for HS are subpar in comparison to those achieved for patients with cystic acne.¹ Patients receiving retinoids must be monitored for specific side effects.¹

A few immunomodulatory medications have been used to treat HS. Examples include methotrexate, azathioprine, and cyclosporine. However, efficacy has been generally low with these therapies, and side effects limit duration of use. Methotrexate is not recommended for treatment of HS by the HS Foundation.¹

Long-term systemic corticosteroids that are tapered to the lowest possible dose can be considered as an adjunct therapy for patients with severe HS who have experienced a suboptimal response to standard therapy. Pulsed or tapered prednisone has also been used as acute rescue therapy or a bridge to other therapy with considerable success; however, its use is also limited by side effects.¹

In clinical practice, combination therapy is typical for moderate to severe HS.⁹ Personally, most of my patients are on combination therapy tailored to their symptoms. In research, there are limited data showing combination therapy is effective in treatment of HS, though more studies are needed.⁷

More recently, investigators have explored treating HS with biologics, which have demonstrated success in the management of other inflammatory diseases such as rheumatoid arthritis and psoriasis.¹⁰ The HS Foundation has recognized the potential therapeutic value offered by biologics, stating that biologics are becoming the cornerstone therapy for moderate to severe HS.^1,11

In research, biologic targets of interest include tumor necrosis factor, or TNF, and interleukin, or IL, 1, 12, 17, and 23 pathways. Currently, approved biologic agents indicated to treat moderate to severe HS include a TNF-α inhibitor and an IL-17A inhibitor.¹

Biologic therapies can target preclinical and subclinical lesions in addition to clinically visible lesions.³ This is an important consideration. Remember, a goal in managing HS is to prevent disease progression, sinus tract formation, and fibrosis.⁴ Of all chronic inflammatory diseases, HS has one of the most negative effects on patient quality of life, with a higher risk of depression and suicide compared to that of the general population.³ As HCPs, we should take this risk seriously and not delay biologic therapy in patients with moderate and severe HS who may benefit from the treatment.^1,2

Of note, primary limitations of biologics include considerable variability and validity of endpoints, lack of dose-ranging studies, and short follow-up periods.¹

In the next and final video, I will share a few tips and resources regarding the overall management of HS. Thank you to our viewers for watching.

References

1. Alikhan A et al. J Am Acad Dermatol. 2019;81(1):91-101.

2. Hunt A et al. Dermatol Ther (Heidelb). 2023;13(7):1391-1407.

3. Sabat R et al. Nat Rev Dis Primers. 2020;6(1):18.

4. Kimball AB, Jemec GBE, eds. Hidradenitis Suppurativa: A Disease Primer. Adis; 2017.

5. Mendes-Bastos P et al. Br J Dermatol. 2023;188(5):591-600.

6. Willems D et al. Patient. 2023;16(2):153-164.

7. Snyder CL et al. Clin Cosmet Investig Dermatol. 2023;16:1833-1841.

8. Garg A et al. J Am Acad Dermatol. 2020;82(2):366-376.

9. Gill L et al. F1000Prime Rep. 2014;6:112.

10. Lee RA, Eisen DB. J Am Acad Dermatol. 2015;73(5)(suppl 1):S82-S88.

11. Novartis AG. Published June 1, 2023. Accessed August 23, 2023. https://www.novartis.com/news/media-releases/novartis-receives-european-approval-cosentyx-first-and-only-il-17a-inhibitor-hidradenitis-suppurativa

12. Ring HC, Yao Y, Maul JT, et al. Br J Dermatol. 2022;187(4):523-530.