Consider a different approach to managing hidradenitis suppurativa

By Denise Fulton, Frontline Medical News

NEWPORT BEACH, CALIF. – Instead of relying on the traditional treatment ladder, consider taking a pathophysiologic approach to managing patients with hidradenitis suppurativa (HS). That was the advice Dr. Haley Naik gave at the PDA Annual Meeting.

Dr. Naik challenged her colleagues to “take a step back and take into account [the patient’s] whole phenotype when making treatment decisions. Perhaps the obese, Caucasian female with axillary and inframammary disease should be managed differently from the thin, African American male who comes in with exclusively gluteal disease.”

The traditional treatment ladder for HS starts with topical antibiotics and moves through systemic antibiotics, anti-inflammatory agents, biologics, and then leads potentially to surgery for the most severe or refractory cases, said Dr. Naik, assistant professor of dermatology at the University of California, San Francisco.

The pathophysiologic approach bases treatment decisions on the patient’s individual presentation. For example, patients with mild disease may be experiencing a dysregulation of their skin microbiome; these patients might be treated with topical or systemic antibiotics with or without an antiseptic regimen such as bleach baths or other antiseptic washes. For HS patients with a hormonal phenotype, an oral contraceptive, spirolactone, or finasteride might be a better treatment option.

The most recent advances in HS management center around the concept that HS is an immune-dysregulatory disease, Dr. Naik said. The Food and Drug Administration approval in September 2015 of adalimumab (Humira) for moderate to severe HS marked the first time a treatment was specifically approved for the disease.

In two parallel phase III trials, patients who received 40 mg of adalimumab weekly responded significantly better – defined as a 50% improvement from baseline in inflammatory nodules and abscesses, with no increase in abscess or draining fistula counts at week 12 – than those on placebo (N Engl J Med. 2016;375:422-434 DOI: 10.1056/NEJMoa1504370).

“The problem [with this treatment] is that dosing and dose frequency is fixed,” Dr. Naik noted. “If your patients are only partially responding to the therapy, you don’t have much wiggle room with this medication.”

Infliximab (Remicade), on the other hand, is easier to titrate, she said. In a prospective, double-blind study, more patients on infliximab showed a 50% or greater decrease in the HS Severity Index score than did those on placebo, even by week 8 (J Am Acad Dermatol. 2010;62:205–217).

“The body of evidence is not as strong or as robust as what we have with adalimumab, but is still quite good,” she said. There is also some evidence supporting the use of anakinra (Kineret) in HS. A recently published pilot study showed that more patients (7 of 10) who received anakinra saw an improvement in HS than did those (3 of 10) on placebo (JAMA Dermatol. 2016 152(1):52-59).

“Further work needs to be done in this area to understand the efficacy of anakinra in HS. I certainly wouldn’t consider anakinra a first- or second-line biologic for the management of HS, but it is certainly an option for patients who have refractory disease.”

Dr. Naik disclosed that she has no relevant conflicts of interest.