Managing Hidradenitis Suppurativa: A Guide to Current Treatment Options

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. On this episode, we’ll hear about the treatment options for hidradenitis suppurativa, or HS, from Dr. Daniel Klufas, who is an Assistant Professor of Dermatology at the University of California, San Francisco. Let’s hear from Dr. Klufas now.

Dr. Klufas:
From a medical perspective, the current treatment options do vary. So for mild HS without any evidence of tunnels or scarring—essentially, going back to that Hurley stage system, a stage I patient—topical antimicrobials can be used. There’s a variety of topicals that are used in clinical practice, but there isn’t great clinical data supporting their efficacy. So then, generally, the next step of treatment includes antibiotics, which can be used to treat secondary inflammation. Most HS lesions are polymicrobial, so empiric treatment with broad spectrum antibiotics is recommended. That being said, monotherapy like doxycycline can be used for milder disease, though for more advanced stages, usually some sort of combination therapy like clindamycin and rifampin is recommended. Now, for the more advanced stages of disease—so our Hurley stage II/III patients and sometimes even some Hurley stage I—biologics, such as our TNF inhibitors—so that’s adalimumab and infliximab—are recommended. And then we have our newer approved drugs such as the IL-17 inhibitors. Secukinumab and bevacizumab are other viable options.

I’m mostly a procedural dermatologist, and procedural intervention also plays a role in all stages of HS; this is something that I perform regularly for my patients. For acute flares, intralesional steroids or procedures such as a punch deroofing to alleviate the pain can be performed, though the latter will often lead to some sort of recurrence. For more definitive management, there are other procedures. So for instance, for milder disease, I perform laser hair removal, and this accomplishes two things. One, it destroys the hair follicle and the associated glands, and two, it can induce thermal damage to the actual inflammatory nodule, effectively destroying them. And then the two most commonly used lasers that I use for that are the long-pulsed Nd:YAG and the Alexandrite. Other interventions, like botulinum toxin, can also be effective. The precise mechanism isn’t known, but it’s thought that possibly the reduction in sweating may impede the growth of environment for the bacteria and thereby reduce some of the inflammation.

And then, finally, true excisional surgery plays a role once that architectural damage of the skin has occurred. So to clarify, once a tunnel or a sinus tract is formed, no medical therapy is going to reverse that, and if the tunnel isn’t removed, this will continue to be a nidus for inflammation. So as such, a simple in-office procedure like deroofing, which is something I regularly perform, is a great option with low morbidity and great patient satisfaction. Larger excisional surgeries are generally performed by other surgical subspecialists and are reserved for advanced stages of disease, usually involving a whole anatomic region or critical structures.

Announcer:
That was Dr. Daniel Klufas talking about treatment options for hidradenitis suppurativa. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!