Dr Iltefat Hamzavi on Managing Hidradenitis Suppurativa

In this podcast, Iltefat Hamzavi, MD, discusses therapeutic options for managing flares, the role of lasers, and new therapies in the pipeline for hidradenitis suppurativa.

Dr Hamzavi is a board-certified dermatologist at Hamzavi Dermatology & Dermatology Specialists, a senior staff physician in the Department of Dermatology at Henry Ford Health System, co-director of the Investigator-Initiated Research Unit at Henry Ford, president of the HS Foundation, and co-author of the HS Guidelines. 

Transcript

Melissa: Hello, everyone. Today we will be speaking with Dr Iltefat Hamzavi about the management of hidradenitis suppurativa.

Dr Hamzavi is a board-certified dermatologist at Hamzavi Dermatology & Dermatology Specialists, a senior staff physician in the Department of Dermatology at Henry Ford Health System, co-director of the Investigator-Initiated Research Unit at Henry Ford, president of the HS Foundation, and co-author of the HS Guidelines. Thank you so much for joining us today.

Dr Iltefat Hamzavi: Thank you for having me.

Melissa: What treatment options are effective for managing HS flares and how do you transition patients from treatments that target flares to other therapeutic options for maintenance?

Dr Hamzavi: There’s a variety of options to treat flares in HS patients and they have to customize obviously to the needs of the individual patient. But from a general algorithm or perspective, we often will use antibiotics to help treat flares.

We start off with doxycycline. If those don’t work, then will often go to a combination of a quinolone and rifampin. Then, if those don’t work, then we go to a combination of quinolone, rifampin, and metronidazole. Much of this work was done by researchers such as Dr Lambert and Dr Seif and is available from the HS Foundation guidelines. Those are the agents that we use mostly for initial flares.

We also do use very short courses of oral cortisone for less than a week, of prednisone, 20 milligrams or so or less. Then, for individual lesions which are not disseminated, then intralesional corticosteroids can also be helpful at 10 milligrams per CC. That’s an option that can also manage it.

Then we try to look at the overall state of the patient. Are these flares happening again, and again, and again? Then we try to develop a medical treatment and a surgical treatment routine that can help manage the overall underlying reasons why somebody continues to get flares despite the interventions.

Along with that is always lifestyle modification where we can make those to improve the patient. But antibiotics, intralesional corticosteroids, and occasionally oral corticosteroids are the key elements for acute flare-ups. Then, surgically we also do options such as deroofing and decompression therapies using deroofing to manage acute flare-ups.

If you have your surgical armamentarium, you have the intralesional corticosteroids, you have your antibiotics and occasional corticosteroids, you can help get people through those acute flare-ups.

Melissa: How do you determine when a patient requires surgical management?

Dr Hamzavi: Generally, there’s three stages of HS, and they’re called Hurley staging. They’re definitely falling by the wayside since we have better and better measures for clinical trials. Within the clinical context, the Hurley staging is very helpful, specifically when you’re using a low-class format.

What I mean by that is, we use a modified definition of Hurley. We call Hurley stage I as discrete nodules. When the nodules connect and form a tunnel underneath your skin, we call a sinus tract or a fistula. When you have that sinus tract that’s called Hurley stage II.

When the sinus tract interconnects, it goes in an X and Y axis in two dimensions, then you’re starting to move into Hurley stage III. Hurley stage I can often be managed with oral antibiotics, topical therapy, intralesional therapy, laser therapy in generalized areas that are recalcitrant to it using laser hair removal devices.

Then once you get into sinus tract formation that is persistent, you often have to look at surgical options in those patients. When you go to Hurley stage II and especially Hurley stage III, you have to remove the nidus of inflammation. These inflammatory cells and the material they produce, the mixture of bacteria, all those things become pasty material. That often has to be removed to reduce further flare-ups. When you remove it, your medical therapy tends to work better. You don’t need as much medical therapy.

Again, when you go to that stage II, stage III HS, sinus tract formation, that’s when surgical therapies are needed. More therapy such as deroofing in stage III, more advanced therapies such as CO2 laser or standard excisional surgery for stage III.

Melissa: What is the role of lasers and energy sources in the management of HS?

Dr Hamzavi: Lasers have been used for almost 10, 12 years. Our group, the Henry Ford Hospital in Detroit, did some initial studies using that and it’s been replicated by many other centers. It’s part of the guidelines evidence of Level B on the HS Guidelines that was published in the JAAD by the HS Foundation and the Canadian HS Foundation.

In those situations, in any clinical practice nowadays, what we do is we use laser hair removal for generalized stage I disease that becomes recalcitrant to therapy or is recurrent. If you treat somebody with some topical washes, and a topical antibiotic, and some lifestyle modifications, and use short courses oral antibiotics and clear up, you don’t really need it.

If you still, in the same underarm, or below the breast, or in the groin area, get recurrent lesions in those areas, then laser hair removal will be very helpful in preventing progression.

The goal isn’t necessarily hair removal. We do have settings that do remove hair, but it can be helpful in removing or preventing new lesions. This retrospective data suggests that it prevents new lesions from occurring. When you ablate the hair follicles or treat the hair follicles and an area keeps getting new lesions, you can slow it down or hopefully remove those.

In stage I disease, localized recurrent areas, laser hair removal seems to be a good option. Obviously, there are other cutting lasers or just CO2 lasers. That’s a whole different conversation for more advanced Hurley stage patients.

Melissa: Are there any new therapeutic options in the pipeline for HS?

Dr Hamzavi: We are so lucky that we are experiencing a mini-boom of new products in the pipeline for HS. We have the existing TNF-alpha inhibitors. Adalimumab is approved for HS. Then, infliximab is not approved for HS but also a good agent if adalimumab does not work.

Then within the pipeline, we have IL-17 inhibitors being developed. We have IL-23 inhibitors being tested. We have C5 inhibitors being tested. We have some new JAK inhibitors are being tested at this point. Also, repurposing other TNF-alpha inhibitors. Also, new work using various forms of IV antibiotics followed by consolidation therapy with oral antibiotics being developed.

All these new compounds are currently in the pipeline. I’m sure I’m missing a few, but it’s an exciting time in the HS community. The patient population, and the researchers, and the clinicians have really been challenged. The patients have suffered greatly and their families for so many years. With all these new trials coming up, it’s an exciting time.

Melissa: What areas of future research are needed to improve the management of HS? For example, diet.

Dr Hamzavi: Diet has a demand from our patient population. There’s lots of anecdotal evidence suggesting that diet can help in a large percentage of our population, maybe up to 55% in our Detroit population patients who’ll often have metabolic syndromes with diabetes, hypercholesterolemia, increased body mass index, but is not the case in all patients.

But many, many patients will describe that a change in diet improved their disease state. The challenge is that we haven’t been able to say that in a rigorous fashion. We’ve been pushing the NIH to look at options of using diets. Then, we’re also developing our own studies of using diet to try to treat HS.

We’re partnering up dietitians to see if there’s any biological assays, blood assays that can predict which foods might make HS worse, then devising and designing clinical trials and their outcomes to measure baseline disease and then intervening with a diet as it improves it.

HS is a complex disease. What area are you measuring? Are you measuring drainage? Are you going to measure new lesions? Are you going to measure pain? Are you going to measure progression of an early-stage patient or late-stage patient?

All those variables have to be parsed out. But it creates a lot of distress for our patient community because sometimes they won’t be appreciative of how science works, where we have to look at the overall goal, compartmentalize, find measures, do the studies, analyze the data, and then going back and do it again.

This is a time-consuming process that hopefully one day we won’t have to do. But that is what we had to do today with our existing body of knowledge but there is movements to do it. Again, it comes down to social will and I believe the social will is there from the physician and scientific community. The patient was definitely there but we’re trying to catch up to them.

Melissa: How has the pandemic affected patients with HS?

Dr Hamzavi: Like everybody else, it’s been difficult. In the beginning, it was so hard to access care and patients have flare-ups. These are some of the sickest people in dermatology. HS is a tremendous, tremendous mental health burden. It’s one of the most common comorbidities. Unfortunately, HS patients have some of the highest rates of suicide of any dermatologic disease.

The impact of mental health was challenging, access to care. We also we’re tracking our patients who have registered under the UCSF, led by Dr Haley Naik, looking at whether or not patients had worse outcomes and we’ll continue to collect that data and look at that.

Limited, limited experience at Henry Ford. The few patients who were on TNF-alpha inhibitors who got COVID all did well. Access to care, mental health effects were challenging.

Patients who are on these stronger biologic medications did OK, but now things are coming back online, at least in our practice, and I think most of the country, so people do have access to care. With the appropriate precautions, we can help we offer the same support that we were offering before the pandemic.

Melissa: What key takeaways would you like to leave our audience with?

Dr Hamzavi: First off, be patient with the HS population, they are some of the most loyal, kind-hearted, caring patients. But in the beginning, they take a little more time explaining what’s going on, assuaging anxiety, because many of them have been on social media or have family members with HS. That causes problems with the experiences.

The visit might take a bit longer, but subsequent visits are much easier. Show that patient that kindness, that empathy, and you will enjoy your career. Because there’s very few diseases that give you so much satisfaction like caring for an HS patient. They’re also incredible people.

Then making sure that you have the ability to manage a flare as we just described earlier. Then, a flare is often an opportunity to get better overall disease control using some of the existing interventions that are reviewed in the HS guidelines in the Journal of the American Academy of Dermatology.

If you can use those guidelines to help slow down their progression and then using surgical interventions for advanced cases, you can use a combination of lifestyle modifications with washes and diet. You can add your acute interventions for flares and build up a baseline level of therapy, and then ultimately also use surgical therapy for recalcitrant areas.

In summary, use your oral treatments well. Know when to go in with your procedures, know how to show empathy and care for your patients, and do the lifestyle modification, and you’re going to have a happy career and you’ll have happy patients who will deeply appreciate all that you do. You’ll appreciate the fact that they are just some wonderful people to work with.

Melissa: Thank you so much for being with us today, Dr Hamzavi, and thank you for listening. If you have any questions or comments you would like to ask Dr Hamzavi, please submit them in the feedback box below. We really enjoy your feedback.