of their most challenging symptoms, according to an expert summary presented at the Skin of Color Update 2020.
Dr. Ginette Okoye
“If your patient is only focused on the appearance of the lesions or the presence of sinus tracts, they might not think your treatment is working,” said Ginette A. Okoye, MD, professor and chair, department of dermatology, Howard University, Washington.
Instead, she advised working with patients to define priorities, allowing them to measure and appreciate improvement. The most difficult symptoms for one patient, such as pain or persistent abscess drainage, might not be the same for another.
There is a large array of treatment options for HS. These were once typically employed in stepwise manner, moving from steroids to hormonal therapies, antibiotics, and on to biologics and lasers, but Dr. Okoye reported that she layers on treatments, guided by patient priorities and responses. “Most of my patients are not on just one treatment at a time,” she said.
In addition to patient goals, her treatment choices are also influenced by the presence of comorbidities such as metabolic syndrome, polycystic ovarian syndrome (PCOS), or inflammatory bowel disease (IBD). For example, she reported she is more likely to include metformin among treatment options in patients with central obesity or insulin resistance, whereas she moves more quickly to a biologic for those with another systemic inflammatory disease such as IBD.
Although multiple factors appear to contribute to the symptoms of HS, the pathophysiology remains incompletely understood, but follicular occlusion is often “a primary inciting event,” Dr. Okoye said.
For this reason, laser hair removal can provide substantial benefit, she noted. Not only does it eliminate the occlusion, but the heat generated by the laser eliminates some of the pathogens, such as Porphyromonas gingivalis, associated with HS.
“Lasers work well for preventing new lesions from forming but also in making active lesions go away faster,” said Dr. Okoye, who relies on the Nd:YAG laser when treating this disease in darker skin. She has found lasers to be particularly effective in mild to moderate disease.
When using lasers, one challenge is third-party insurance, according to Dr. Okoye, who reported that she has tried repeatedly to convince payers that this treatment is medically indicated for HS, but claims have been routinely denied. As a result, she has had to significantly discount the cost of laser at her center in order to provide access to “a modality that actually works.”
Incision and drainage of inflamed painful lesions is a common intervention in HS, but Dr. Okoye discourages this approach. Because of the high recurrence rates, the benefits are temporary. Instead, she recommends an intralesional injection of triamcinolone acetonide diluted with equal amounts of lidocaine.
With this injection, “there is immediate pain relief followed by significant resolution of the inflammation,” she said. Because of the likelihood that patients seeking care in the emergency department for acutely inflamed lesions will receive surgical treatment, Dr. Okoye recommends offering patients urgent appointments for steroid injections when painful and inflamed lesions need immediate attention.
In contrast, marsupialization of abscesses or sinus tracts, often called deroofing, is associated with a relatively low risk of recurrence, can be done under local anesthesia in an office, and can lead to resolution of persistent nodules in patients with mild disease.
“This is an easy procedure that takes relatively little time,” advised Dr. Okoye, who provided CPT codes (10060 and 10061) that will provide reimbursement as long as procedural notes describe the rationale.
Metformin is an attractive adjunctive therapy for HS in patients with type 2 diabetes or features that suggest metabolic disturbances, such as central obesity, hypercholesterolemia, hypertension, or hypertriglyceridemia. It should also be considered in patients with PCOS because metformin decreases ovarian androgen production, she said.
When prescribing metformin in HS, which is an off-label indication, “I prefer the extended release formulation. It has a better profile in regard to gastrointestinal side effects and it can be taken once-daily,” Dr. Okoye said.
Citing a study that suggests patients with HS have even worse quality of life scores than do patients with diabetes, Dr. Okoye also emphasized the importance of psychosocial support and lifestyle modification as part of a holistic approach. With multiple manifestations of varying severity, individualizing therapy to control symptoms that the patient finds most bothersome is essential for optimizing patient well being.
Tien Viet Nguyen, MD, who practices dermatology and conducts clinical research in Bellevue, Wash., agrees that a comprehensive treatment program is needed. First author of a recent review article on HS, Dr. Nguyen agreed that common comorbidities like IBD, PCOS, and diabetes are accompanied frequently by a host of mental health and behavioral issues that contribute to impaired quality of life, such as depression, low self-esteem, sexual dysfunction, impaired sleep, and substance use disorders.
“Therefore, addressing these important comorbidities and quality of life issues with other health care professionals as a team is the best approach to improving health outcomes,” he said in an interview.
Dr. Nguyen also recently authored a chapter on quality of life issues associated with HS in the soon-to-be-published Comprehensive Guide to Hidradenitis Suppurativa (1st Edition, Dermatology Clinics). He agreed that optimal outcomes are achieved by an interdisciplinary team of health care providers who can address the sometimes independent but often interrelated comorbidities associated with this disorder.
Dr. Okoye has financial relationships with Pfizer and Unilver, but neither is relevant to this topic.