A recent video series, “Navigating Hidradenitis Suppurativa Chronicles,” presented by Tiffany Mayo, MD, Associate Professor and Vice Chair of Diversity and Inclusion at the University of Alabama at Birmingham, delves into the complexities of hidradenitis suppurativa (HS), a chronic and debilitating skin disorder. Dr. Mayo, who also directs the Clinical Research Unit in the Department of Dermatology at the Heersink School of Medicine, discussed the disease’s etiology, diagnostic challenges, stages of progression, and emerging treatment options, particularly biologics.
HS, which affects an estimated 0.05% to 4.1% of the global population, primarily impacts areas with apocrine glands, such as the armpits and groin. It is characterized by painful nodules, abscesses, and draining lesions. While the exact cause remains unclear, research suggests that a combination of genetic and environmental factors leads to inflammation of hair follicles. This inflammation results in follicular blockage, rupture, and continued tissue damage, driven by cytokines like interleukin (IL)-17, IL-23, IL-1β, IL-12, and tumor necrosis factor (TNF)-α.
Dr. Mayo emphasized the significant burden HS places on patients, with chronic pain being the most commonly reported symptom. According to studies, 62% of patients experience abscesses that do not resolve, and the condition is associated with high rates of mental health challenges, including depression and anxiety. Furthermore, patients with HS are at a greater risk of suicide, and 40% are unable to work due to the disease’s disabling nature. In fact, HS has been found to impair quality of life more severely than conditions such as psoriasis, acne, and atopic dermatitis.
Diagnosing HS is often difficult, typically relying on clinical evaluation rather than lab tests. Delays in diagnosis are common, with many patients not receiving an accurate diagnosis until 7 to 10 years after symptom onset. This delay can lead to severe disease progression, including fibrosis, scarring, and sinus tract formation—damages that are often irreversible. Dr. Mayo stressed the importance of early diagnosis and intervention, noting that treating HS at an early stage can prevent permanent scarring and improve long-term outcomes.
HS progresses through three stages: mild, moderate, and severe. In the mild stage, patients may experience deep, painful nodules that evolve into abscesses without scarring or sinus tracts. The moderate stage is marked by recurrent abscesses and scarring, while the severe stage features extensive lesions, interconnected tracts, and ruptured nodules, often accompanied by constant pain. If left untreated, the disease can lead to significant disfigurement, including keloids, contractures, and immobility.
Dr. Mayo highlighted that the severity of HS is not always reflected in its clinical presentation. Subclinical lesions, which may not be visible on the skin, can be detected using imaging tools such as ultrasound or magnetic resonance imaging (MRI). Additionally, patient-reported assessments, such as the Hidradenitis Suppurativa Impact and Symptom Assessments, can help in accurately staging the disease.
The treatment approach for HS aims to manage symptoms and prevent disease progression. Dr. Mayo noted that treatment plans should be individualized, taking into account the disease stage, patient preferences, and potential comorbidities. She advised clinicians to educate patients thoroughly on available treatment options, including the risks and benefits of each. Despite extensive counseling and paperwork required for treatments, resources are available to support clinicians, such as treatment guidelines and authorization templates.
Clinical management of HS can be complex, often involving a combination of medical treatments (topicals, systemic antibiotics, immunomodulators, retinoids, and biologics) and procedural interventions (laser therapy, excisions, and deroofing). Dr. Mayo focused particularly on systemic therapies, which are commonly used for moderate to severe cases. Antibiotics, once the cornerstone of HS treatment, are now recommended only as adjunctive therapy due to issues like low efficacy and antibiotic resistance. Similarly, hormone therapies may be useful in certain patients, though their effectiveness is not well established, and some may experience exacerbation of symptoms. Retinoids and immunomodulatory drugs, such as methotrexate, azathioprine, and cyclosporine, also offer limited efficacy and carry potential side effects.
Biologics have emerged as a promising treatment for moderate to severe HS, showing success in managing other inflammatory conditions like rheumatoid arthritis and psoriasis. Clinical guidelines now recognize biologics as a cornerstone therapy for HS, though challenges remain in the research, including variability in study outcomes, a lack of dose-ranging studies, and short follow-up periods. Current biologic treatments target pathways involving TNF, IL-1, IL-12, IL-17, and IL-23. These therapies not only address visible lesions but also target subclinical lesions, which is crucial in preventing further disease progression and improving patient outcomes.
Dr. Mayo stressed the importance of early intervention with biologic therapy to avoid disease complications and to reduce the negative impact on quality of life, particularly given HS patients’ higher risk for mental health issues such as depression and suicide. Delayed treatment can lead to irreversible damage and missed opportunities for disease control.
In conclusion, Dr. Mayo highlighted the critical need for increased awareness, timely diagnosis, and comprehensive treatment plans for HS. While challenges remain in managing this complex disease, patient education and collaboration with specialists can significantly improve care. As Dr. Mayo stated, “We are all responsible for ensuring that patients are accurately diagnosed and receive the treatment they need.”
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