Patient Selection Criteria in Hidradenitis Suppurativa

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Robert G. Micheletti, MD: The other class of drugs that I think deserves special mention is the biologics. For patients with more severe disease, these can be appropriate and can be very, very useful to calm the inflammation. So, there are infliximab and adalimumab, the two TNF inhibitors that have been shown to be efficacious in various studies. Etanercept really has not shown efficacy in the studies that have been performed. And then there is some growing literature on ustekinumab and anakinra, as well. We talked about how in patients with hidradenitis, TNF, Th17, IL-1-beta are upregulated. There’s a method to the madness. There’s a reason these things have been tried, and there’s a reason they’re being studied.

In particular, now with the most recent studies on adalimumab, we have our first FDA-approved drug, adalimumab, based on the results that were seen. For patients, particularly those who have more severe disease, this can be a game changer. And we see patients go from total misery to doing much better, so reason for excitement in our therapeutic options.

When we talk about choosing a therapy that’s appropriate for a particular patient, again, we want to think back to that Hurley staging—Hurley stage 1, 2, and 3—really breaking down as mild, moderate, and severe. And when we’re thinking about our patients that way, it helps dictate what treatment is likely to be efficacious. For mild, Hurley stage 1 patients—the patients with open comedones, a few scattered recurring inflammatory lesions—these are patients who are going to benefit from an approach like a topical wash, chlorhexidine, or benzoyl peroxide, clindamycin solution, and then some comedones, like doxycycline, as an initial agent.

For patients with more moderate disease—sinus tract formation, a higher level of inflammatory nodules—these are patients who might respond to doxycycline, but really tend to do better, in my experience, with the clindamycin/rifampin combination. Or perhaps you start to think about some of the hormonal agents for added efficacy in addition to your antibiotic regimen. Also, for patients who have moderate disease that is maybe incompletely responsive to that clindamycin/rifampin combination or certainly for patients with more severe disease, then we want to be thinking about some of the more aggressive agents like the biologics, infliximab or adalimumab, and others. We really take advantage of the fact that we have so many agents, at least that we can think about using, and also the surgical options. So, the average patient, I would say, over the time that they’re seeing the provider and coming back for follow-ups, that patient may get intralesional Kenalog injections when having an acute flare, may start on doxycycline or clindamycin/rifampin, and then progress to something else or vice versa. You might do laser. You might do other things. And really, over time, based on what’s happening at that moment, you can utilize some of these various options and put together a combination of treatments that can be effective.

I do think that there are the rare patients who have such severe disease that even from the very beginning, you know that doxycycline, clindamycin/rifampin are not going to get the job done. And I would say that patient is the one with the suppurating erosive disease that almost looks like pyoderma gangrenosum or another just very inflammatory condition. Those patients, I think, really need TNF inhibitors from the get-go. And it’s really important to recognize that because I’ve seen patients who are put on therapies that are really more meant for mild or moderate disease, and they just continue to progress and get more and more inflamed. So, getting those patients on appropriate therapy, again, thinking about Hurley stage 1, 2, and 3—mild, moderate, and severe—it really is helpful in terms of dictating appropriate therapies.

Transcript Edited for Clarity