Comprehensive Management Approaches for Hidradenitis Suppurativa

At Fall Dermatology Week, Alexandra Charrow, MD, FAAD, presented a detailed overview of current and emerging strategies for managing hidradenitis suppurativa (HS). Her session explored lifestyle interventions, pharmacologic treatments, and surgical options, offering practical insights for effective care.

Dr Charrow began by emphasizing lifestyle modifications essential for HS management. Smoking cessation is critical due to nicotine’s impact on skin turnover. She advised against hair removal methods like shaving and waxing, which can exacerbate skin trauma, and recommended loose clothing to minimize chafing. The use of clinical-strength antiperspirants, antibacterial cleansers, or antidandruff shampoos was suggested for bacterial decolonization, although supporting evidence is still limited. Dietary adjustments, such as avoiding whey protein and high-glycemic foods, were also noted as potentially beneficial, particularly for patients with higher body mass index.

For Stage I and II HS patients who are treatment naïve, Dr Charrow recommended maintenance therapies, such as zinc gluconate with copper, doxycycline, or a combination of clindamycin and rifampin. Spironolactone was highlighted as an effective option for women, typically requiring around 3 months to show improvement. Advanced cases (Stage II/III) often necessitate biologic therapy. Dr Charrow pointed out the “window of opportunity” for effective intervention with tumor necrosis factor (TNF) inhibitors, such as adalimumab and infliximab.

Dr Charrow discussed the role of biologics, including adalimumab at standard and increased dosages and infliximab tailored to patient weight and treatment response. Regular monitoring of therapeutic drug levels is crucial, especially when patients experience a loss of response. She noted that immune-mediated issues and antibody formation can lead to treatment failure. “Switching TNF inhibitors or drug classes,” she advised, “can be effective when antibodies are detected with low drug levels.” Promising newer treatments, including biologics targeting IL-17 (e.g., secukinumab), IL-12/23 (e.g., ustekinumab), and Janus kinase inhibitors, were also highlighted.

Surgery remains a definitive option for patients unresponsive to medical treatments. Dr Charrow detailed evidence supporting deroofing procedures, which have lower recurrence and infection rates compared to traditional excisions. For optimal results, she recommended starting with smaller, less recurrent areas such as the axilla and continuing biologic therapy alongside surgical interventions.

Dr Charrow concluded by emphasizing the importance of a comprehensive, patient-specific approach to HS management that integrates lifestyle changes, tailored medical therapies, and surgical options. Collaboration among dermatologists, primary care providers, and specialized HS clinics is essential to improving patient outcomes and quality of life.

Reference

Charrow A. Hidradenitis suppurativa: novel medical and surgical approaches. Presented at: Dermatology Week; November 13–16, 2024; Virtual.