Life has windows of opportunity but so does medicine—a point in time when intervening may change the course of what happens next. Like anything else, it’s important to take advantage when those opportunities arise because once they’re gone… they’re gone. And when the window is there, “Take it!” In dermatology, hidradenitis suppurativa (HS), a chronic, progressive condition, has a window of opportunity where we can intervene and potentially change the trajectory of the disease.
Historically, we’ve approached HS with surgical interventions. I can remember when HS referrals came mostly from general surgery or plastics after patients had undergone extensive, multiple procedures to control their condition. At that time, HS was managed primarily by surgery, with medical treatment as a secondary thought. But my, how the times have changed! With the evolution of our understanding of HS and the advent of new systemic therapies, medical intervention is now at the foundation of HS treatment and tied to a window of opportunity.
When you think of HS, most people associate it with painful, draining nodules or a series of individual flares. When HS seems quiet, it’s important to highlight that quiet does not mean the underlying disease process has stopped. HS might be defined by flares, but it’s essential to remember it can progress, and we can intervene to halt that progression. This is our window of opportunity. You might wonder, is there a clinical definition of when this window occurs? While there isn’t a full consensus, an expert panel proposed a definition based on those with moderate HS, defined as patients with inadequate control of HS symptoms on conventional therapies, or one inflamed skin tunnel (draining/non-draining), or four or more inflammatory lesions (including inflammatory nodules and abscesses) involving two or more anatomic areas. As for what constitutes progression, the expert panel suggested the development of one or more new tunnel(s) and/or the extension of existing tunnels, or development of one or more persistent HS lesions in an anatomical region not previously affected, or any increase in the number of persistent HS lesions in an affected anatomical region. These definitions are helpful to guide conversations around how we take advantage of the window of opportunity and recognize the progression of HS in patients.
The good news is progression isn’t inevitable—but untreated or inadequately controlled inflammation can contribute to it happening. The quiet between flares can be deceptive but we must remember the inflammation in HS is still running in the background, a fact that should make us change our treatment paradigm from a reactive to proactive. Reactive is draining the abscess or adding antibiotics for a flare. Proactive treatment is a disease-control centered approach that focuses on HS as a chronic condition with the goal of reducing inflammatory activity, preventing new lesions, addressing tunnels/scarring and maintaining control. Reactive interventions are still a part of our treatment but they should be more à la carte while the proactive approach should be the entrée.
So how do we get proactive and seize the window? Right now, our biologic therapies are a good option. Biologics sound kind of frightening but they are a powerful tool to fight inflammatory conditions in dermatology like hidradenitis suppurativa. Instead of turning off the entire immune system, biologics aim to turn down the specific inflammatory signals driving disease. More importantly, biologics represent an important shift in how we think about HS: from repeatedly treating individual lesions to targeting the inflammation driving the disease. Currently we have three biologic therapies approved for HS including adalimumab, secukinumab and bimekizumab. And the options don’t stop there. The pipeline for new HS drugs is incredible, and more options will be coming to the market over the next few years.
Trotter’s Take: HS is defined by its chronic nature and potential to progress. Just don’t treat the disease you see today. Ask whether there is an opportunity to change the disease you’re going to see five years from now.
Want to learn more about the biologic treatment landscape with HS? Then listen in on my podcast with Dr. Graham Lichtman, as we help you seize that window of opportunity.
