Treatment of Hidradenitis Suppurativa in 2024

Hidradenitis suppurativa is one of the toughest inflammatory conditions dermatologists treat as it impacts social, psychological, and professional aspects of a patient’s life. Andrea Murina, MD, reviewed oral antibiotics, injectable biologics, and procedures and how to combine them for HS. For long-term maintenance, she recommended spironolactone, metformin, and dapsone. Isotretinoin 20 mg to 60 mg daily is well-suited for patients with evidence of comedones or follicular occlusion phenotypes, while acitretin is good for men and postmenopausal women. Useful additions are zinc 90 mg daily or niacinamide 30 mg daily. Short flares should be managed with oral antibiotics, intralesional steroids, and prednisone if needed. Pain management in HS is another important topic for your patients, and there are a variety of treatment modalities to deploy in treatment. Appropriate wound care, NSAIDs, duloxetine, topical lidocaine, abscess drainage, physical therapy, and even opioids for breakthrough pain may be utilized. 

Procedural treatments should be considered for both focal and widespread disease in good candidates. Focal disease can be treated with deroofing procedures, Nd:YAG laser, or wide excision, while widespread involvement may benefit from targeting selective areas for excisional surgery in combination with a biologic. Established biologics include adalimumab and secukinumab, which are both FDA approved for HS, and infliximab off-label at 7.5 mg/10 mg per kg every 4 weeks. In 2 RCTs, over 40% of patients on secukinumab achieved at least a 50% reduction in total inflammatory and abscess count by week 16, and over 75% of these patients maintained their response until week 52. However, a few new biologics are on the way including bimekizumab, an IL-17 inhibitor, spesolimab, an IL-36 inhibitor, and various JAK inhibitors. Bimekizumab demonstrated remarkable efficacy with over 50% of patients achieving HiSCR response at week 16 in BE HEARD II at both 2- and 4-week dosing intervals. Draining tunnels improved at week 12 in patients treated with speoslimab, though significant differences were not seen in abscess and inflammatory nodule count. Dr Murina ended her talk with a warning that rising temperatures may increase HS flares.