HS Tips and Lizards

Speaker 1 (00:00):

Every patient deserves to be seen. The Tremfya guselkumab photo library offers hundreds of real patient photos, easily filtered by patient characteristics, disease locations, and severity. Learn more about Tremfya for your patients at tremfyahcp.com.

Ranna Jaraha (00:28):

Welcome to The Practical Dermatology Podcast. This month, we have an interview with Dr. Jennifer Hsiao, an update from Dr. Jashin Wu on psoriasis, and the latest news from around dermatology. Dr. Jashin Wu presented on biologics for psoriasis at SCALE this month, and he talked to us about some of the key takeaways.

Jashin J. Wu, MD, FAAD (00:50):

Hi, I'm Jay Wu. I spoke at the SCALE meeting in Nashville, Tennessee. I was asked to speak about biologics for psoriasis. Some of the updates that I discussed was that, for palmoplantar pustular psoriasis, there was a nice meta-analysis that looked at the various treatments used for PPPP, and they showed that guselkumab seemed to be the most effective agent for this difficult subtype to treat psoriasis.

(01:14):

There was also meta-analysis that looked at the best biologics for psoriasis. In no particular order, they mentioned infliximab, ixekizumab, risankizumab, and bimekizimab.

(01:27):

Generally speaking, I agreed with that list. Infliximab we don't use so much nowadays, of course, because it is an IV infusion, but it is one of the more effective agents. Ixekizumab, I think it was OK, but I actually prefer brodalumab. I think it's a little bit more effective. Of course, there's no head-to-head studies, but this is just talking from my own clinical experience.

(01:44):

And then we discussed some information on bimekizumab, which was the most recently approved biologic for psoriasis. It was approved about a year and a half ago. And we discussed some of the five-year data presented at AAD, looking at the efficacy and safety over the five-year open-label extension studies, and it shows to be very effective and safe still at the five-year point.

Speaker 1 (02:02):

Every patient deserves to be seen. The Tremfya guselkumab photo library offers hundreds of real patient photos, easily filtered by patient characteristics, disease locations, and severity. Learn more about Tremfya for your patients at tremfyahcp.com.

Ranna Jaraha (02:27):

Now, here's Dr. Lisa Swanson.

Lisa Swanson, MD, FAAD (02:30):

Hello, everybody, and welcome to another Practical Dermatology Podcast. I am super excited for this one, you guys. I'm baseline excited about most things, but this is a next-level kind of Taylor Swift level of excitement to introduce you to my guest today, Dr. Jenny Hsiao. And she is a dermatologist at the University of Southern California and a friend of mine and fellow Swiftie. I cannot believe we were lucky enough to get her on the pod today. And we're going to talk about hidradenitis suppurativa, everybody's favorite topic.

Jennifer L. Hsiao, MD (03:10):

Thank you so much for having me.

Lisa Swanson, MD, FAAD (03:11):

Thank you so much for being here. Jenny, you are the expert, in my opinion, in hidradenitis suppurativa. If I ever have any HS questions, I'm like, "I just need to ask Jenny, and then I'll know what to do."

(03:25):

What are some of your go-to treatments right now in the treatment of hidradenitis suppurativa?

Jennifer L. Hsiao, MD (03:33):

I'm so glad we get to chat about this because we've also had sort of offline conversations about patients and things like that. And I think right now it's such a good time for HS. Just it's been neglected for so long. And we're finally seeing treatments starting to come out for HS, so I am very excited, just like you are.

(03:53):

Go-to treatments right now ... I kind of think about HS in terms of, no matter a patient's severity, whether they're milder HS or moderate to severe, we need a multimodal approach to therapy. When I think about my milder HS patients, I'm really thinking about different treatment categories. What topicals can we use? Are there hormonal or metabolic modulators we can use? Sometimes perhaps an oral retinoid. A really common sort of treatment combo I might use is let's use benzoyl peroxide or have a cleanse a few times a week.

(04:26):

A lot of patients may have failed topical clindamycin by the time they come to see us. We could consider something like topical resorcinol. Topical ruxolitinib also had positive phase 2 results, so it could be considered off-label, for example.

(04:39):

And then in terms of oral therapies, I love spironolactone for my female patients with HS. I think it works really well. We can consider combined oral contraceptive pill as well. Finasteride for my male patients. Metformin we can consider, especially if a patient has, for example, pre-diabetes or other reasons where it could be helpful.

(05:00):

And then oral antibiotics. I'd love to hear your thoughts on it, too, but I really feel like it's really meant as more of a bridge to longer-term therapy because we don't want to have a patient just on oral antibiotics for years and years. The goal that I really have is to minimize use of oral antibiotics the way we want to, for example, minimize steroid use for other conditions.

(05:22):

Would love to hear your thoughts on that too.

Lisa Swanson, MD, FAAD (05:24):

I'm the same way. Ted Rosen gave a very scary talk about antibiotic resistance and the end of the world. And ever since then, I have been even more diligent with my antibiotic stewardship and really trying to limit duration and even talking more about the hormonal options for female patients, like the spironolactones and the birth control pills and the oral isotretinoin, as opposed to more and more oral antibiotics.

(05:51):

You mentioned metformin. I have not yet prescribed metformin. What is your kind of safety spiel to patients when you prescribe metformin? What would I need to tell my patients about it if I'm going to branch out and prescribe it?

Jennifer L. Hsiao, MD (06:09):

I feel this is absolutely a field or area that derms will be starting to go into, especially with metformin, maybe GLP-1 agonists down the line. With HS in particular, there have been studies showing that, even in patients without pre-diabetes or diabetes, metformin can be helpful, particularly for the more milder cases of HS. I'll start with that by saying ... Especially for a patient who doesn't have diabetes because it can be confusing. I'll say, "I know you don't have diabetes. This is really meant to try to help with that metabolic aspect of HS," and then I'll let them know the main side effects are stomach upset, nausea, vomiting. Take it with food, for sure.

(06:50):

My dose is to typically start at 500 milligrams a day, and then I'll increase them to 500 milligrams twice a day as long as they tolerate it. There are studies going up to even higher. But I feel, for most patients, 500 milligrams twice a day is a good point.

(07:04):

And then there is that rare risk of, for example, lactic acidosis that there is with metformin, but I honestly just counsel patients, "Just take it with food. Do your normal amount of exercise. If there's any other symptoms that come up, let me know," but haven't had any issues. And it's really nice because it's also cheap. It's a nice, easily accessible medication for our patients.

Lisa Swanson, MD, FAAD (07:26):

Which is so important and another advantage to things like spironolactone and birth control pills.

Jennifer L. Hsiao, MD (07:30):

100%.

Lisa Swanson, MD, FAAD (07:31):

You mentioned GLP-1s. I know a lot of derms are dabbling in this. Have you dabbled? Are you prescribing them yet?

Jennifer L. Hsiao, MD (07:41):

Yes, I have in a few cases. Although, I would say, as of right now, in terms of literature to support the use of GLP-1 agonists in HS, it's just not robust at this point in time. When I'm thinking about starting a patient on it, I do feel, as of right now, it's helpful to have that partnership with a primary care doctor or with an endocrinologist.

(08:06):

And then in your case, especially with kiddo patients, for example, or adolescents, in terms of tiptoeing into that area, which is another sort of aspect to consider, I think is helpful because even getting insurance coverage for these medications for on-label indications is already tough. When we think about trying to get it for something like HS, it's very challenging even just to have access. For that, I think we need more data to really support dermatologists regularly prescribing for HS.

Lisa Swanson, MD, FAAD (08:37):

I agree. I agree. It seems, from what I've read, of course the loss of weight helps HS. It seems there's the hypothesis that there are also some anti-inflammatory benefits to these treatments. But yes, it seems it would be nice to know more before we completely dive in.

(08:57):

You mentioned age. I am primarily a pediatric dermatologist, and we have noticed this somewhat scary trend of HS happening at younger ages. Acne is too, and it's because puberty is happening at younger ages. It would be wonderful to see approvals of more medicines down to younger ages. We have adalimumab down to 12, which is great, but then secukinumab and bimekizumab are both 18, which is disappointing to me. Thoughts on that?

(09:28):

I know you primarily see adults, but I feel like early treatment is becoming more and more important in those patients that we can tell are headed down a dangerous path, and so it would be awesome to have more tools in our younger patients.

Jennifer L. Hsiao, MD (09:42):

100%. I completely agree. I actually see kiddos 12 and up in my practice, which I think works really well with HS because, I agree with you, a lot of that onset is around that age period. Puberty is moving up. When I do hear about cases of, for example, kiddos with HS onset younger than puberty, it does make me think, is there something else going on, like precocious puberty or things like that? I feel like I'm covering a lot of the ages with 12 and up, fortunately.

(10:13):

But I would say this. I think that beyond also just sort of having indications for pediatric patients, it's nice to also have trials that are dedicated to this, so we can really see, what is this in terms of generalizability of efficacy, in terms of what does it mean to start at a younger onset of disease, what is the safety profile?

(10:38):

Even with adalimumab, it wasn't a trial that was done. It was based on pharmacokinetics, simulating models, and stuff like that. Absolutely we need more attention paid to pediatric HS because a lot of people's lives get thrown off during that time. It's that adolescent phase.

Lisa Swanson, MD, FAAD (10:59):

It's a tough time, period. And then to have HS on top of it, my gosh. And a lot of these kids, these teens, they'll suffer in silence for a while before they bring it to the attention of a parent or a family member or a caregiver, and they attribute it to things like an ingrown hair, or they're not cleaning properly. All this stuff. They really go through a lot of distress before they finally bring it to the attention, and then we can step in and help. I think increasing awareness for our teenage patient population would be so important too.

(11:32):

Adalimumab is our one biologic approved down to 12 so far. So far. And I have had experiences with a adalimumab working well at first and then pittering out. And I've been reading about checking adalimumab antibodies. I wondered if you had any thoughts on that.

Jennifer L. Hsiao, MD (11:50):

It's a great question. I think I'm very happy we had adalimumab that was approved in 2015 to sort of start this journey for all of us finally. But I think all of us have struggled with durability of response, and I think it can be very disheartening for patients who do finally feel like they're doing better, and then they come in one visit, they're like, "I don't think it's working anymore." At that point in time when patients feel it's not working as well, you can check anti-drug antibodies, which I've done. And what you do is basically the morning before they're going to take their next injection, you can have a lab ordered for them to get their blood drawn to check for their trough level and basically their drug serum level at that time as well as their anti-drug antibody level. Basically, if their level, drug level, for example, is low, but their anti-drug antibody level is high, perhaps it's time to consider switching therapy.

(12:49):

There's also questions like, could you rescue? Could you use methotrexate to do rescue, et cetera? But I do feel, at this point in time, another issue we have is that we have not characterized adalimumab sort of optimal drug levels as well as we should. There's been some initial studies going in which is literally suggesting that you need an adalimumab level at super high in the 20s compared to IBD or things like that, more than six, in order to be a good adalimumab responder. We just need more data, I think, to help us because otherwise we're getting levels, but do we even know what level we want to aim for?

Lisa Swanson, MD, FAAD (13:28):

Right. Right. I kind of wondered, in reading what I've read, if we were going to be like rheumatologists and recommending methotrexate along with adalimumab to prevent the formation of those antibodies, and that's a whole new thing.

(13:41):

I know that the pipeline for HS is rich and exciting and provides so much hope for those suffering with HS and those who treat patients with HS. Gosh, this has been a long time coming.

(13:58):

Are there any pipeline agents that you are most excited about? Most anticipating?

Jennifer L. Hsiao, MD (14:06):

To first just give a thumbs up to those that we do have, we have adalimumab, TNF inhibitor. Another class of medications, the IL-17s. We have secukinumab. IL-17A inhibitor. Bimekizumab came online last year. IL-17 ANF inhibitor. I consider all three to be first-line agents. I think adalimumab, secukinumab and bimekizumab are all reasonable first starts for your patient. You might choose one over the other for various reasons like comorbidities, et cetera, but we still know it's just not enough. And we're not at a place where we are with psoriasis where with confidence we're able to prescribe something to someone and be like, "I know you're going to be 90% better within X amount of time." Absolutely, there's still so much space for development of new medications.

(14:56):

One of the things I'm really excited about is povorcitinib. A JAK1 selective inhibitor, reached its primary endpoints on its phase 3 trials. This was announced just recently. What it means for us is hopefully next year we'll have a JAK inhibitor that's approved for HS. This would be for adults with moderate to severe HS, but it would open up a new class for us, which I think is always very exciting. And it's an oral medication, so it's a different mechanism of delivery. I'm excited about that.

(15:26):

On sort of the JAK inhibitor sort of pathway, upadacitinib, which is already on the market, I'm already using off-label for HS. Positive phase 2 trials. It's in a phase 3 study at this point in time now already. The upadacitinib study is different because they're actually looking specifically at patients who are sort of TNF failure. They're taking up that sort of role of a biologic recalcitrant patient. Will be exciting to see, but they are enrolling 12+.

Lisa Swanson, MD, FAAD (15:54):

Yes, I know.

Jennifer L. Hsiao, MD (15:55):

I'm excited about this.

Lisa Swanson, MD, FAAD (15:57):

I'm actually participating in that trial because I was so … I wanted to applaud their efforts of going down to 12 right from the get-go. Very exciting.

Jennifer L. Hsiao, MD (16:08):

And then in the IL-17 category, sonelokimab is a nanobody IL-17 ANF inhibitor. It had strong phase 2 results, and it also is in phase 3 trials with also a dedicated VELA-TEEN trial for adolescents 12 to 17. There is a study that's dedicated to teens with sonelokimab. Also exciting.

Lisa Swanson, MD, FAAD (16:32):

I love it.

Jennifer L. Hsiao, MD (16:34):

We're totally making so much ... We're making ground.

Lisa Swanson, MD, FAAD (16:39):

Yes. Yes.

Jennifer L. Hsiao, MD (16:39):

In these areas, which is exciting.

Lisa Swanson, MD, FAAD (16:41):

I have dabbled a little bit in the oral JAKs for HS. I had a patient that ... Bad HS. Originally had folliculitis decalvans and nodulocystic acne as well when we started our journey together. And initially, all of his things got better with oral isotretinoin, but then the HS recurred. The folliculitis decalvans and the acne were fine, but the HS recurred. A second round of isotretinoin didn't help. We did adalimumab, which helped for a while and then didn't, and then we put him on secukinumab and he, after two doses, had what I would call kind a purge of his HS where everything really kind of worsened at that time, and so we stopped it. We did put him on some oral antibiotics, and I was like, "What else could work fast, and what else could I give him right here today?" Because it was really awful. I was very worried about him and his just mental health and wellbeing.

(17:37):

And so I started him on upadacitinib. We had samples. His insurance actually covered it. Great. And it was really a miracle for him. I am really looking forward to more data and experience with the JAKs for HS.

Jennifer L. Hsiao, MD (17:50):

100%. I feel like we don't know right now with a patient sitting in front of us what their particular response is going to be to a TNF versus an IL-17 versus a JAK. And so just having the options is so important because, as clinicians, we just want choices, and we want the ability when something doesn't work that we can try something else, not just have one, and then if it doesn't work, we feel like we're just up the river and no canoe. I am very grateful for this potential new mechanism of action.

(18:22):

We also have another one, an IL-1, that's coming potentially. Lutikizumab had positive phase 2 results. It was an IL-1 alpha-beta inhibitor. It was studied in phase 2 in sort of TNF recalcitrant patients, but now it's in phase 3 for all comers with moderate to severe, not necessarily those who are biologic recalcitrant. That'll be exciting to see.

(18:47):

We also are ... Our site is going to be part of the remibrutinib study. Bruton's tyrosine kinase inhibitor. Also a pill. Again, a nice option for patients. And I think it's exciting because remibrutinib hopefully will be coming online later this year for chronic spontaneous urticaria. That would mean it's on the market and sort of available as another potential off-label treatment while we're in the phase 3 study.

(19:13):

A lot of really exciting things sort of in the pipeline, including different mechanisms of action. For our moderate to severe HS patients, I'm just hoping listeners know that right now we have those three that are approved that we talked about. But as you said, we have JAK inhibitors we can reach for. We can reach for high-dose, high-frequency infliximab infusions. There's still ustekinumab, the 12/23 inhibitor. There's multiple things we can do and to not wait because we really want to not hold these therapies while we're watching patients progress in front of us. We want to try to get in there early and try to help halt that progression or at least mitigate it if possible.

Lisa Swanson, MD, FAAD (19:56):

Yes. I think that the importance of early treatment is really becoming more and more apparent and obvious to us, and it's such a wonderful time to be treating HS patients after dealing with hardships for years and years. I bet all of this puts a pep in your step in the clinic every day because you have so many more options to help your patients, which is wonderful.

(20:18):

I also want to tell the audience that Jenny has a beautiful article about hidradenitis suppurativa in our April edition of Practical Dermatology. Everyone should go out and read that.

(20:28):

And I wanted to end in these closing moments by doing my favorite thing, two truths and a lie. Jenny, I asked for you to create two truths and a lie for me, and then I might ask a couple questions and see if I can guess which one is the lie.

Jennifer L. Hsiao, MD (20:44):

All right. I did give this thought. Probably more thought than I should have.

Lisa Swanson, MD, FAAD (20:47):

I'm excited.

Jennifer L. Hsiao, MD (20:53):

Here we go. I lived in Hawaii for a year and a half when I was a child. I have a bearded dragon named Buzzy Cat, and I feel like this one's too easy, but Taylor Swift is my favorite.

Lisa Swanson, MD, FAAD (21:06):

I gave that one away at the beginning. I gave that one away. I know that that one's true. We're down to Hawaii for a year and a half as a kid and a bearded dragon named Buzzy Cat? Buzzy Cat. Where did you get that name?

Jennifer L. Hsiao, MD (21:25):

My kid named it.

Lisa Swanson, MD, FAAD (21:28):

That's making more sense. Was that from a children's show, or did they just make it up out of the blue, Buzzy Cat?

Jennifer L. Hsiao, MD (21:34):

The eight-year-old just came up with it.

Lisa Swanson, MD, FAAD (21:36):

My gosh. And what drew you guys to a bearded dragon in the first place?

Jennifer L. Hsiao, MD (21:42):

There's allergies in our family, and my son has always wanted a snake, and I'm deathly afraid of snakes, so this was kind of a compromise. At least this one has legs.

Lisa Swanson, MD, FAAD (21:54):

Yes. There you go. There you go. They're definitely less scary than a snake. And then which island did you live on for a year and a half as a kid?

Jennifer L. Hsiao, MD (22:03):

Oahu.

Lisa Swanson, MD, FAAD (22:05):

Oahu. And did you live right in Honolulu or-

Jennifer L. Hsiao, MD (22:08):

In Honolulu.

Lisa Swanson, MD, FAAD (22:08):

Honolulu. Now, this is tough. I think the lie is the Hawaii thing.

Jennifer L. Hsiao, MD (22:14):

It's the bearded dragon. No, we do have a bearded dragon. His name is Lasagna.

Lisa Swanson, MD, FAAD (22:22):

Tricky, tricky, tricky. You knew so much about bearded dragons-

Jennifer L. Hsiao, MD (22:30):

I know. Just so you know, Buzzy Cat was the name of our beta fish.

Lisa Swanson, MD, FAAD (22:35):

Buzzy Cat did exist. That was another …

Jennifer L. Hsiao, MD (22:37):

Yes. My son did name Buzzy Cat, and my son named Lasagna.

Lisa Swanson, MD, FAAD (22:41):

My gosh. I love it. I love it. Lasagna is actually my favorite food. I'm much like Garfield. I hate Mondays, and I love lasagna.

Jennifer L. Hsiao, MD (22:49):

Spaghetti is my favorite food.

Lisa Swanson, MD, FAAD (22:50):

My gosh. We should go …

Jennifer L. Hsiao, MD (22:51):

We should go get Italian. We know what to do.

Lisa Swanson, MD, FAAD (22:54):

I love it. I love it. Well, thank you all so much for tuning in to this wonderful podcast with my friend and colleague, Dr. Jenny Hsiao, and I hope you guys all learned something and about HS and about Jenny Hsiao. Have a great day, everybody. Thanks for listening.

Ranna Jaraha (23:12):

And now for the news. In our top story, a major new study reveals that patients living in lower socioeconomic neighborhoods are more likely to be diagnosed with hidradenitis suppurativa. In a new cross-sectional analysis published in JAMA Dermatology, researchers evaluated the association between neighborhood level, socioeconomic status, and new HS diagnoses. More than 65,000 dermatology patients in the San Francisco Bay Area between 2019 and 2024 were included in the analysis. Patients were stratified into socioeconomic status quintiles based on census tract-level data, which included factors such as income, housing costs, education, and employment.

(23:48):

Among the study population, 485 individuals were newly diagnosed with HS. Adjusting for age, sex, and race ethnicity, patients in the lowest socioeconomic status quintile had more than three-fold higher odds of receiving an HS diagnosis compared to those in the highest quintile. The authors noted a strong dose-response relationship between neighborhood deprivation and HS risk across all lower quintiles.

(24:11):

The study authors said the findings support the hypothesis that social drivers of health at the neighborhood level, such as access to resources, education, and healthcare, may influence the development of HS.

(24:23):

A new meta-analysis highlights the therapeutic potential of simvastatin for vitiligo, showing significant benefits in repigmentation and disease severity reduction. Simvastatin is an HMG-coenzyme A reductase inhibitor with anti-inflammatory and immunomodulatory effects. It is commonly used to treat high cholesterol and triglyceride levels in the blood. The systematic review and meta-analysis published in the archives of dermatological research included six randomized controlled trials encompassing 371 vitiligo patients. The studies compare simvastatin either to controls or in pre-post-treatment assessments.

(24:58):

Primary outcomes included changes in vitiligo area scoring index and rates of excellent repigmentation. Secondary endpoints assessed lipid profile changes. Simvastatin significantly improved VASI scores with no between-study heterogeneity. The odds of achieving greater than or equal to 75% repigmentation were significantly higher in the simvastatin group. Lipid parameters also improved.

(25:19):

The researchers concluded that, in addition to its efficacy in improving lipid parameters, the findings support simvastatin as a promising adjunctive treatment for vitiligo pending further trials.

(25:31):

And now for a new Updates in Skin Cancer feature in which leaders in the dermatologic space provide updates on the latest trends and innovations in the treatment of melanomas and carcinomas. In this week's episode, Dr. J. Michael Guenther, a surgical oncologist at St. Elizabeth Healthcare in Edgewood, Kentucky, discusses how to use gene expression profile testing for managing melanoma patients. Here is a portion of the feature.

Dr. J. Michael Guenther (25:53):

The recurrence risk of a patient is also a precious piece of information because it guides their follow-up. If they have low risk, which many of them do, praise God, they go back to their dermatologist for routine follow-up. They don't need to see surgical oncologists, and they don't need expensive testing and time away from work and co-pays and that kind of thing. And the anxiety relief is palpable.

(26:13):

Having said that, patients who have higher-risk lesions ... They stay into the fold, and they stay close to the doctors and follow-up. And if we have a problem, we tend to find it early where it's salvageable. The two principle uses in my practice are, if we have low-risk disease, de-escalation, potentially avoiding node biopsies back to dermatology for observation for their second lesion or their basal cell or whatever.

(26:37):

But the flip side is, if we have high-risk disease, whether it's node positive or a high risk of recurrence, we have places to park them. We have evidence of adjuvant therapy that works. We have evidence that close follow-up translates into high survival rates, and we can give a patient what they need. It's matching their care to the risk that they have. And I think that's a very efficient way to practice medicine, especially with melanoma.