Defining Success in HS Treatment, Biological Selection, and Comorbidity Screening: A Conversation with Dr. Jennifer Hsiao

In a conversation published on HCPLive, University of California East Dermatology Professor and co-director of a HS specialty clinic Jennifer L. Hsiao, MD, answered questions about defining treatment success, making choices among biologics, and where oral JAK inhibition might fit in. Hsiao also addressed these topics in two presentations, including one with Iltefat Hamzavi, MD. In the following conversation, Hsiao discussed treatment expectations, defining success, making choices among biologics, and where oral JAK inhibition might fit in at the [conference] in Las Vegas with the HCPLive team.

HCPLive: How do you decide which of the approved biologics to start with and when to switch? Jennifer Hsiao, MD: “We are really fortunate to have three FDA-approved therapies. We have adalimumab, a TNF-α inhibitor; secukinumab, an IL-17A inhibitor; and bimekizumab, an IL-17A/IL-17F inhibitor. At this point, adalimumab and secukinumab are approved for patients 12 years and older, which helps with our treatment options in terms of age range. At this stage, I really think about the patient’s preferences. A patient may come in and say, “I heard this about this drug. I definitely don’t want to start on it.” It’s also important to take into account what the patients have heard; if they have a specific reason to be strongly against one of the options, you may not want to push it during that visit. The patient’s comorbidities also play a role, and ultimately, access does play a role.

HCPLive: If a patient is willing to try a medication, I really want to get that medication into their hands as quickly as possible. With delays, patients may say, “You know, there’s more than enough difficulty in this,” and you may miss a window of time when they’re open to starting therapy. Insurance formulas often come into play here, and I think strong bridges and patient assistance programs can be helpful. But ultimately, our goal is to identify the patient during that window of opportunity, hopefully in early moderate disease, start them with one of the three therapies we have available, and help them start to mitigate disease progression or at least feel better at the moment.

When considering JAK inhibitors, the first thing I’m excited about is that we’ll have an oral option. There are still some patients who are afraid of injections, so it’s nice to be able to offer a different route of administration. Then there are the patients I mentioned; perhaps the pathophysiology of HS is not dominated by one cytokine and is more heterogeneous. By inhibiting a pathway such as the JAK-STAT signaling, it may be beneficial for these patients to affect a greater number of cytokines.

So definitely, we need more treatments in our toolbox, and it’s exciting to have drugs on the horizon. I think JAK inhibitors are probably the most advanced; povorcitinib is an JAK1-selective inhibitor that recently published a paper with efficacy and safety data up to 54 weeks. It would be really exciting to have access to these drugs once they are approved.

Which Comorbidities Should Be Screened?

HCPLive: Which comorbidities should dermatologists screen for in patients with HS, and what does a realistic workflow look like?

Jennifer Hsiao, MD: “The first thing I need to say is that we don’t need to do everything at the first visit. The first visit can be intimidating. The patient needs to share their story with you, and at the same time, you as a clinician are trying to understand where the patient came from and what stage they’re at, and you’re putting together a treatment plan. This comorbidity screening may also take place during your physical examination.

For cutaneous comorbidities, look for acne symptoms and check the scalp. Is there dissecting cellulitis on the scalp? You’ll probably also want to check the groin and buttocks regions, which are areas that are commonly affected by HS, so are there any pilonidal cysts? You can address these cutaneous comorbidities during your physical examination. You can also ask questions about them: Do you have lesions on your scalp? Do you have lesions on your buttocks?

For other comorbidities, you can hire a primary care provider who can help with most of them. On the dermatology side, I believe that one is a tobacco smoker and can recognize that; but it should not be brought up at the first visit, “You should quit smoking.” It can be brought up at a later visit after you have established a relationship with the patient and clearly state that you are doing this from a general health perspective, not because you are not interested in smoking, or because you do not believe that smoking causes HS or that they are somehow at fault for HS. Doing this is really important.