Q&A: How Does the Current HS Landscape Look? With Kiera Booth, MD

As Hidradenitis Suppurativa (HS) Awareness Week draws attention to the challenges faced by patients living with the chronic inflammatory skin condition, Kiera Booth, MD, board-certified dermatologist at Premier Dermatology and Cosmetic Surgery, spoke in an interview with HCPLive on recent advances shaping HS management.^1,2

With an expanding array of biologic therapies and additional treatment options in development, Booth noted that clinicians now have more opportunities than ever to help patients achieve meaningful disease control and improve quality of life. In an interview with HCPLive, Booth highlighted the importance of individualized treatment selection, the growing role of procedural interventions such as deroofing, and the need to address persistent barriers to care, including delayed diagnosis and undertreatment.

She also shared her perspective on emerging therapies, particularly Janus kinase (JAK) inhibitors, and discussed how the evolving therapeutic landscape may continue to improve outcomes for patients with HS in the years ahead. This Q&A interview with Booth highlights each of these points regarding HS:

HCPLive: It is great to be able to speak with leaders in dermatology such as yourself who can speak to hidradenitis suppurativa (HS) and help to raise awareness in honor of HS Awareness Week during the first week of June. How do you currently approach treatment selection for patients with moderate to severe HS?

Booth: I think the one of the biggest things when trying to pick medication or treatment for HS is the patient's expectations and what their goals are, how frequently they're having flare-ups, whether they're very severe flare-ups that are infrequently, and that would still be moderate to severe, or they're having very frequent flare-ups but they're just so numerous that it's creating a lot of disease burden.

HCPLive: What recent therapies or clinical data in HS do you think dermatologists should be paying the closest attention to right now?

Booth: I think there have been in the past few years a couple of new medications that have come out, some injectable biologics that are really great options for patients, and an expanded toolbox for providers that make HS so much more fun to treat, because there are just so many more options; we're able to get so many more patients feeling better.

HCPLive: How would you say the treatment landscape for HS has changed over the last few years?

Booth: I think there have been some changes over the past few years with the approval of Bimzelx and Cosentyx, but I think that the treatment landscape is going to just explode over the next few years with the medications that are currently in clinical trials. There are going to be even more options for patients. Also, there has been a lot more discussion and teaching about procedural options for patients. I think a lot more clinicians are getting comfortable with treatments like deroofing, which is just providing the best care for patients when there's the combination of medical and surgical management for HS.

HCPLive: How important is deroofing for clinicians in dermatology when they're approaching HS and HS treatment?

Booth: I think deroofing can be hugely impactful to patients with HS. So often, there's a big delay in diagnosis that we've heard about a lot. Because of that, patients have long-standing tunnels and larger areas, or different areas that continue to come back. It's always the same spot that flares, so deroofing procedures are able to get rid of those areas in a way that minimizes the likelihood of recurrence compared to some of the older surgical techniques with excisions with big grafts or flaps that have a slightly higher chance of having recurrence in that local area.

HCPLive: You touched on the concept of delayed diagnoses. How big of a deal is that in the HS treatment space, and how can we approach it differently? Is it a matter of education?

Booth: The delay in diagnosis is huge. I think it's something that has a lot of parts that play into it. There's the delay in getting patients in front of a dermatologist, which often delays diagnosis if they're only going to the ER, and the ER doctor is only treating an acute flare-up. They're not getting the long-term management for this chronic condition, but I think there's also been a delay in getting into some of the advanced therapies. [This is] because they are somewhat newer, and some people, some patients have a hesitancy with the idea of systemic medications or biologics, but getting to treat their disease under control as quickly as possible is so important. [This is] because otherwise you're creating these permanent cysts and tracks and tunnels underneath the skin, and those are going to be there; even if the inflammation gets under control later down the road, there's going to be some amount of scarring or permanent changes made by the chronic inflammation of HS.

HCPLive: When managing moderate to severe age HS, what would you say, generally speaking, are the biggest challenges clinicians still face?

Booth: There's no one medication that is perfect for everyone, and there are definitely still patients that are suboptimally controlled on the current treatment options. Also, there are patient limitations for certain medications, and so if patients have Crohn's disease or ulcerative colitis, then they, they can't do one of the IL-17s, and so that really limits their treatment options, but some of the newer medications on the horizon are really exciting.

HCPLive: Looking ahead, what types of treatment strategies or drug targets do you think could have the biggest impact on HS care in the future?

Booth: I think for sure the biggest thing that's coming in HS is the JAKs. Having JAK inhibitors in the HS space is going to be great to provide an oral option that's going to be very potent at reducing inflammation, and also some of the options that are that are in the pipeline have multiple indications, and so those will be great for treating those patients with multiple comorbidities. If there's one medication that treats multiple conditions that can be helpful in some patients.

HCPLive: Do you urge clinicians to make sure to have a conversation about JAK inhibitors with regards to some of the safety concerns related to heart conditions and black box warnings? Do you feel like that's a conversation needing to be had?

Booth: It's definitely something that clinicians need to be comfortable with to understand the data and where both where the boxed warnings came from and also how they relate to the current medications and the current patients. [This is] both for themselves to feel comfortable prescribing the medication and then to be able to explain this to patients, because it's very nuanced…I think there is more and more evidence that the initial trials that led up to the boxed warnings were maybe related to such a different patient population, it doesn't translate well. Also, each individual state has its own set of systemic risk factors associated with it, and having any chronic inflammatory condition is going to put you at risk for other comorbidities outside of the skin. How that relates to a medication is both positive and negative. Decreasing systemic inflammation in the skin can help with other comorbidities, or the medications can have side effects.

HCPLive: What do you hope clinicians walk away with for HS Awareness Week, and what do you hope they spread the word about regarding HS management?

Booth: For HS awareness week, I'm hopeful that clinicians will feel engaged and empowered to treat HS patients. These are patients that have been suffering often for a very long time, and often in private that, and so it's something that is so impactful and can really change their lives. As I said, it's there are several options now. It's soon to be lots of options, and treating HS now is so different than it was 10 years ago. When we were there, there was nothing you could do to help these people. It felt horrible. It was a long visit. It was a hard visit. Nobody got results that they wanted. Now there's really great options for medications that are safe and effective and get patients so much better.

Booth had no disclosures of note to highlight.

References

1. Krueger JG, Frew J, Wolk K, et al. Hidradenitis suppurativa: new insights into disease mechanisms and an evolving treatment landscape. Br J Dermatol. 2024 Jan 23;190(2):149-162. doi: 10.1093/bjd/ljad345. PMID: 37715694.

2. Ribero S, Dapavo P, Casalegno C; HS Awareness Working Group. Improving the disease awareness: how a communication campaign brings hidradenitis suppurativa to the light. J Eur Acad Dermatol Venereol. 2019 Oct;33 Suppl 6:7-9. doi: 10.1111/jdv.15828. PMID: 31535765.