Luis Garza, M.D., Ph.D., on sweat, smoking, biologics and the future of hidradenitis suppurativa treatment

His treatment for hidradenitis suppurativa starts with lifestyle measures and moves step-by-step toward biologics, Luis Garza, M.D., Ph.D., a professor of dermatology at Johns Hopkins University School of Medicine and hidradenitis suppurativa expert, told Managed Healthcare Executive in a recent interview.

Garza, who takes care of approximately 150 hidradenitis suppurativa patients at any one time, first advises patients to avoid smoking and processed foods, eat a healthy diet and exercise. He also advises patients to clean sweat off the skin, because he and his colleagues suspect that triggering chemicals may be released in sweat, accumulate and be reabsorbed in the areas where the symptoms of hidradenitis suppurativa appear. He said he suggests daily washing with the hospital soap Hibiclens (chlorhexidine) to reduce normal skin bacteria that may aggravate the disease and possibly to wash away those chemicals.

For mild flares, Garza recommends a topical antibiotic to reduce commensal bacteria. For severe flares, he recommends an oral antibiotic, but only for short periods, because he finds that long courses do not do much, he said.

When those measures don’t work, Garza said he moves to biologics. Insurers typically want physicians to work down the list from least to most expensive, and Garza notes that the less expensive options do have efficacy. He starts with a tumor necrosis factor (TNF) inhibitor such as Humira (adalimumab), then moves to the interleukin-17 (IL-17) inhibitors Cosentyx (secukinumab) and Bimzelx (bimekizumab). After that come intravenous infusions such as Remicade (infliximab). Garza expects JAK inhibitors, which have not yet been approved for HS, to gain approval and to have a place in treatment.

Looking at the drug development pipeline, Garza expects IL-1 inhibitors to join the IL-17 inhibitors, along with JAK inhibitors, giving physicians two more options. IL-1 inhibitors might prove better earlier in the disease, or perhaps later; Garza says it will take testing to find out where each new therapy fits.

He is skeptical, however, that the near-term pipeline will deliver a major advance. “Sadly, none of the drugs that are going to be coming to market soon are any more evidence-based than the ones that have been in the past,” Garza said. Pharmaceutical companies, he explains, prefer to pursue drugs that can be used for many diseases, rather than focusing on a single disease, because that gives them “more shots on goal.”

“We’re still waiting for that really specific medication for HS,” Garza told MHE, using the initials for the disease.

Over the longer term, Garza said he is hoping for evidence that would shed light on the very earliest events that mediate hidradenitis suppurativa, which is the focus of his research. Other investigators are exploring ways to boost the body’s natural anti-inflammatory defenses rather than inactivating the overactive parts of the immune system. Garza said he also hopes for advances that would identify subtypes of hidradenitis suppurativa.