Biologic Mechanisms and When to Escalate Therapy in HS

This episode, "Biologic Mechanisms and When to Escalate Therapy in HS," features the panel unpacking today's treatment landscape for HS.

Dr. Bush walks through the current standard of care for HS, describing three FDA-approved biologics: adalimumab, secukinumab, and bimekizumab, layered alongside oral and topical antibiotics, intralesional steroid injections, medicated washes, metformin, and spironolactone. Treatments are often stacked depending on the individual patient. Chao argues the standard of care should mean treating patients earlier rather than waiting, since delayed escalation historically allowed scarring to develop before advanced options were used. Dr. Bush agrees clinicians once knew far less and treated conservatively by default, but now understand what untreated HS becomes, prompting faster action. She notes therapies can start simultaneously rather than sequentially, combining an antibiotic, a biologic, and a surgical referral for the same patient without waiting. Turning to mechanisms, Dr. Bush explains that TNF inhibitors block inflammation furthest upstream, right after follicular rupture activates the innate immune system. Secukinumab blocks IL-17A more specifically downstream, preventing it from binding its receptor. Bimekizumab is unique because it blocks IL-17A and IL-17F simultaneously, interrupting the feedback loop that perpetuates inflammation. Chao notes today's therapies are far more targeted than those available twenty years ago, with less collateral damage elsewhere in the body. On escalation triggers, Dr. Bush shares a patient who appeared mild on exam, with just one nodule and one abscess, but had missed six workdays that month and five the previous month. She placed him on a biologic despite the modest exam findings, reasoning that flare history and functional impact matter more than what is visible on a given day. Chao adds that he proactively reassures patients that frightening internet photos reflect a pre-biologic era, and that building trust matters as much as clinical reasoning when recommending escalation. Dr. Bush agrees that earning a patient's buy-in, reading the room, comes before introducing the idea of a biologic.

Our next episode, "Case 1: Assessing Severity and Barriers to Biologics in HS," applies these decisions to a real patient facing years of unresolved axillary and groin disease.