Case 2: Escalating Therapy After Biologic Failure in HS

In "Case 2: Escalating Therapy After Biologic Failure in HS," the panel shifts to the series' second patient case.

Chao presents a second case: a 37-year-old man with an eight-year history of HS whose disease is worsening after an initial response to adalimumab. He improved in lesion burden, drainage, and pain during his first five months of treatment, but developed recurrent flares and persistent drainage over the following four months despite continued therapy. Exam findings include persistent painful nodules and daily drainage in the perineal, gluteal, and axillary regions, three to four inflammatory flares per month, multiple interconnected draining tunnels, and extensive scarring. He has obesity with a BMI of 31, is a former smoker, and has no history of psoriasis, inflammatory arthritis, or inflammatory bowel disease. His quality of life is significantly affected: pain with sitting and exercise, daily dressing changes causing distress, difficulty functioning, missed work, and a heavy social and psychological burden. His treatment history includes oral doxycycline for 12 weeks, combined clindamycin and rifampin for 10 to 12 weeks, and adalimumab for about nine months. Dr. Bush recognizes the pattern from her own practice and recommends switching therapy, since adalimumab has stopped working, and considering surgical procedures alongside a new biologic. She would gently raise comorbidities, mentioning GLP-1 medications as an entry point, since naming that option often makes patients receptive even when they resist other lifestyle discussions. Chao agrees, saying he raises GLPs with nearly every overweight or obese HS patient. Both emphasize giving this patient hope, noting current biologics are strong and more therapies, including new oral agents, are coming. Dr. Bush's treatment goals center on eliminating drainage, reducing flares, and restoring normal function, and she speculates that combination therapy may eventually help patients like this one, reflecting on how eight years of unchecked disease have cost him much of his thirties.

Our next episode, "Distinguishing Flares from Loss of Response in HS," examines how to tell a true flare from a genuine loss of response.