Derm On Air: Biologic Therapy Selection in Hidradenitis Suppurativa

Three biologics now carry approval for moderate to severe hidradenitis suppurativa (HS), and clinicians increasingly introduce them early to intervene before tunneling and scarring take hold. Choosing among them depends less on a single efficacy ranking than on trial populations, dosing flexibility, and comorbidity profile.

On a recent episode of Derm on Air, host Cynthia Trickett, MPAS, PA-C, of North Dallas Dermatology Associates, spoke with Buchi Neita, MCMSc, PA-C, of Epiphany Dermatology. The discussion focused on how phase 3 data for adalimumab, secukinumab, and bimekizumab should guide treatment selection.

Adalimumab (Humira), a tumor necrosis factor (TNF) inhibitor approved for HS in 2015 and now indicated for patients 12 years and older, set the benchmark in PIONEER I and II. With 40 mg weekly, rates of HS clinical response (HiSCR50) at week 12 reached 41.8% vs 26.0% with placebo in PIONEER I (P = .003) and 58.9% vs 27.6% in PIONEER II (P < .001).¹ Serious adverse event rates resembled placebo, and open-label extension data showed roughly 53% of patients maintaining HiSCR50 through week 168 on continuous weekly dosing.

Secukinumab (Cosentyx), an interleukin (IL)-17A inhibitor approved for HS in 2023, met its primary end point in SUNSHINE and SUNRISE. Week 16 HiSCR50 rates ranged from 42% to 46% in arms reaching significance vs placebo, with responses sustained to week 52 and headache as the most common adverse event.² Maintenance dosing every 4 weeks can be intensified to every 2 weeks for inadequate response, a flexibility suited to the variable course of HS.

Bimekizumab (Bimzelx), approved for HS in 2024, inhibits both IL-17A and IL-17F, a meaningful distinction given IL-17F expression within HS tunnels, now recognized as inflammatory structures in their own right. In BE HEARD I and II, week 16 HiSCR50 rates with dosing every 2 weeks reached 48% (138/289) and 52% (151/291), vs 29% (21/72) and 32% (24/74) with placebo. Responses were maintained or increased through week 48, and frequent treatment-emergent adverse events included HS flares, coronavirus infection, and oral candidiasis.³

Comorbidity profile often decides the choice in practice. Coexisting inflammatory bowel disease, more prevalent among patients with HS, favors TNF inhibition over IL-17 blockade, while a history of recurrent candidiasis warrants caution with IL-17 agents.

Without head-to-head trials, and with each agent studied in a distinct population on a distinct dosing schedule, biologic selection in HS rests on fit with the individual patient rather than on a single efficacy hierarchy.

REFERENCES:

1. Kimball AB, Okun MM, Williams DA, et al. Two phase 3 trials of adalimumab for hidradenitis suppurativa. N Engl J Med. 2016;375(5):422-434. doi:10.1056/NEJMoa1504370
2. Kimball AB, Jemec GBE, Alavi A, et al. Secukinumab in moderate-to-severe hidradenitis suppurativa (SUNSHINE and SUNRISE): week 16 and week 52 results of two identical, multicentre, randomised, placebo-controlled, double-blind phase 3 trials. Lancet. 2023;401(10378):747-761. doi:10.1016/S0140-6736(23)00022-3
3. Kimball AB, Jemec GBE, Sayed CJ, et al. Efficacy and safety of bimekizumab in patients with moderate-to-severe hidradenitis suppurativa (BE HEARD I and BE HEARD II): two 48-week, randomised, double-blind, placebo-controlled, multicentre phase 3 trials. Lancet. 2024;403(10443):2504-2519. doi:10.1016/S0140-6736(24)00101-6