Distinguishing Flares from Loss of Response in HS

"Distinguishing Flares from Loss of Response in HS" finds Chao and Bush distinguishing ordinary flares from a true loss of response.

Dr. Bush explains that a brief flare, calmed with a steroid injection or a short antibiotic course while the overall disease stays controlled, does not necessarily mean therapy has failed. But a patient who is not responding well overall should move to something better. She advocates using every available tool, including stacking multiple medications and considering de-roofing procedures rather than relying on a single agent. Chao describes a patient on bimekizumab, isotretinoin, ampicillin, and topical clindamycin simultaneously, calling that combination simply the reality of treating this disease well. He lets patients take the lead on this decision. If a patient does not feel controlled despite looking better on exam, that dissatisfaction is a legitimate reason to escalate, and ignoring it risks losing the patient to another provider who will offer more options. Dr. Bush agrees, comparing this dynamic to early psoriasis treatment, and notes the reverse can also occur, where a patient underestimates how active their own disease really is, making shared decision-making essential in both directions. Discussing next-line selection between bimekizumab and secukinumab, Dr. Bush weighs comorbid history, favoring secukinumab for patients with recurrent yeast infections, but admits insurance coverage often drives the final decision more than clinical preference. Chao discusses dosing burden directly with patients, asking whether a five-week weekly injection load or a risk of oral or vaginal candidiasis matters more to them, sometimes choosing bimekizumab when a patient prefers less frequent dosing. Both agree the two agents are clinically very close, calling the choice "splitting hairs," while expressing gratitude that clinicians now have this kind of choice at all, compared to the far more limited options available two decades ago.

Up next, "How Emerging Oral Therapies Target HS Inflammation," shifts to a new class of oral therapies in development for HS.