Earlier Biologic Intervention Is Necessary in Moderate to Severe Hidradenitis Suppurativa

Dermatology Times recently concluded its second annual Horizons in Advanced Practice meeting in Tampa, Florida. The exclusive meeting brought together physician assistants and nurse practitioners from across the country to review cases of complex atopic dermatitis (AD) and other type 2 inflammatory diseases, psoriasis, chronic hand eczema (CHE), and hidradenitis suppurativa (HS) during sessions led by experts in the specialty.

During the second half of breakout sessions, Lakshi Aldredge, MSN, ANP-BC, DCNP, FAANP, a dermatology nurse practitioner at the Veterans Affairs Portland Health Care System in Oregon, reviewed clinical trial and long-term data supporting biologic use in hidradenitis suppurativa (HS) and discussed practical considerations for patient selection, timing, and durability of response.

HS severity assessment remains a challenge, noted Aldredge, emphasizing that Hurley staging alone may underestimate disease burden, particularly in patients with recurrent nodules, pain, and scarring but limited sinus tract formation. These patients often meet criteria for moderate disease and may benefit from biologic therapy despite inadequate response to multiple antibiotics or adjunctive systemic agents.

“I often start with the 4 Es: evaluation, education, expectations, and emotional support,” said one attendee while discussing quality-of-life impacts.

Biologic Options

Among the available options, tumor necrosis factor and IL-17 inhibition continue to anchor biologic management, Aldredge said. Adalimumab (Humira; AbbVie), the first biologic approved for HS, demonstrated significant efficacy in the phase 3 PIONEER I (NCT01468207) and II (NCT01468233) trials, with weekly dosing achieving higher rates of Hidradenitis Suppurativa Clinical Response (HiSCR) at week 12 compared with placebo. Long-term extension data showed sustained responses and a safety profile consistent with prior experience.¹

IL-17 inhibitors have expanded the biologic landscape. In the phase 3
SUNSHINE (NCT03713619) and SUNRISE (NCT03713632) trials, secukinumab (Cosentyx; Novartis Pharmaceuticals Corporation) administered every 2 or 4 weeks achieved significantly higher HiSCR rates at week 16 compared with placebo in adults with moderate to severe HS. Long-term follow-up through 104 weeks demonstrated durable responses, including achievement of HiSCR75 and HiSCR90
(≥ 75% and ≥ 90% reduction, respectively, in total abscess and nodule count from baseline, with no increase in draining tunnels or new abscesses), with stable exposure-adjusted incidence rates for adverse events of interest.²

Similarly, bimekizumab (Bimzelx; UCB) demonstrated robust efficacy in the phase 3 BE HEARD I (NCT04242446) and II (NCT04242498) trials, with significantly greater HiSCR responses at week 16 versus placebo. Long-term data through 96 weeks showed sustained clinical benefit with a manageable safety profile, further supporting IL-17 blockade as a viable strategy in HS.³

“The take-home point with bimekizumab is don’t give up after 48 weeks—it will continue to get better,” Aldredge said.

All Around Care

No matter which biologic clinicians select for their patient, Aldredge encouraged the use of over-the-counter adjunctive treatments of vitamin D, zinc gluconate, and metformin.

“The only patient I started on [bimekizumab] was a 45-year-old African American [man]. He had a 12-year history of HS, and it was so severe,” said one attendee. “When he came to me, he was in tears talking about the story. But one thing that nobody else did was listen to him. He thanked me for diagnosing him and telling him what HS was. I was grateful [bimekizumab] was available at the time.”

Aldredge emphasized that biologic selection should be individualized, incorporating disease phenotype, comorbidities, patient preferences, and expectations regarding long-term therapy. Collectively, these data reinforce a shift toward earlier biologic intervention to reduce flares, limit progression, and improve quality of life in patients with moderate to severe HS.

“We have at least 3 biologics that have been approved for hidradenitis suppurativa. Bimekizumab has shown the greatest efficacy with good long-term and safety data. However, we still have a long way to go with this disease, and we’re looking forward to JAK [Janus kinase] inhibitors for this disease and perhaps the possibility of [a] bimekizumab and GLP-1 combo,” Aldredge concluded.

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. doi10.1016/S0140-6736(24)00101-6