At a recent Case-Based Roundtable event, Harrison Nguyen, MD, MBA, MPH, reviewed 2 HS patient cases and discussed the role of biologics.
“Ten years ago, the average delayed HS diagnosis was 15 years. We’re now nationally around 7 years. That’s still too long, but we’ve made a lot of headway,” said Harrison Nguyen, MD, MBA, MPH, at a recent
Nguyen, a board-certified dermatologist, Mohs surgeon, and managing director of Harrison Dermatology & Research Group, moderated a roundtable discussion on hidradenitis suppurativa (HS), “Optimizing Biologic Therapy in HS: Real-World Cases and Expert Perspectives.”
A 27-year-old woman with a 3-year history of HS presents with recurrent axillary nodules that significantly impair daily functioning. Examination reveals a single inflammatory nodule with established rope-like scarring in the left axilla, consistent with progressive, chronic disease. Despite sequential use of topical clindamycin, oral doxycycline, combination oral clindamycin/rifampin, metformin, and hormonal therapy, she has experienced inadequate control and persistent symptomatic burden.
“Historically, it’s been thought that a biologic was a ‘bigger gun’ than long‑term antibiotics. I would argue long‑term antibiotic treatment can actually do more harm and is riskier than some of the IL‑17s,” Nguyen said.
Pain, drainage, and concern about further scarring have contributed to increasing psychosocial distress, highlighting the need for escalated intervention. Given her refractory course and functional limitations, Nguyen noted that initiation of biologic therapy is appropriate to target the underlying inflammatory pathways and reduce future lesion formation.
Gorelick reviewed with attendees data on secukinumab (Cosentyx; Novartis), bimekizumab (Bimzlex; UCB), and adalimumab (Humira; AbbVie). In the SUNSHINE trial (
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“I want to treat someone as early as possible… the IL‑17 side‑effect profile is so favorable that I want to treat them if they’re having more frequent outbreaks… there’s potential harm in recurrent antibiotic exposure,” said an attendee.
A 35-year-old man with a 6-year history of moderate HS presents with recurrent axillary and groin nodules and abscesses that flare approximately monthly. His disease has led to persistent pain, drainage, and functional limitations, affecting both occupational performance and intimacy. Despite treatment with topical clindamycin, intermittent oral antibiotics, and episodic corticosteroids for flares, symptom control remains inadequate.
His decision to decline biologic therapy 2 years prior was based on concerns about treatment duration and potential adverse effects; however, increasing frustration with ongoing disease activity has prompted reevaluation of management options. Given his chronic, relapsing course and significant quality-of-life burden, escalating to a targeted biologic therapy is appropriate to address the underlying inflammatory pathways, reduce flare frequency, and prevent further tissue damage.
“My experience with biologics is: this is not a cure. Patients are still going to get lesions. But they’re not as painful, don’t last as long, and they’re not getting as many new ones,” an attendee said.
With the second case, Nguyen reviewed long-term efficacy data for secukinumab and bimekizumab. For patients who responded well to the initial 4-week secukinumab dosing and continued, 69.8% achieved HiSCR 75 and 47.9% achieved HiSCR 90 at week 104. For bimekizumab, 85.4% of patients maintained HiSCR 50 at 96 weeks, 77.1% maintained HiSCR 75 at 96 weeks, and 57.6% maintained HiSCR 90 at 96 weeks.
“Patients who do well on bimekizumab do really well. At 3 years, about 90% of patients have achieved HiSCR 75,” Nguyen said.
Throughout the roundtable discussion, 4 key themes were clear:
Attendees emphasized that HS management is inherently multi-component, combining topical antiseptics, systemic antibiotics, and short steroid tapers with hormonal and metabolic adjuncts such as spironolactone, oral contraceptives, metformin, and emerging off-label interest in GLP-1 receptor agonists. Lifestyle modification and routine comorbidity screening were emphasized, while intralesional triamcinolone was positioned as a short-term rescue rather than disease-modifying therapy.
Attendees noted that adalimumab remains familiar and often payer-preferred, but challenges persist, including forced biosimilar switching, variable durability, and concerns about antidrug antibodies. Increasingly, IL-17 inhibitors such as secukinumab and bimekizumab are favored earlier based on higher HiSCR response rates and durable long-term data, despite manageable candidiasis risk. TNF-α inhibitors are now more selectively reserved, particularly for pediatric or niche clinical scenarios.
Several clinicians suggested that prolonged or repeated systemic antibiotic use may now carry greater long-term risk—particularly antimicrobial resistance and microbiome disruption—than modern IL-17 biologics. This evolving risk–benefit perspective was cited to support earlier biologic initiation, especially for patients with recurrent flares, sinus tracts, or significant prior antibiotic exposure.
Attendees endorsed a “window of opportunity” in HS, noting that a substantial proportion of Hurley I patients progress to more advanced disease. Early biologic therapy combined with timely surgical intervention—particularly deroofing or localized excision—was viewed as potentially disease-modifying. Nguyen encouraged clinicians to take ownership of HS surgery under tumescent anesthesia as part of comprehensive care, rather than routinely referring all cases externally.
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