Monitoring Biologic Response in HS

This episode, "Monitoring Biologic Response in HS," has the panel discussing what patients should expect after starting a biologic.

Dr. Bush describes counseling patients to expect gradual improvement rather than quick clearance. She checks in around one month, not expecting the patient to be clear but watching for fewer flares, and tells patients every treatment deserves four to six months, sometimes up to twelve, before judging its full effect, comparing it to regrowing hair after loss. She balances honesty about the timeline with maintaining hope, since promising too little can make patients give up early. Chao adds that he frames treatment as a gradual ramp-up punctuated by occasional flares, since factors like activity, clothing, or daily life triggers can never be fully controlled. On monitoring, Dr. Bush runs baseline TB testing, hepatitis screening, and basic labs before starting any biologic, offering HIV testing if requested. She continues TB testing for TNF inhibitors because insurance still requires it, and hopes forthcoming guidance will eventually remove that requirement for IL-17 and IL-23 inhibitors. She checks liver enzymes on bimekizumab and otherwise follows patients less intensively on IL-17 agents than on TNF inhibitors, seeing patients doing well every three to four months versus monthly for those struggling. Chao follows a similar pattern, monitoring TNF-inhibitor patients closely out of habit while easing up on IL-17 patients to spare them extra office visits and copays. Both assess response by asking how patients feel functionally, not only by counting lesions. Dr. Bush notes an important pitfall: patients, especially those with darker skin tones, often mistake post-inflammatory erythema or hyperpigmentation in resolving areas for active disease. Chao adds that this pigment change, though visible for a long time, actually signals healing rather than ongoing inflammation, and both agree that leading visits with quality-of-life questions captures what matters most to patients.

In "Case 2: Escalating Therapy After Biologic Failure in HS," the panel turns to a second, more complex patient whose first biologic has stopped working.