Optimizing Biologic Therapy in HS: Part 3

Hidradenitis suppurativa (HS) occupies a unique and challenging space in dermatology. It is common enough that many clinicians encounter it regularly, yet complex enough that management can be varied across practices. The disease is medically challenging, often procedurally intensive, and associated with a significant psychosocial burden for patients, with care frequently shaped by insurance constraints. Importantly, HS is a disease in which timing can play a critical role in long-term outcomes.

Across 3 recent Dermatology Times Case-Based Roundtables—moderated by Martina Porter, MD; Joe Gorelick, MSN, FNP-C; and Steven Daveluy, MD—clinicians explored 3 cases of HS, each with their own complex needs. Though discussed in different locations and through different professional lenses, these cases revealed a consistent theme: Many patients with HS are escalated too late, treated too narrowly, and evaluated too superficially.

Rather than debating abstract guidelines, these roundtables centered on real patients whose disease trajectories reflect the consequences of delayed intervention, the risks of overreliance on antibiotics, and the disconnect that can exist between visible disease and lived experience. Together, the cases depicted how HS often unfolds in real life: Early inflammation is underestimated, moderate disease is managed conservatively by nondermatology clinicians, and severe disease is often associated with permanent skin damage.

What emerged from these conversations was not a single preferred drug or protocol but a shared approach of how dermatology clinicians define severity, evaluate readiness for biologics, and incorporate patient-reported burden into decision-making.

Redefining Severity

The last case involved a young woman with clinically mild HS. Lesion counts were low, and there was no evidence of deep tunneling or scarring. Yet the patient reported significant distress related to visible lesions, odor, and fear of flares. Her social life, confidence, and emotional well-being were increasingly affected. As Gorelick noted, “HS doesn’t just cause pain—it dictates where patients go, what they wear, how they work, and whether they feel comfortable being close to another person.” Across all 3 roundtables, this case generated some of the most passionate discussions.

The Limits of Traditional Staging

Clinicians were quick to acknowledge that traditional staging systems fail patients like this. Hurley staging captures anatomy, not lived experience. Daveluy articulated this shift clearly: “Patient-reported experience often matters more than lesion counts for decision-making.” Pain, embarrassment, and emotional burden were repeatedly cited as legitimate drivers of escalation.

Gorelick echoed this sentiment during his own session. “HS is one of those conditions that, when it happens, will derail your entire day, and rightfully so,” he said. Even a single lesion can be life-altering. “For many patients, the unpredictability is worse than the pain. They’re constantly bracing for the next flare,” Porter said.

How Watchful Waiting Can Backfire

A recurring concern was the risk of rapid progression in certain HS phenotypes. Clinicians discussed how inflammation can escalate quickly, even when early disease appears mild on examination. “You can have very few lesions and still have devastating quality-of-life impact, and that’s something traditional severity scales miss,” Daveluy said.

Several attendees admitted that earlier in their careers, they might have reassured a patient like this and adopted a watchful waiting approach. However, with experience, many now view that strategy as risky—particularly when psychosocial distress is already significant.

Treating Impact, Not Just Anatomy

Treatment recommendations emphasized early procedural and laser-based interventions aimed at reducing inflammation and preventing progression. Counseling was central: validating the patient’s experience, addressing fears, and building a personalized plan focused on quality of life.

Although biologic therapy was not universally recommended as an immediate next step, clinicians agreed that psychosocial burden alone could justify escalation if symptoms persisted or worsened. This represented a meaningful departure from older paradigms that prioritized physical findings above all else.

An Overall Shift in Expectations

Although the urgency differed across the 3 cases, biologics were central to every discussion. Gorelick’s roundtable provided detailed context from pivotal trials. Adalimumab, the first biologic approved for HS, demonstrated HiSCR50 response rates of 41.8% and 58.9% in the PIONEER I (NCT01468207) and PIONEER II (NCT01468233) trials. Although these results were once groundbreaking, many clinicians now view them as a baseline rather than a goal.

Secukinumab showed HiSCR50 responses of approximately 45% to 46% in the SUNSHINE (NCT03713619) and SUNRISE (NCT03713632) trials, with long-term durability extending beyond 2 years. Its flexible dosing schedule and established safety profile were viewed as strengths.

Bimekizumab generated the most enthusiasm. In the BE HEARD I (NCT04242446) and BE HEARD II (NCT04242498) trials, approximately half of patients achieved HiSCR50 at week 16, with sustained HiSCR75, HiSCR90, and even HiSCR100 responses through 96 weeks. Attendees highlighted its dual IL-17A/IL-17F inhibition and HS-specific dosing.

Real-world sentiment echoed trial data. One attendee shared, “I ended up in an HS Reddit forum…. Half of the thread was about bimekizumab and people talking about their life-changing experiences.” Concerns about candidal infections were discussed openly but viewed as manageable. As Gorelick put it, “Would that prevent you from prescribing it? We can handle a thrush.”

Multimodal Care as the Unifying Principle

Across all 3 cases, one principle remained constant: HS is rarely controlled with a single therapy. Biologics were consistently discussed as part of a broader strategy that includes procedural intervention, antibiotics when appropriate, hormonal therapy, lifestyle counseling, and patient education. Emerging tools such as ultrasound for detecting subclinical tunnels and symptom-tracking apps were viewed as promising adjuncts.

Attendees also discussed real-world barriers—insurance delays, prior authorization fatigue, and step therapy requirements—that often shape treatment decisions more than clinical conviction. Daveluy noted that insurance requirements frequently dictate treatment timing more than clinical judgment.

Why Case-Based Dialogue Matters

Beyond the clinical insights, clinicians repeatedly emphasized the value of the roundtable format itself. “It is nice to meet other clinicians in the area, and I think that this is more interactive than a lecture,” Porter said.

Daveluy echoed this sentiment: “I love getting the opportunity to talk to other dermatologists passionate about treating HS.” These conversations allowed clinicians to share frustrations, validate instincts, and refine decision-making in ways that journal articles cannot.

Conclusion

Taken together, these cases illustrate a specialty in transition. Dermatologists are redefining what constitutes severity, lowering thresholds for escalation, and placing greater emphasis on patient experience.

The lesson is clear: When inflammation is allowed to persist, the consequences are lasting. When clinicians listen closely, intervene earlier, and embrace multimodal care, the course of HS can change. These cases were not simply educational exercises. They were reminders that HS is a disease of cumulative damage—and that timing, empathy, and decisive action matter just as much as the therapies themselves.