Recognizing the Right Time to Start Biologics in HS

Hidradenitis suppurativa (HS) is often considered one of the most challenging chronic inflammatory skin diseases to manage in routine clinical practice. Characterized by recurrent and painful nodules, abscesses, draining tunnels, and progressive scarring in intertriginous areas, the disease carries a disproportionate burden on quality of life, psychosocial functioning, and work productivity. At 3 recent Dermatology Times Case-Based Roundtable events, F. George Hougeir, MD; Afsaneh Alavi, MD; and Harrison Nguyen, MD, MBA, MPH, moderated discussions with dermatology clinician attendees to review 3 patient cases of HS and the use of biologics. Hougeir is a dermatologist and Mohs surgeon at Southeast Dermatology Specialists in Georgia; Alavi is a dermatologist and director of the medical dermatology fellowship at Mayo Clinic in Minnesota; and Nguyen is a dermatologist, Mohs surgeon, and managing director of Harrison Dermatology and Research Group in Texas. The moderators agreed that the clinical impact of HS often far exceeds what is suggested by lesion counts alone, particularly in patients with ongoing pain, drainage, and anxiety related to disease progression.

Although HS is frequently described using static staging systems such as Hurley classification, moderators emphasized that these tools offer an incomplete picture of disease burden. As Hougeir noted, although Hurley staging remains widely used, attendees emphasized its limitations in capturing dynamic inflammatory activity.

Many clinicians now rely on dynamic assessments, including inflammatory lesion counts and patient-reported outcomes, to guide treatment decisions. Measures such as the International Hidradenitis Suppurativa Severity Score System and Hidradenitis Suppurativa Clinical Response (HiSCR) were referenced as helpful frameworks, particularly when evaluating response to systemic therapies over time.

Across the dinner discussions, clinicians revisited a familiar but evolving question: How can biologic therapies be optimized for patients with moderate to severe HS in real-world settings? Although antibiotics, hormonal agents, and procedural interventions remain part of standard treatment, the moderators consistently noted that many patients cycle through these options with incomplete or transient benefit. This pattern often results in delayed disease control and cumulative tissue damage.

The expanding biologic options have shifted the focus from short-term symptom suppression to long-term disease modification. Attendees highlighted that biologics are increasingly being considered not only for severe disease but also for patients with moderate HS whose quality of life is substantially impaired. Nguyen agreed that earlier and more strategic use of biologic therapy has the potential to alter disease trajectory, reduce flares, and improve long-term outcomes.

Rather than recounting individual presentations, the discussions highlighted recurring clinical themes that transcend any single case. These themes—when to escalate therapy, how to choose among biologics, how to define meaningful success, and how to sustain response—formed the basis of expert dialogue and provided a practical framework for clinicians navigating HS management today.

When Is a Biologic Appropriate for HS?

One recurring point of discussion centered on identifying the appropriate moment to transition from conventional therapies to biologic treatment. In one representative case, a young woman with a multiyear history of HS presented with inflammatory nodules, a draining tunnel, and established scarring in the axillae. Despite multiple prior therapies—including topical and systemic antibiotics, hormonal modulation, and adjunctive agents—disease control remained inadequate, with ongoing pain, drainage, and functional impairment.

Moderators agreed that this type of clinical scenario is common in daily practice. Patients may technically meet criteria for moderate disease yet experience a level of physical discomfort and psychosocial distress more consistent with severe HS. Alavi emphasized that reliance on prolonged antibiotic courses often reflects therapeutic inertia rather than true disease control and may delay more effective interventions.

“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.

Attendees noted that recurrent flares, early tunnel formation, and progressive scarring should prompt reconsideration of treatment strategy. Several attendees highlighted that anxiety around disease progression, fear of worsening scarring, and limitations on work or social participation are clinically meaningful signals that treatment goals are not being met.

Across discussions, patient-reported outcomes played a central role in escalation decisions. Pain severity, drainage frequency, and impact on daily activities were frequently cited as factors that justified biologic initiation, even when objective lesion counts appeared modest. Nguyen agreed that biologic therapy should not be viewed solely as a last resort, but rather as an appropriate next step when conventional approaches fail to achieve adequate disease control.

In this context, biologics were framed as tools for altering the inflammatory course of HS rather than simply managing flares. Experts emphasized that early identification of patients who may benefit from biologic therapy may help prevent irreversible tissue damage and reduce the long-term burden of disease.

Choosing Among the Available Biologics

With multiple biologics now available for HS, discussions shifted toward the practical factors that influence agent selection in real-world practice. The moderators agreed that treatment choice is rarely driven solely by efficacy data. Instead, they described a multifactorial decision-making process that incorporates patient characteristics, disease phenotype, prior treatment history, and long-term management considerations.

Tumor necrosis factor inhibitors and IL-17 pathway inhibitors were discussed extensively, with speakers referencing both clinical trial outcomes and their own practice experience. Measures such as HiSCR50 and HiSCR75 (HiSCR defined as at least a 50% or 75% reduction, respectively, in abscess and inflammatory nodule count without an increase in abscesses or draining fistulas) were considered useful benchmarks, but Hougeir emphasized that the depth and durability of response are equally important when selecting therapy for a chronic disease.

IL-17 inhibitors, including secukinumab (Cosentyx; Novartis) and bimekizumab (Bimzelx; UCB), were frequently highlighted, given their recent approvals and expanding evidence base in HS. Nguyen noted that these agents may be particularly relevant for patients with persistent inflammatory activity, frequent flares, or inadequate response to prior therapies. Differences in dosing schedules, response rates, and long-term data were discussed as factors that may influence agent selection in individual patients.

“I want to treat someone as early as possible…. The IL-17 [adverse] 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,” one attendee said.

Conclusion

Across these case-based discussions, moderators and clinician attendees emphasized that HS management is evolving rapidly as biologic therapies expand and clinical experience grows. Although traditional approaches such as antibiotics and procedural interventions remain important components of care, many patients continue to experience persistent inflammation, pain, and progressive tissue damage despite these strategies.

Biologic therapies are increasingly being integrated earlier in the treatment pathway, particularly for patients whose disease burden is not adequately captured by lesion counts alone. Moderators agreed that factors such as recurrent flares, early tunnel formation, quality-of-life impairment, and patient-reported symptoms should prompt clinicians to reconsider treatment strategy and evaluate whether systemic biologic therapy may be appropriate.

At the same time, no single biologic therapy is universally optimal. Treatment decisions require careful consideration of disease characteristics, prior therapies, comorbid conditions, safety profiles, and patient preferences. Shared decision-making and proactive patient education were viewed as essential components of successful long-term management.

Ultimately, the discussions reinforced that effective HS care requires both timely intervention and sustained monitoring. As additional long-term and real-world data emerge for newer biologics, clinicians will continue refining strategies to optimize response durability, improve quality of life, and potentially alter the long-term trajectory of this complex inflammatory disease.