Biologic Treatment for Hidradenitis Suppurativa

Kelsey S. Flood; Martina L. Porter; Alexa B. Kimball


Am J Clin Dermatol. 2019;20(5):625-638. 

In This Article

Abstract and Introduction


Patients with hidradenitis suppurativa (HS) are often undertreated and there are limited efficacious therapies available for treating this population. Biologics are an emerging therapeutic modality used in the management of many inflammatory conditions including HS. Implementation of biologics is typically reserved for moderate-to-severe cases or in those cases that are refractory to treatment. Though many biologics have been trialed for use in HS, only one biologic, adalimumab, is currently US FDA (Food and Drug Administration) approved for the treatment of moderate-to-severe HS. Limitations in the use of biologics for HS include the many scoring systems utilized in research studies and the relatively few well-designed, adequately powered clinical trials.


Patients with hidradenitis suppurativa (HS) have painful inflammatory nodules, abscesses, and fistula distributed classically in the axilla, groin, buttocks, and inframammary region. The pathophysiology of HS is complex; contributing factors include immune dysregulation, hormones, genetics, the microbiome, environmental and physical factors, among others. A variety of therapeutic regimens have been employed in the management of HS, including lifestyle interventions, surgery, topical antibiotics, systemic antibiotics, systemic hormonal therapies, topical steroids, intra-lesional steroids, systemic steroids, and biologics. The potential efficacy of biologics in HS was first realized in patients with inflammatory bowel disease (IBD) undergoing treatment with biologics who incidentally happened to demonstrate improvement in their HS.[1]

Several studies have demonstrated an altered inflammatory milieu in HS, supporting a mechanism for the efficacy of biologics.[2–4] As our understanding of cytokines involved in HS pathophysiology expands, several biologics have been trialed in HS management including agents targeting tumor necrosis factor (TNF), interleukin-12 (IL-12) and interleukin-23 (IL-23), interleukin-17 (IL-17), and interleukin-1 (IL-1). This paper reviews existing research on use of biologics in HS. Commonly used dosing, expected time to response, duration of response, and safety concerns will also be reviewed. Of note, longitudinal data regarding the safety of biologics in HS is lacking, in part given the more recent adoption of biologics for HS. Experience obtained from use of biologics in other conditions, including psoriasis, rheumatologic diseases, and inflammatory bowel disease, is frequently extrapolated to the HS population and will therefore be reviewed in this article.