Biologics for Hidradenitis suppurativa: evolution of the treatment paradigm

ABSTRACT

Introduction

Hidradenitis suppurativa (HS) is an autoinflammatory skin disease with a high unmet need for effective medical management. Clinically, it is characterized by inflammatory nodules that may progress into abscesses, draining tunnels and extensive scarring, mainly affecting apocrine gland-bearing areas.

Areas covered

Treatment options include topical and systemic medications and a variety of surgical procedures. The anti-TNF-α antibody adalimumab and the anti-IL-17 secukinumab are the only two approved biologics for HS, showing moderate efficacy. HS research is a rapidly growing field, with a wide range of agents leveraging distinct mechanisms of action currently under development. Drugs targeting the IL-17 and Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathways are the most advanced in both ongoing and completed Phase 3 studies, promising deeper levels of response. Use of other, off-label biologics is also discussed.

Expert opinion

A therapeutic algorithm is proposed based on comorbidities and existing evidence. Patient-tailored combinations between biologics and other biologics or small molecules will hopefully allow clinicians to target most events in HS pathophysiology in a complementary way while obtaining a meaningful effect on their devastating manifestations.

KEYWORDS:

• Hidradenitis suppurativa
• biologics
• medical management
• combination
• therapeutic algorithm

Article highlights

• Biologics have had a significant impact on HS management, albeit falling short of reaching the same level of response seen in psoriasis.

• The anti-TNF-α antibody adalimumab and the anti-IL-17 secukinumab are the only two approved biologics for HS, showing only moderate efficacy in around 50% of patients.

• Several therapeutics targeting the IL-17, JAK-STAT, IL-36, IL-1 and complement pathways are currently under development for HS.

• Whereas the number of clinical trials for HS has rapidly risen in recent years, signals of effectiveness derived from real-life evidence should not be disregarded.

• Careful consideration of comorbidities as well as dose/frequency intensified regimens are key to effective patient management.

Declaration of interest

AV Marzano reports consultancy/advisory boards disease-relevant honoraria from AbbVie, Boehringer-Ingelheim, Novartis, Pfizer, Sanofi, and UCB. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was funded by the Italian Ministry of Health (Ricerca Corrente 2023), Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan (Italy).