Clinician Perspectives on Managing Adverse Effects in HS

Cutaneous adverse effects occur in approximately 10% of patients treated with IL-17 inhibitors for hidradenitis suppurativa (HS), with higher risk among those with previous history of psoriasis or eczema and more severe baseline HS disease. These reactions manifest as eczematous or psoriasiform rashes, often in intertriginous distributions where they may overlap with HS lesions and can include concerning findings like fissuring in the retroauricular area, perianal region, and inguinal creases. Management approaches start with topical therapies similar to those used for mild atopic dermatitis or psoriasis, including newer brand-name medications that offer safer profiles for use in sensitive areas.

For patients with persistent or severe cutaneous reactions, particularly those with underlying severe HS, dual biologic therapy or combination treatment with Janus kinase (JAK) inhibitors may provide synergistic benefits addressing both the paradoxical skin reactions and residual HS inflammation. Class switching represents another viable strategy, as patients may tolerate different molecules within the IL-17 inhibitor class or achieve better outcomes with TNF inhibitors if cutaneous reactions prove unmanageable. Some practitioners employ prophylactic fluconazole before each dose, hypothesizing that treating yeast colonization may prevent some cutaneous reactions, particularly given their predilection for intertriginous locations.

Additional management strategies include early use of topical calcineurin inhibitors like tacrolimus and topical JAK inhibitors in areas prone to fissuring or dermatitis, along with preventive measures for oral candidiasis including topical antifungals and sugar-free xylitol gum. Comprehensive patient counseling before treatment initiation proves essential for maintaining adherence, with practitioners emphasizing that cutaneous adverse effects, while uncomfortable, remain manageable within dermatologic expertise. Depression monitoring represents another important safety consideration, with rare but significant cases requiring treatment discontinuation, alongside routine liver function testing as indicated by current labeling requirements.