From Tunnels to Treatment: Advancing HS Management - Episode 4
HS Biologic Therapy: Selecting, Starting, and Monitoring Response
With three approved biologics, the choice of agent, the timing of initiation, and the definition of disease control all matter. The panel connects comorbidities, a simple screening question, and patient-reported outcomes to practical decisions.
In "HS Biologic Therapy: Selecting, Starting, and Monitoring Response," our experts turn to the current standard of care and how they decide when and how to start advanced therapy.
The discussion turns to current therapy, including the treatment landscape and the standard of care. The panel notes that three biologics are now FDA approved for HS. Before adalimumab, nothing was on label, and clinicians relied on chemotherapeutics, a slurry of antibiotics, and procedures. Adalimumab and secukinumab are approved down to age 12, while bimekizumab is approved down to age 18. Each has unique strengths. For patients with many draining tunnels, IL-17F inhibition can be especially useful because that pathway is amplified in tunnels and sinuses. Comorbidities also guide selection. TNF inhibitors may be avoided in congestive heart failure, demyelinating disease, or a family history of either, and favored in inflammatory bowel disease, where one agent can treat both conditions.
Asked whether every patient needs a biologic, the panel suggests that any frequency of flares or involvement of multiple areas warrants consideration of an advanced therapeutic. One screening question asks whether the patient has had more than two flares in more than two areas in the past six months. A yes suggests active moderate-to-severe disease at high risk of progression. Draining tunnels or any structural damage should prompt a conversation that lays the foundation for biologic therapy.
On monitoring, the panel describes disease control as provider and patient dependent. Patient-reported outcomes carry heavy weight, including returning to work or school and feeling confident in one's skin. Skin pain is a key marker, alongside the absence of progressive scarring. One clinician asks patients to imagine their control a year from now matching today's. Responses vary widely, since some patients who are 95% better remain unhappy while others at 50% can finally leave the house.
The next episode in this series, "HS Surgery: De-Roofing Alongside Biologic Therapy," features the panel weighing in on surgical options that can be combined with biologic treatment.
