IL-17 Inhibitors in HS Practice

Secukinumab and bimekizumab represent the 2 approved IL-17 inhibitors for hidradenitis suppurativa (HS), with distinct mechanisms of action and clinical profiles. Secukinumab, an IL-17A inhibitor, offers a slightly better cutaneous safety profile with lower rates of skin-related adverse events, though it typically requires a longer timeline to achieve maximal therapeutic effect. Bimekizumab, targeting both IL-17A and IL-17F, may provide more rapid response and more extensive disease improvement, particularly for drainage symptoms, but carries higher risk of cutaneous adverse effects including folliculitis and dermatitis.

Clinical experience with IL-17 inhibitors in HS demonstrates their revolutionary impact on treatment options, offering alternative pathways for patients who fail to respond to TNF inhibitors. Drug monitoring studies of TNF inhibitors revealed that many patients maintained high drug levels without achieving adequate response, suggesting their disease was driven by alternative inflammatory pathways like IL-17. This insight enabled more strategic use of IL-17 inhibitors for patients whose disease biology makes them better candidates for this therapeutic class.

Practitioners have expanded IL-17 inhibitor use beyond traditional clinical trial entry criteria, treating patients with milder disease who experience significant quality of life impact or recurrent severe flares. The safety profile of IL-17 inhibitors makes them particularly appealing as gateway biologics for younger patients or those with childbearing potential who express hesitancy about starting immune-modulating therapy. For more severe disease, particularly when drainage represents a prominent symptom, the dual IL-17A/F inhibition offered by bimekizumab may provide superior outcomes despite requiring more proactive management of potential cutaneous adverse effects.