Tips on Optimizing HS Biologics, Combinations, and Surgery

Hidradenitis suppurativa (HS) management increasingly centers on what clinicians do after selecting a biologic, according to a session presented at the 2026 Fall Clinical Dermatology Conference in Las Vegas. In the session, titled “Perspectives in HS: Are We All On the Same Page?”, Andrea Murina, MD, of Tulane University School of Medicine, outlined practical approaches to optimizing therapy, layering treatments, and reconsidering the role of surgery. The session also featured Michael Payette, MD, MBA, founding partner of Central Connecticut Dermatology.

Murina noted several patient groups associated with HS, including those with early-onset disease, smokers, and individuals with inflammatory bowel disease, Down syndrome, or genetic syndromes such as SAPHO and PAPA. She then turned to a common clinical dilemma: whether to switch or add therapies when a patient continues to flare.

How Can Clinicians Optimize Biologic Therapy in HS?

Murina explained 3 currently available agents carry high-confidence evidence for achieving Hidradenitis Suppurativa Clinical Response (HiSCR) 75 versus placebo: adalimumab, secukinumab, and bimekizumab. She cautioned the supporting comparative data are not derived from head-to-head trials.

Adherence emerged as a central concern. Claims data presented by Murina showed 6 in 10 patients discontinued adalimumab within 1 year of initiation, with female sex, younger age, and Medicaid coverage identified as risk factors. She attributed this pattern to a combination of patient-level and system-level factors and emphasized counseling patients who respond well to remain on therapy and continue follow-up visits.

Long-term data for the IL-17 inhibitors were also highlighted. With secukinumab, approximately 40% of patients achieved HiSCR 100 through 204 weeks, with upper respiratory tract infections and candidal infections among reported adverse events. Bimekizumab showed similar long-term HiSCR 100 rates of roughly 40% to 44% over 3 years, alongside a somewhat higher incidence of oral candidiasis.

Before switching agents, Murina encouraged clinicians to consider dose escalation or more frequent dosing, adding procedures, or incorporating a topical or oral therapy.

Which Combination Therapies May Help Patients With HS?

Murina pointed to topical ruxolitinib, studied in a small trial of mild-to-moderate HS, as a reasonable add-on for patients with more severe disease receiving systemic therapy. She also cited a small case series in JAAD Case Reports suggesting topical roflumilast may help address residual inflammatory lesions.

For systemic combinations, she noted most supporting evidence comes from the gastroenterology and psoriatic arthritis literature. Tumor necrosis factor (TNF) inhibitors may be paired with Janus kinase (JAK) inhibitors such as tofacitinib or upadacitinib, though this approach can raise the risk of infections, acne, and laboratory abnormalities, and requires monitoring. Murina described TNF inhibitors combined with phosphodiesterase 4 (PDE4) inhibitors as a relatively safe option, given years of experience in psoriasis, and noted TNF and IL-23 inhibitor combinations have shown good safety in ulcerative colitis.

For patients receiving an IL-17 inhibitor, adding a JAK inhibitor has been associated with minimal reported adverse effects, although patient numbers remain small. IL-17 inhibitors may also be combined with PDE4 inhibitors.

Do All Patients With Severe HS Need Surgery?

Murina said more effective biologics may reduce the need for surgery, even among patients with the most severe disease, a shift she described as surprising relative to her prior practice. She stressed systemic HS therapies, including biologics, should not be stopped during procedures, including when coordinating care with plastic surgeons.

She closed with a case of a patient with multiple draining tunnels on the back who started bimekizumab and underwent deroofing of a single lesion. When the patient returned for a potential second procedure, both Murina and the patient agreed it was no longer necessary, illustrating the potential of long-term targeted biologic therapy in severe disease.

References

1. Murina A, Payette M. Perspectives in HS: are we all on the same page? Presented at: 2026 Fall Clinical Dermatology Conference; October 8-11, 2026; Las Vegas, NV.