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- Presentation
Combination Therapies for Hidradenitis Suppurativa: Evidence-Based Approaches and Emerging Options
Description
The speaker reviews evidence-based and emerging combination therapies for hidradenitis suppurativa (HS), emphasizing that HS is often difficult to control with a single systemic agent, especially in refractory patients with comorbidities. Because high-quality studies are limited, much of the combination approach is based on case reports, case series, and real-world experience. The talk outlines multiple treatment targets, including inflammation, hormones, keratinization, bacteria/biofilm, cytokines, and B cells, and stresses early treatment, dose optimization, increased dosing frequency, and adding procedures when needed. Data are summarized for FDA-approved biologics such as secukinumab and bimekizumab, noting that many patients do not reach complete response and that safety is generally acceptable but includes risks like candidiasis and possible IBD flares with bimekizumab. Off-label small molecules discussed include infliximab at high-dose/high-frequency regimens, apremilast, and remibrutinib. The most studied combinations include biologic plus apremilast, TNF plus IL-17, TNF plus IL-1, TNF plus PDE4, and IL-17 plus JAK inhibitors, with side effects ranging from mild infections and acne to occasional serious infections. The speaker also highlights GLP-1 receptor agonists, especially in patients with diabetes or obesity, citing case series showing improvements in pain, PGA scores, and inflammatory markers when used alongside antibiotics and biologics. Overall, the message is to start with approved biologics, optimize dosing, and consider carefully selected combination therapy for refractory disease and overlapping inflammatory conditions.
View moreConclusions
- Hidradenitis suppurativa often remains inadequately controlled with a single systemic agent, so combination therapy is frequently needed to close the treatment gap.
- The best-supported strategy is to treat earlier and optimize dose and frequency before assuming a therapy has failed.
- FDA-approved biologics such as secukinumab and bimekizumab provide meaningful long-term benefit, but a substantial proportion of patients still do not reach complete clearance.
- Earlier initiation of biologic therapy appears to produce better outcomes than waiting until disease is more advanced.
- Off-label small molecules, especially high-dose/high-frequency infliximab, upadacitinib, apremilast, and remibrutinib, may help refractory patients when standard therapy is insufficient.
- The evidence for dual biologic or biologic-plus-small-molecule combinations is limited and mostly based on case reports or small series, so these regimens are reserved for selected difficult cases.
- Safety is a major consideration with combination therapy, with infection risk and other adverse effects requiring careful monitoring.
- GLP-1 receptor agonists look promising for HS, particularly in patients with obesity or diabetes, and are associated with reduced disease severity, pain, and inflammatory burden.
- Combination medical therapy is most appropriate for refractory HS and for patients with coexisting inflammatory comorbidities, rather than as routine first-line escalation for all patients.
- Procedures, antibiotics, hormonal agents, and weight-loss-directed therapy can all be combined with systemic treatments to lower overall disease burden and improve outcomes.
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