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- Presentation
Novel and Pipeline Therapies for Hidradenitis Suppurativa Management
Description
The speaker reviewed novel and pipeline therapies for hidradenitis suppurativa (HS) and emphasized a treatment strategy that first controls inflammation with medical therapy and then addresses irreversibly damaged tissue surgically if needed. She stressed starting biologics or small molecules early, once HS begins to progress, scar, form tunnels, or significantly affect daily function, rather than waiting for severe disease. Treatment goals include reducing pain, itch, fatigue, drainage, and the development of new lesions in new locations; recurrent lesions often suggest tunnels and may ultimately require surgery. Among current therapies, TNF inhibitors remain important: adalimumab has pivotal trial support, but many patients need dose escalation to 80 mg weekly, and infliximab often requires high-dose/high-frequency treatment; infection, malignancy, and infusion-reaction risks were discussed, along with the possible use of methotrexate or azathioprine to reduce antibody formation. IL-17 inhibitors, including secukinumab and bimekizumab, are FDA-approved and have strong efficacy data, while sonelokimab is a promising phase 3 agent with encouraging longer-term results. Safety points included fungal/candidal infection risk and caution in patients with inflammatory bowel disease, while noting these drugs can be used in older adults, patients with malignancy, and those with demyelinating disease. She also highlighted emerging options such as oral JAK1 inhibitors (upadacitinib and povorcitinib), topical ruxolitinib, the IL-1 inhibitor lutikizumab, and the BTK inhibitor remibrutinib, all showing promising early data. Overall, she concluded that HS inflammation is substantial, timely medical optimization is essential before surgery, and several new therapies are advancing the field.
View moreConclusions
- Hidradenitis suppurativa should be treated with a two-step strategy: first control inflammation medically, then remove irreversibly damaged tissue surgically if needed.
- Biologic or small-molecule therapy should be started early once HS shows progression, scarring, tunneling, or functional impact rather than waiting for end-stage disease.
- The main goals of medical therapy are to reduce pain, itch, fatigue, and drainage, prevent new lesions in new locations, and lessen the burden of recurrent inflammatory lesions.
- Current medical treatments are generally better at controlling inflammation than eliminating established tunnels, so surgery remains necessary for persistent tunnel disease.
- Adalimumab remains an effective first-line biologic for many patients, but dose escalation to 80 mg weekly is often needed for partial responders.
- Infliximab can be effective for HS, but optimal control typically requires higher doses and/or more frequent infusions than standard schedules.
- IL-17 inhibitors have raised the efficacy bar in HS and can produce durable responses, including higher levels of skin clearance over time.
- Bimekizumab and sonelokimab appear especially promising among IL-17-targeting therapies, with a meaningful subset of patients achieving high-level or even complete inflammatory response.
- IL-17 inhibitors have a generally reassuring safety profile, but clinicians should monitor for candidal/fungal infection, possible inflammatory bowel disease, and GI symptoms.
- JAK1 inhibitors are promising oral options for HS and may offer substantial efficacy with manageable safety when patients are monitored carefully.
- Topical ruxolitinib may become a useful option for milder disease and possibly as adjunctive therapy in more severe disease.
- IL-1 inhibition and BTK inhibition represent additional emerging mechanisms that may help patients who fail existing therapies or need new options.
- Overall, HS inflammation is robust and timely medical treatment with dose escalation or therapy switching is essential before proceeding to surgery.
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