What to Expect With Biologics for Hidradenitis Suppurativa


Erin Azuse

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Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic skin condition characterized by the development of small, painful lumps under the skin.

For some patients with moderate to severe HS, finding an effective treatment can be a challenge. However, the use of biologic therapy, or biologics, appears promising for a large percentage of these patients.      

What is HS?

The symptoms of HS appear when sweat glands under the skin become inflamed. Areas where skin rubs together are most commonly affected, including underarms, the groin, and underneath the breasts. HS is more frequently seen in women and usually begins after puberty.

HS can be mild or severe, but it recurs and may worsen over time. The lumps can rupture, leaking bloody or foul-smelling fluid. Scarring may develop, and tunnel-like channels under the skin, called sinus tracts, sometimes form between the affected areas. This is often painful as well as psychologically distressing for HS patients.

Since there is no cure for HS, treatment is aimed at improving pain, reducing breakouts, and avoiding complications. Treatment options for HS include:

  • Retinoids: These medications are made from vitamin A and can help with skin conditions.

  • Oral and injected steroids: Steroids are used to decrease inflammation and discomfort.

  • Antibiotics: Different antibiotics can be used to fight infections that may develop.

  • Hormonal therapy: The oral contraceptive pill improves symptoms for some patients.

  • Pain medication: Nonsteroidal anti-inflammatory drugs like ibuprofen help with pain and swelling, but stronger medication like morphine or fentanyl can be ordered by your doctor if needed.

  • Surgical procedures: Various methods can be used, from cutting into the abscess and allowing it to drain to surgically removing large areas of affected skin.

Sometimes, these treatments don’t offer the relief that patients are seeking, so research continues to combat this.

How are biologics different than other hidradenitis suppurativa treatments?

The success of biologics with other inflammatory diseases such as rheumatoid arthritis and psoriasis led researchers to explore their effectiveness with HS. Biologics are created from living cells and are designed to target specific points in the body’s immune response. Rather than treat the symptoms of the disease, biologics attempt to prevent the inflammation from occurring in the first place. In the case of HS, researchers found that blocking an immune system protein called tumor necrosis factor (TNF) slowed or stopped the body’s inflammatory reaction and decreased symptoms of HS.

Currently, one TNF-blocking biologic has been approved by the U.S. Food and Drug Administration (FDA) called adalimumab (Humira). In clinical trials, many patients reduced their number of painful lesions by at least 50% and did not develop any new areas of HS. Adalimumab can be given as a self-injection every two weeks.

Another TNF-blocker, infliximab (Remicade) is also being studied for treating HS. It is given as an infusion into a vein, spaced out over several weeks, and in trials appears to have a similar effectiveness to adalimumab.

What else needs to be considered before starting a biologic for HS?

Though biologics are changing the way HS and other diseases are treated, they are not right for everyone. Biologics are complex to make and store, and as a result, can be quite expensive. They also may increase the risk of infection, heart failure, and certain cancers, such as leukemia and lymphoma. Talk to your doctor about the following things before starting a biologic:

  • Getting a tuberculosis (TB) test and if you have any history of TB: TB can be dormant, without any symptoms, for many years, but the use of a biologic increases the risk of the disease becoming active.

  • How to recognize signs of infection: Because biologics suppress the immune system, secondary infections can develop.

  • If you should receive any vaccines before starting treatment, including the flu vaccine: Also due to the immune system suppression, it is important to be up to date on vaccines to keep you healthy. It is usually recommended to get live vaccines, 1 to 3 months before starting a biologic.

  • If you are pregnant or planning on becoming pregnant: You should always have a discussion with your doctor about any medication you are taking and its possible effect on your pregnancy.

As with any new treatment, your doctor will consider the risks versus benefits to determine if a biologic is a good option for your hidradenitis suppurativa. Keep the lines of communication open as you work together to manage your disease.

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