Hidradenitis suppurativa (HS) is a common, yet challenging disorder to treat. In this seminar-in-depth, Hadar Lev-Tov, MD and Andrea Murina, MD review the latest treatment options available to dermatologists for HS management. Recent studies have shown that certain inflammatory cytokines (such as IL-17, IL-1b, TNF-a, and IL-36) play a large role in the pathogenesis of HS, and that Janus kinase (JAK) inhibition can affect these pathways. Drs Lev-Tov and Murina discussed the current small molecule pipeline for HS treatment.

Povorcitinib, a JAK1 inhibitor, is currently in Phase 3 studies. In a Phase 2 dose-ranging study of povorcitinib, 52.2% to 55.6% of patients achieved 50% reduction from baseline in total abscess and inflammatory nodule count (HiSCR50) at Week 16 with sustained improvement out to Week 52 (61.3-66.7% achieving HiSCR50). Up to one third (32.3-35.3%) of patients achieved HiSCR90 after 52 weeks of povorcitinib therapy in that study as well. Upadacitinib, a JAK1 inhibitor, is also in Phase 3 studies for HS. A small cohort study evaluating efficacy of upadacitinib 15 mg once daily in 20 patients found that 75% of patients achieved HiSCR50 at Week 4. Those who did achieve HiSCR50 were increased to upadacitinib 30 mg daily, and all remaining patients achieved HiSCR50 by Week 12.

Moving on to biologic therapies, Drs Lev-Tov and Murina reviewed efficacy data for secukinumab, an IL-17A inhibitor, and bimekizumab, an IL-17A/F inhibitor, both of which are approved to treat HS. In pivotal studies, secukinumab led to sustained and durable improvement in HS lesion scores, with 76.5% to 87.5% of responders maintaining HiSCR50 at Week 104. Bimekizumab is the latest biologic to get FDA approval for HS. At the approved dose of bimekizumab 320 mg Q2W for 16 weeks followed by 320 mg Q4W thereafter, 50.4% to 61.1% of patients achieved HiSCR50 at Week 16 with up to 79.9% achieving HiSCR50 at Week 48. Impressively, in a long-term open label extension study, 57.6% of patients on bimekizumab achieved HiSCR90 at Week 96 while 44.2% of patients achieved HiSCR100.

To conclude, Drs Lev-Tov and Murina encouraged the audience to remember the surgical tools in their toolbox. Despite improving medical therapies, some draining tunnels will be resistant to systemic medications. For these cases, Drs Lev-Tov and Murina recommended deroofing procedures. Studies of deroofing procedures have demonstrated high patient satisfaction scores and low recurrence rates.