Biologics for Hidradenitis Suppuratitis: What to Expect

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that causes papular bumps or boils to form under the skin. These areas are painful and often produce foul-smelling discharge.

While the exact cause of HS is being studied, it is known that the immune system has an effect on the hair follicles and skin of the disease. Genetics and environment may also play a role in HS.

Treatment for HS depends on the severity of the disease. In the early stages of HS, lifestyle changes (such as losing weight and avoiding deodorants that contain harsh chemicals) and home remedies (such as Epsom salt baths) can help prevent flare-ups and prolong the disease’s progression.

Maintaining proper hygiene and preventing open sores from becoming infected are also major components of a treatment plan. Topical or oral antibiotics, steroids, and anti-inflammatory drugs may also be prescribed.

In later stages of the disease, biological agents that work by suppressing the immune system may also be tried. While only one biologic for HS has been approved by the U.S. Food and Drug Administration (FDA), there are others that are used off-label (when a drug is prescribed for a condition that has not yet been formally approved) of).

In this article, you’ll learn how biologics work, their risks, and benefits, and how to decide if they’re right for you.

Hidradenitis suppurativa and the immune system

HS is associated with an excessive inflammatory response in the skin. This reaction is responsible for the lesions and ulcers and scarring that occur with the disease.

immune system and inflammation

Inflammation is the immune system’s response to harmful substances and events. These noxious stimuli can be anything from injury to infection to exposure to toxic compounds.

Inflammation is usually a good thing: It stops the infection from spreading and helps wounds heal. Inflammation usually manifests as tissue redness, swelling, warmth, and pain.

However, when the immune system overreacts to a stimulus, the inflammatory response can become overwhelming and can be chronic, leading to disease processes like HS.

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The role of the immune system in hidradenitis suppurativa

In HS, the immune system overreacts to blocked hair follicles, leading to severe inflammation. This inflammation becomes the hallmark HS skin lesions of papular boils that eventually erupt.

HS skin lesions contain cytokines (a type of cells released by the immune system) and other inflammatory proteins such as tumor necrosis factor-alpha (TNF-a), interleukin-17 (IL-17), interleukin-23 ( IL-23), interleukin 1 beta (IL-1b), and other interleukins.

These inflammatory cells become widespread, leading to HS symptoms such as painful inflammation, pus-filled abscesses, and eventually rope scarring under the skin.

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What are biologics and how do they treat HS?

Biologics are a treatment option for HS because they suppress the immune system in a targeted manner.

How biologics work

Biologics are a class of drugs derived from biological sources, such as plant, fungal, and mammalian cell lines, that function similarly to cells in the body.

They are used to replace or control certain cells to treat many different diseases. With HS, they work by switching off and on certain immune cells, which help reduce inflammation and symptoms associated with the disease.

Biologics for hidradenitis suppurativa

In people with HS, blood levels of cytokines, or TNF-a, are very high. Humira (adalimumab) is a biologic approved for HS that blocks TNF-a replication.

A fully human monoclonal antibody, Humira, binds and blocks TNF-a cells. The drug was also associated with a decrease in other white blood cells or inflammatory cells.

By stopping the inflammatory process, the number of HS lesions is reduced and the pain associated with them is reduced.

While Humira is the only FDA-approved drug for HS, several other biologics are used off-label. Typically, they are used if Humira is unresponsive.

These biologics target other inflammatory cells. These include but are not limited to:

  • Stelara (ustekinumab), inhibits interleukin 12 (IL-12) and IL-23
  • Cosentyx (secukinumab), inhibits IL-17
  • Tremfya (guselkumab), inhibits IL-23

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Risks and Side Effects of HS Biologics

Like all drugs, biologics have risks and side effects. Your healthcare provider will assess whether the risks of a biological product like Humira outweigh the benefits.

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Treating HS with Humira and other biologics can suppress the immune system and may reduce your ability to fight infections. Contact your healthcare provider if you develop any type of infection.

Common side effects include, but are not limited to:

  • Bruising, flushing, itching, or swelling at the injection site:
  • nausea
  • headache
  • rash
  • back pain
  • upper respiratory tract infection

Rare side effects include, but are not limited to:

  • severe allergic reaction
  • Serious infections, such as invasive fungal infections or tuberculosis
  • Demyelinating diseases (diseases that damage the myelin sheath that protects nerve fibers in the brain and spinal cord)
  • heart failure
  • low blood counts
  • Lupus-like syndrome (drug-induced lupus erythematosus, an autoimmune disease that attacks healthy tissue in the skin, joints, brain, and other organs)
  • Lymphoma (cancer of the lymphatic system to prevent disease)

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Are biologics for hidradenitis suppurativa right for me?

Biologics are often used for moderate-to-severe HS, usually after other treatments have failed.

First-line treatments include, but are not limited to:

  • Lifestyle changes, such as quitting smoking or losing weight
  • Avoid skin trauma, such as shaving
  • Benzoyl Peroxide Wash
  • antibiotics (drugs that fight bacterial infections)
  • Maintain HS-specific hygiene procedures
  • Anti-inflammatory drugs (including NSAIDs or NSAIDs such as aspirin and Advil, a type of ibuprofen)
  • Retinoic acid (drug derived from vitamin A)
  • Steroids (synthetic drugs that reduce inflammation)

Talk to your healthcare provider

Treatment with biologics requires close supervision. Talking with your healthcare provider can help determine if biologics are right for you. The provider will assess your HS stage.

HS is divided into three stages. These are called Hurley stages and progress from mild to severe. In Hurley stage 1, when lesions are few, treatment usually involves lifestyle changes and topical antibiotics.

In Hurley stage 2, lesions may appear in clusters and heal more slowly. Biologics are most often prescribed when HS progresses. Hurley Stage 3 is the most advanced stage. At this stage, the lesions are extensive and scarring is invasive.

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what to expect

Humira comes in the form of an injection. Your healthcare provider will train you on how to give it, and your first dose will be injected in their office. After that, you’ll self-administer it weekly by injecting it into your thigh or stomach.

It is recommended to change the injection location to avoid on-site reactions.

Most people will see improvement in about three months, but it can take up to six months to see visible results.

While biologics are promising, they’re not for everyone.

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Biologics work by suppressing the immune system and are often used in moderate to severe HS when other treatment options have failed. The benefits of drugs often outweigh the side effects, but it’s important to note that your ability to fight infection is diminished when you’re using biologics. Discuss any concerns with your healthcare provider.

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HS can be a painful and often isolated disorder. While there is no cure, biologics offer hope as the disease progresses. If you have tried other treatment options that are no longer effective, discuss your options with your healthcare provider.

Maintaining open lines of communication with your healthcare provider can give you a sense of control over your health and improve your treatment plan and quality of life.

Frequently Asked Questions

  • Is Remicade FDA Approved for Hidradenitis Suppuratitis?

    Although studies have shown promising data with the use of Remicade (infliximab) to treat HS, it has not yet been approved by the FDA for use in HS.

  • Which biologics are approved for hidradenitis suppurativa?

    Humira is the only biologic approved for HS.

  • Does Humira work for hidradenitis suppurativa?

    Humira is effective in 50% of HS patients.

  • Is Stelara effective for hidradenitis suppurativa?

    Stelara (ustekinumab) has been effectively used off-label to treat HS.