Biologics for Hidradenitis Suppurativa: What to Expect

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

While research is ongoing into the exact cause of HS, it's known that the immune system has an effect on hair follicles and skin in this disease. Genetics and the 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 with harsh chemicals, as well as home remedies such as Epsom salt baths, can help prevent flare-ups and prolong the progression of the disease.

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

In later stages of the disease, biologics that work by suppressing the immune system can also be tried. Though there is only one biologic for HS that's been approved by the Food and Drug Administration (FDA), there are others that are used off-label (when a medication is prescribed for a condition it hasn't been officially approved for).

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

Close up of woman injecting stomach with medication.

Emilija Manevska / Getty Images

Hidradenitis Suppurativa and the Immune System

HS is associated with an excessive inflammatory response in the skin. This response is what produces the lesions and sores that occur with the disease, as well as the scarring.

The Immune System and Inflammation

Inflammation is the immune system’s response to harmful substances and occurrences. These harmful stimuli can be anything from an injury to infection to exposure to a toxic compound.

An inflammatory response typically is a good thing: It’s what stops the infection from spreading and helps wounds heal. Inflammation commonly appears as redness, swelling, heat, and pain in tissues.

However, when the immune system overreacts to stimuli, the inflammatory response becomes overwhelming and can be chronic, causing disease processes like HS.

The Role of the Immune System in Hidradenitis Suppurativa

In HS, the immune system overreacts to clogged hair follicles, causing significant inflammation. This inflammation turns into the hallmark HS skin lesion of a pimple-like boil that eventually erupts.

HS skin lesions contain cytokines (a type of cell 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, causing HS symptoms like painful inflammation, abscesses full of pus, and eventually scarring in rope-like patterns under the skin.  

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 way.

How Biologics Work

Biologics are a class of medications derived from biological sources such as plants, fungi, and mammalian cell lines that function like cells in the body.

They're used to replace or control certain cells to treat many different diseases. For HS, they work by turning off and on certain immune cells, which helps reduce the inflammation and symptoms associated with the disease.

Biologics for Hidradenitis Suppurativa

In people with HS, the amount of the cytokine, or TNF-a, in the blood is extremely elevated. Humira (adalimumab), the one approved biologic for HS, stops TNF-a from replicating.

A fully human monoclonal antibody, Humira, binds to TNF-a cells and blocks their ability to function. The drug is also associated with a reduction of other leukocytes or inflammatory cells.

By stopping the inflammatory process, the number of HS lesions decreases and so does the pain associated with them.

While Humira is the only FDA-approved drug to treat HS, there are several other biologics that are used off-label. Often, they're used if no response is seen with Humira.

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

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

Risks and Side Effects of Biologics for HS

As with all medications, biologics come with risks and side effects. Your healthcare provider will assess whether the risks for a biologic like Humira outweigh the benefits.

Using Humira and other biologics for HS suppresses the immune system and may lower your ability to fight infection. Contact your healthcare provider if you develop an infection of any kind.

Common side effects include but are not limited to:

  • Bruising, flushing, itching, or swelling at the injection site:
  • Nausea
  • Headaches
  • Rash
  • Back pain
  • Upper respiratory infections

Rare side effects include but aren’t limited to:

  • Serious allergic reactions
  • Serious infections, such as invasive fungal infections or tuberculosis
  • Demyelinating disease (conditions that damage the myelin sheath that protects nerve fibers in your brain and spinal cord)
  • Heart failure
  • Low blood count
  • Lupus-like syndrome (drug-induced lupus erythematosus, an autoimmune disorder that attacks healthy tissue of the skin, joints, brain, and other organs)
  • Lymphoma (cancer of the lymphatic system that protects against diseases)

Are Biologics for Hidradenitis Suppurativa Right For Me?

Biologics are typically prescribed for moderate to severe HS, typically after other treatments have failed.

Frontline treatments include but aren’t limited to:

  • Lifestyle changes such as quitting smoking or losing weight
  • Avoiding skin trauma, such as shaving
  • Benzoyl peroxide washes
  • Antibiotics (drugs that fight bacterial infections)
  • Maintaining a hygiene routine specifically for HS
  • Anti-inflammatory medications (including nonsteroidal anti-inflammatory medications, or NSAIDs, such as aspirin and Advil, an ibuprofen)
  • Retinoids (medications derived from vitamin A)
  • Steroids (synthetic medications that reduce inflammation)

Talk to Your Healthcare Provider

Treatment with a biologic requires close supervision. Talking with your healthcare provider can help determine whether a biologic is right for you. The provider will assess the stage of your HS.

HS is categorized into three stages. These are known as Hurley stages and progress from mild to severe. In Hurley stage 1, when there are few lesions, treatment often involves lifestyle changes and topical antibiotics.

In Hurley stage 2, the lesions may appear in clusters and be slower to heal. Biologics are most often prescribed when HS has advanced. Hurley stage 3 is the most advanced stage. In this stage, lesions are widespread and scarring is invasive.

What to Expect

Humira comes in injection form. Your healthcare provider will train you on how to administer the drug and your first dose will be injected in their office. After that, you'll administer the drug yourself by injecting it in your thigh or stomach on a weekly basis.

It's recommended to change locations of injection to avoid reactions at the site.

Most people see improvement in about three months, but it could take up to six months to see marked results.

While biologics are promising, they don't work for everyone.

Summary

Biologics work by suppressing the immune system and are typically prescribed for moderate-to-severe HS when other treatment options fail. The benefits of the drug often outweigh the side effects, but it's important to note that your ability to fight infection can diminish while on a biologics. Talk to your healthcare provider about any concerns.

A Word From Verywell

HS can be a painful and often isolating disease. While there's no cure, biologics offer hope as the disease progresses. If you have tried other treatment options that no longer work, talk to your healthcare provider about your options.

Maintaining an open line 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 suppurativa?

    Although studies have shown promising data on using Remicade (infliximab) for HS, it's not yet FDA approved for 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 people with HS.

  • Does Stelara work for hidradenitis suppurativa?

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

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10 Sources
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  1. Genetic and rare diseases information center. Hidradenitis suppurativa.

  2. Seyed Jafari SM, Hunger RE, Schlapbach C. Hidradenitis Suppurativa: Current Understanding of Pathogenic Mechanisms and Suggestion for Treatment AlgorithmFront Med (Lausanne). 2020;7:68. Published 2020 Mar 4. doi:10.3389/fmed.2020.00068

  3. Chen L, Deng H, Cui H, et al. Inflammatory responses and inflammation-associated diseases in organsOncotarget. 2017;9(6):7204-7218. Published 2017 Dec 14. doi:10.18632/oncotarget.23208

  4. Chan JCN, Chan ATC. Biologics and biosimilars: what, why and how?ESMO Open. 2017;2(1):e000180. Published 2017 Mar 24. doi:10.1136/esmoopen-2017-000180

  5. Włodarek K, Ponikowska M, Matusiak Ł, Szepietowski JC. Biologics for hidradenitis suppurativa: an update. Immunotherapy. 2019;11(1):45-59. doi:10.2217/imt-2018-0090

  6. Berman HS, Villa NM, Shi VY, Hsiao JL. Guselkumab in the treatment of concomitant hidradenitis suppurativa, psoriasis, and Crohn's diseaseJ Dermatolog Treat. 2021;32(2):261-263. doi:10.1080/09546634.2019.1654067

  7. MedlinePlus. Adalimumab Injection.

  8. Medication Guide. Humira.

  9. Kyriakou A, Trigoni A, Galanis N, Sotiriadis D, Patsatsi A. Efficacy of adalimumab in moderate to severe hidradenitis suppurativa: Real life dataDermatol Reports. 2018;10(2):7859. Published 2018 Oct 1. doi:10.4081/dr.2018.7859

  10. Ghias MH, Johnston AD, Kutner AJ, Micheletti RG, Hosgood HD, Cohen SR. High-dose, high-frequency infliximab: A novel treatment paradigm for hidradenitis suppurativaJ Am Acad Dermatol. 2020;82(5):1094-1101. doi:10.1016/j.jaad.2019.09.071