Hidradenitis Suppurativa: Painful Nodules and Biologic Therapy
Hidradenitis suppurativa isn't just a skin rash. It’s a relentless, painful condition that turns everyday movements into agony. Imagine deep, recurring lumps under your arms, in your groin, or under your breasts-each one swollen, infected, and oozing. These aren’t pimples. They’re abscesses that rupture, form tunnels under the skin, and leave behind scars that never fully fade. For millions worldwide, this isn’t rare-it’s daily life. And until recently, doctors had little more than antibiotics and surgery to offer.
What Exactly Is Hidradenitis Suppurativa?
Hidradenitis suppurativa (HS) starts when hair follicles get clogged-not by dirt, but by thickened skin cells. This blockage triggers a violent immune response. Inflammation explodes around the follicle, forming painful nodules that grow into abscesses. Over time, these abscesses connect under the skin, creating tunnels called sinus tracts. The areas affected? Where sweat and friction meet: armpits, groin, buttocks, under breasts. It’s not caused by poor hygiene. It’s not contagious. And it’s far more common than most people realize-between 1% and 4% of the population, with women affected three times more often than men.
Most people first notice symptoms between ages 20 and 29. Many carry it for years before getting a proper diagnosis. Why? Because it’s often mistaken for ingrown hairs, boils, or even sexually transmitted infections. By the time it’s correctly identified, the damage is often advanced. That’s why early recognition matters so much.
The Old Way: Antibiotics, Surgery, and Temporary Relief
For decades, treatment was a cycle of frustration. Doctors prescribed oral antibiotics like clindamycin or tetracycline to reduce inflammation. Some patients got hormonal therapies-birth control pills or anti-androgens-to help regulate flare-ups. When those failed, surgery became the go-to: draining abscesses, cutting out affected tissue, even skin grafts.
But here’s the truth: antibiotics don’t stop the root cause. Surgery removes damaged tissue, but it doesn’t prevent new lesions from forming elsewhere. And recovery? Long, painful, and often incomplete. Many patients ended up stuck in a loop: flare-up → treatment → temporary relief → flare-up again.
The Biologic Revolution: Targeting Inflammation at Its Source
All that changed with biologic therapies. Unlike antibiotics that broadly suppress the immune system, biologics are precision tools. They’re lab-made proteins that lock onto specific inflammatory signals in the body-like turning off a faulty alarm.
The first FDA-approved biologic for HS was adalimumab (a fully human monoclonal antibody that blocks TNF-alpha, a key driver of inflammation), approved in 2015. It’s given as a weekly or every-other-week injection. In clinical trials, about 42% of patients saw at least half their lesions clear within 12 weeks-far better than placebo.
Then came secukinumab (a human monoclonal antibody that targets IL-17A, another major inflammatory cytokine), approved in early 2024. It works faster than adalimumab. In one trial, patients saw abscesses shrink within four weeks. By week 16, nearly 45% achieved a 50% reduction in lesions. And at one year? More than half still had significant improvement.
The newest player is bimekizumab (a dual inhibitor that blocks both IL-17A and IL-17F, two closely linked inflammatory signals). Approved in mid-2024, it’s showing the highest response rates so far. In a major trial, nearly 67% of patients hit the 50% lesion reduction mark by week 16. That’s a 39% absolute improvement over placebo.
How Do These Biologics Compare?
| Biologic | Target | Dosing | HiSCR50 at Week 12-16 | Key Advantages | Key Limitations |
|---|---|---|---|---|---|
| Adalimumab | TNF-α | 40 mg weekly or every other week | 41.8% | Longest real-world data; effective in severe scarring | More frequent injections; lower long-term response than IL-17 inhibitors |
| Secukinumab | IL-17A | 300 mg weekly for 5 weeks, then every 4 weeks | 44.5% | Faster onset; better long-term results | Higher cost; may not help patients with deep sinus tracts |
| Bimekizumab | IL-17A and IL-17F | 320 mg every 4 weeks after loading dose | 66.9% | Highest efficacy; less frequent dosing | Newest option; limited long-term safety data |
It’s not just about clearing skin. These drugs are changing lives beyond the surface. Patients on biologics report better sleep, less pain, and the ability to wear normal clothing again. Some even see improvements in cholesterol-triglycerides drop, HDL rises-suggesting these therapies may lower long-term heart disease risk, which HS patients are more prone to.
Who Gets Biologics? It’s Not for Everyone
Not every HS patient qualifies. Doctors use the Hurley staging system to decide:
- Stage I: Isolated abscesses, no tunnels. Usually managed with antibiotics or lifestyle changes.
- Stage II: Recurrent abscesses with some tunnels. Biologics are recommended if other treatments fail.
- Stage III: Widespread, interconnected tunnels and abscesses. Biologics are often the best option-but only if scarring isn’t too advanced.
Before starting any biologic, patients must be tested for tuberculosis, hepatitis B and C, and heart conditions. These drugs suppress parts of the immune system, so infections can become serious. You can’t start if you’ve had recent pneumonia or an abscess that hasn’t healed.
Response is checked at 12 weeks using the IHS4 score. If there’s no improvement, switching to another biologic is common. Many patients don’t respond to the first one. That’s normal. It’s trial and error.
Real Patients, Real Stories
On patient forums, stories are raw and honest. One woman in Melbourne shared how she stopped wearing tank tops after her first flare-up at 22. After starting secukinumab, she wore them again for the first time in seven years. Another man, who’d been on six different antibiotics over eight years, finally found relief with bimekizumab-but he pays $1,200 out of pocket each month because his insurance denies coverage.
Common complaints? Injection site reactions (burning, redness), upper respiratory infections, and the cost. In the U.S., monthly prices range from $5,800 for adalimumab to $6,900 for bimekizumab. Insurance approval varies wildly. Medicaid patients are approved at less than half the rate of those with private insurance.
But the most repeated advice from patients? Start early. The longer you wait, the more scarring builds up. Once tunnels form under the skin, biologics can’t undo them. Surgery might be needed anyway.
The Future: What’s Coming Next?
The pipeline is full. Three new biologics are in late-stage trials:
- Guselkumab (targets IL-23) showed 58% lesion reduction in early results.
- Spesolimab (blocks IL-36) is being tested for patients with severe, inflammatory flares.
- TAK-279 (a TYK2 inhibitor) is showing promise in early trials.
Researchers are also working on blood tests that can predict who will respond to which biologic-based on a 12-gene signature. Imagine knowing before you start treatment whether adalimumab will work for you. That’s coming within a few years.
Combination therapy is another frontier. Early data shows better results when biologics are paired with surgical removal of deep tunnels. One study found 89% of patients achieved major improvement with this combo, compared to 67% with biologics alone.
What You Can Do Today
If you have HS, here’s what actually helps:
- See a dermatologist who specializes in HS. Not all do. Ask if they treat HS regularly.
- Stop smoking. Smoking doubles your risk of severe HS and makes biologics less effective.
- Maintain a healthy weight. Even a 5-10% loss can reduce flare frequency.
- Don’t delay treatment. The sooner you start, the less permanent damage you’ll get.
- Track your symptoms. Use a journal or app to log flare-ups, pain levels, and medication side effects. This helps your doctor adjust treatment faster.
HS isn’t curable yet. But it’s treatable. Better than ever before. Biologics aren’t magic-they come with risks and costs. But for many, they’re the first real chance at a life with less pain, fewer scars, and more freedom.
