Efficacy and Safety of Bimekizumab in Moderate to Severe Hidradenitis Suppurativa: A Phase 2, Double-blind, Placebo-Controlled Randomized Clinical Trial

Differentiating the Role of Inflammation in Hidradenitis Suppurativa from that in Other Inflammatory Skin Diseases

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease characterized by nodules, abscesses, and sinus tunnels, primarily in intertriginous areas. Symptoms of HS are associated with reduced psychosocial health and physical function. HS shares some pathogenic, cellular, and molecular features with other inflammatory skin diseases, highlighting its heterogeneity and complexity. This heterogeneity in disease presentation may contribute to the diagnosis delay observed with HS. The primary objective of this review is to highlight the initiating events, inflammatory signature, molecular features, and clinical features that differentiate HS from other inflammatory skin diseases to improve outcomes for patients with HS.

Biologic therapies and small molecules in the treatment of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a debilitating chronic skin condition challenging to manage. Treatment options range from topical and systemic medications to various surgical procedures. With the expanding knowledge of cytokine signaling pathways, systemic treatment for hidradenitis suppurativa is entering an exciting phase, offering new opportunities to address imbalanced immune responses. The primary categories of treatment include biologics and small molecules. Currently, the only three approved biologics for HS are the anti-TNF-α antibody adalimumab, the anti-IL-17A secukinumab and the anti-IL-17A/17F, bimekizumab. While studies indicate moderate effectiveness of all three drugs, achieving adequate disease control remains challenging for many patients. Research in the field of HS is rapidly evolving, with a wide range of treatments being developed that leverage various mechanisms of action. Drugs targeting the IL-17 and Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathways show promise in ongoing and completed phase 3 studies, offering the potential for more comprehensive treatment responses.

Immunohistochemical Expression of Haptoglobin in Skin Lesions of Hidradenitis Suppurativa

BACKGROUND

Meta-inflammation is a hallmark of hidradenitis suppurativa (HS). Research on meta-inflammation in HS is growing, but there is still no research on haptoglobin as an inflammatory protein in lesional HS skin. This study examines the relationship between haptoglobin expression in HS skin lesions and clinical parameters.

METHODS

An examination was performed on 44 skin samples from HS patients and 10 healthy skin samples. Clinical parameters were then compared with haptoglobin expression.

RESULTS

Median haptoglobin expression was significantly higher in the Hurley stage III lesions compared with milder stages (H-score: 37.6 versus 17.1, p = 0.028). High haptoglobin expression (≥30.8% positive cells) was associated with advanced disease (Hurley stage III: 80% versus 41.7%, p = 0.01), active smoking (80% versus 50%, p = 0.039), increased pain (visual analogue scale: 5 versus 1.5, p = 0.03), and a higher prevalence of diabetes (35% versus 8.3%, p = 0.029) and hypertension (55% versus 25%, p = 0.042). No significant associations were found with the BMI, disease duration, or CRP levels.

CONCLUSIONS

High haptoglobin expression (positive cells ≥ 30.8%) in a skin lesion is associated with higher HS severity, active smoking, more pain and the comorbidities of diabetes mellitus and arterial hypertension in HS patients.

Hidradenitis Suppurativa Tunnels: Unveiling a Unique Disease Entity

Hidradenitis suppurativa tunnel structures lined with epithelium within the dermis are unique features of advanced disease stages that significantly impair patients' QOL. The presence of hidradenitis suppurativa tunnels is associated with a decreased likelihood of achieving a clinical response, even when receiving biological therapy. The cellular and molecular mechanisms underlying tunnel formation and pathology are only partially understood, which hampers the development of more effective targeted therapies. Tunnels create a unique microenvironment that drives a vicious cycle of hidradenitis suppurativa inflammation, with tunnel keratinocytes exhibiting an activated phenotype characterized by distinct gene expression signatures. In this review, we summarize the current literature and discuss aspects of the pathophysiology of tunnels, including the role of hair follicle epidermal stem cells in tunnel formation, potential role of fibroblast-mediated epithelial-mesenchymal transition, role of dermal papilla fibroblasts, and aberrant proinflammatory repair response contributing to the observed fibrosis and scarring. Finally, tunnel structures are characterized by unique microbial dysbiosis and an overabundance of Gram-negative anaerobes that are not targeted by current therapeutics. In addition to outlining the possible mechanisms of tunnel formation, we provide perspectives on the translation of current knowledge into more effective treatment approaches for patients with hidradenitis suppurativa tunnels.

The role of interleukin inhibitors in the treatment of hidradenitis suppurativa; a systematic review of clinical trials

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder that presents significant treatment challenges. Recent advancements have enhanced our understanding of its pathophysiology, leading to the development of novel therapeutic strategies. This systematic review evaluates the role of interleukin (IL) inhibitors as emerging treatment options for HS. A systematic search was conducted in PubMed/Medline, Scopus, and Web of Science databases for studies published up to September 2nd, 2024, with inclusion limited to clinical trials available in English. The National Institute of Health (NIH) Quality Assessment Tool for clinical trials and before-after studies with no control group was used to assess the methodological quality of the included studies. Out of 1289 studies, 20 met our inclusion criteria involving 3957 patients. Moreover, four ongoing trials were retrieved from ClinicalTrials.gov. Secukinumab showed sustained hidradenitis Suppurativa Clinical Response (HiSCR) improvements, particularly in biologic-naïve patients with common adverse events (AEs). Bimekizumab was effective with biweekly dosing, while the four-week regimen had inconsistent results, with rare reports of AEs. Brodalumab and bermekimab provided rapid and sustained HiSCR responses with lesion reductions, which were well tolerated. Guselkumab and ustekinumab showed promising but statistically nonsignificant improvements with mild AEs. Risankizumab did not significantly improve HiSCR rates but showed Dermatology Life Quality Index (DLQI) benefits. Anakinra offered moderate efficacy with prolonged exacerbation-free periods but led to some treatment discontinuations. Spesolimab reduced inflammatory lesions and draining tunnels while maintaining a favorable safety profile. IL inhibitors, especially IL-17 inhibitors, have demonstrated efficacy in treating moderate-to-severe HS, while IL-23 inhibitors have shown inconsistent results. Despite their generally favorable safety profiles, further research is needed to optimize treatment strategies and assess long-term outcomes.

The Challenges of Assessing Hidradenitis Suppurativa: Outcome Measures

Accurate assessment of disease severity and treatment response are essential in the clinical management of hidradenitis suppurativa (HS) and vital in research efforts, particularly investigations of potential therapeutics. Key elements of the history and physical examination can inform treatment decisions to meet the needs of each individual patient. Over time, and through diligent and purposeful research, outcome measures capable of accurately and reliably assessing treatment response suitable for both research and clinical use have been developed and refined. This review explores HS clinical assessment, existing outcome measures, and emerging tools to enable accurate assessment, improve care, and optimize treatment strategies.

North American clinical practice guidelines for the medical management of hidradenitis suppurativa in special patient populations

BACKGROUND

Hidradenitis suppurativa (HS) affects different patient populations that require unique considerations in their management. However, no HS guidelines for these populations exist.

OBJECTIVE

To provide evidence-based consensus recommendations for patients with HS in 7 special patient populations: (i) pregnancy, (ii) breastfeeding, (iii) pediatrics, (iv) malignancy, (v) tuberculosis infection, (vi) hepatitis B or C infection, and (vii) HIV disease.

METHODS

Recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system to ascertain level of evidence and selected through a modified Delphi consensus process.

RESULTS

One hundred eighteen expert consensus statements are provided for the management of patients with HS across these 7 special patient populations.

The roles of interleukin (IL)-17A and IL-17F in hidradenitis suppurativa pathogenesis: evidence from human in vitro preclinical experiments and clinical samples

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic relapsing inflammatory skin disease associated with significant comorbidities and poor quality of life. Despite uncertainty about pathways driving inflammation in HS lesions, the cytokines interleukin (IL)-17A and IL-17F have been shown to be upregulated in patients with HS. Previous studies have demonstrated that the monoclonal IgG1 antibody bimekizumab selectively inhibits IL-17F in addition to IL-17A.

OBJECTIVES

To further investigate the roles of IL-17A and IL-17F in HS pathogenesis.

METHODS

RNA sequencing (RNAseq) was conducted on skin biopsies taken at baseline and after treatment at week 12 of a phase II proof-of-concept study of bimekizumab in patients with moderate-to-severe HS. Differentially expressed genes were identified between baseline lesional and nonlesional samples and between lesional samples before and after bimekizumab treatment, to describe molecular disease mechanisms and treatment effect. Human hair follicular keratinocytes (HHFK) were cultured and treated with a supernatant of stimulated T helper (Th)17 cells in combination with anti-IL-17A, anti-IL-17F, anti-IL-17A and anti-IL-17F, or IgG control antibodies. Total mRNA was analysed by RNAseq. Cellular supernatants from the stimulated HHFKs were used as a source of Th17-induced chemoattractants in neutrophil chemotaxis assays.

RESULTS

RNAseq revealed that the most prominently upregulated genes in HS lesions included those associated with neutrophil biology. Bimekizumab treatment resulted in reduced expression of these genes. The extent of reduction in gene expression was dependent on achieving HiSCR50 (≥ 50% reduction from baseline in the total abscess and inflammatory nodule count, with no increase from baseline in abscess or draining tunnel count). In vitro dual inhibition of IL-17A and IL-17F had greater attenuation of Th17-induced HS-associated genes and neutrophil migration in HHFKs vs. IL-17A or IL-17F inhibition alone. In situ hybridization found that IL-17A- and IL-17F-producing cells in HS lesions can lack the IL-23 receptor and IL-1β could induce IL-23-independent IL-17F expression in vitro. Furthermore, mucosal-associated invariant cells in HS tunnels expressed IL-17F and IL-1 receptor type 1. IL-1β-, IL-17A- and IL-17F-expressing cells were found to be co-localized in HS lesions.

CONCLUSIONS

These data support the hypothesis that IL-17A and IL-17F play central roles in HS, a neutrophilic dermatosis. The presence of IL-1β may partly explain the high expression of IL-17F in lesional HS tissue.

Priors and decision thresholds in phase 2 and phase 3 randomized controlled trials evaluating drug efficacy using Bayesian methods: a systematic review

OBJECTIVES

To describe the priors and decision thresholds in phase 2 and 3 randomized controlled trials (RCTs) evaluating drug efficacy using Bayesian methods.

STUDY DESIGN AND SETTING

A systematic review of phase 2 and 3 RCTs evaluating drug efficacy through Bayesian inference was conducted across the MEDLINE, EMBASE, and Cochrane databases, with no date restrictions until September 2022. The type of prior used for the analysis of the primary endpoint and its characteristics (type and parameters of the distribution, justification, and sensitivity analysis), the use of a posterior probability decision threshold defined a priori, and its value, were extracted.

RESULTS

From 1161 articles screened, 69 articles were ultimately included, encompassing a total of 91 comparisons, as some trials assessed multiple primary endpoints or treatments. The prior was assigned to treatment effect in 51% of the cases (n = 46) to each arm in 37% (n = 34) and was not explicitly defined in 12% (n = 11). Prior distribution was described (with its parameters) in 59% of cases (n = 54). A decision threshold was set a priori in 68% of the results (n = 62), and its value ranged from 70% to 99% (median 95%).

CONCLUSION

The inconsistent description of priors, along with the wide variation and occasional absence of decision thresholds, underscore the need for clear guidelines on the use and reporting of Bayesian methods.

PLAIN LANGUAGE SUMMARY

Bayesian methods are being used more frequently in clinical trials to assess drug's efficacy. These methods offer flexibility by incorporating prior knowledge into the analysis. However, the use of Bayesian approaches is still not widespread, and there are challenges with how results are interpreted, partly due to a lack of clear standards. We conducted a systematic review to describe how Bayesian methods were used and reported in phase 2 and 3 clinical trials assessing drug efficacy. We looked at the types of prior information used in the analyses and how decisions about efficacy were made based on the results. Out of 1161 studies reviewed, 69 were included in the analysis, covering 91 drug comparisons. The priors in Bayesian drug trials were assigned to treatment effects or each arm, often justified but variably describe. Similarly, decision thresholds for determining drug efficacy were preset in most studies, but with heterogeneity in the thresholds used to conclude. Our findings highlight the need for clearer guidelines on using Bayesian methods in clinical trials to improve transparency and consistency in how results are reported.

Severe Paradoxical Scalp Psoriasis Induced by Bimekizumab in a Young Multifailure Hidradenitis Suppurativa Patient

This article explores the ongoing research into the complex pathogenesis of hidradenitis suppurativa (HS) and the persistent challenges in finding effective treatments. With 113 clinical studies currently listed on ClinicalTrials.gov, the quest for novel therapeutic approaches for HS remains vigorous. In this context, bimekizumab stands out as a promising option-a fully humanized IgG monoclonal antibody that selectively targets both interleukin (IL)-17A and IL-17F, showing rapid and significant improvements in HS disease activity. The case study presented in this article features a 24-year-old woman with HS, whose previous treatments had been unsuccessful until she began therapy with bimekizumab. While the patient experienced marked improvement in her HS symptoms, she developed paradoxical scalp psoriasis, complicating her treatment plan. This case highlights not only the therapeutic potential of bimekizumab but also the need for careful monitoring and management of possible adverse effects. Furthermore, the article emphasizes the need for additional research to confirm the efficacy of bimekizumab in larger patient groups, possibly through phase 3 clinical trials and real-world studies. It also underscores the importance of developing comprehensive management strategies for paradoxical reactions, which may become more common as new treatment options for HS are introduced. In summary, the article reflects the evolving landscape of HS treatment, with bimekizumab representing a promising advancement. However, it calls for careful consideration of potential adverse events and the need for further research to solidify its role in HS management.

Hidradenitis suppurativa with and without draining tunnels: A real-world study characterizing differences in treatment and disease burden

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory, neutrophilic skin disease associated with a considerable clinical burden. In more severe disease, subepidermal draining tunnels may form.

OBJECTIVES

To characterize the clinical profile of patients with moderate-severe HS with and without draining tunnels, and the clinical and health-related quality of life (HR-QoL) burden of draining tunnels.

METHODS

Data were drawn from the Adelphi HS Disease Specific Programme™, a cross-sectional survey with retrospective data collection, across the United States, France, Germany, Italy, Spain and the United Kingdom between November 2020 and April 2021. Patients were aged ≥10 years and had HS. Clinical outcomes, recorded by physicians, comprised patient demographics and HS characteristics, symptoms and treatment. HR-QoL measures included patient and physician survey questions, and validated HR-QoL instruments.

RESULTS

Of the 580 patients with moderate-severe HS, 46% had draining tunnels. Patients with draining tunnels had more abscesses, inflammatory nodules and scarring than those without. Patients with draining tunnels were significantly (p < 0.05) more likely to be treated with biologics (41% vs. 27%), but often patients with tunnels who were eligible for biologics had not received them. Patients with draining tunnels experienced significantly more inflammation/redness (73% vs. 63%), drainage from lesions (62% vs. 40%) and pain on sitting (48% vs. 37%) than those without (p < 0.05). Draining tunnels were also significantly associated with low mood/depression (30% vs. 18%), sleep disturbance (28% vs. 19%) and fatigue (28% vs. 18%) versus no tunnels (p < 0.05). Physicians agreed that patients with draining tunnels experienced a negative impact of disease compared to those without. This was reflected in patient-reported surveys and HR-QoL instruments.

CONCLUSIONS

Patients with moderate-severe HS and draining tunnels experience greater clinical and HR-QoL burden than those without, emphasizing the importance of tunnels in disease impact.

An evolutionary tale on clinical trials in hidradenitis suppurativa

The therapeutic pipeline for moderate-to-severe hidradenitis suppurativa (HS) is robust. Successes and lessons learned have led to improvements in trial designs aimed at avoiding prior pitfalls, as well as high placebo response in HS, which remains a fundamental threat to drug development. Herein, we review the evolutions in HS trials over the last 20 years with respect to overall design, sample size, diversity in enrolment, inclusion criteria, concomitant medications, rescue therapy, endpoints and statistical design analysis plans. Areas of focus that merit future consideration are also highlighted.

Exploring itch in hidradenitis suppurativa with lessons from atopic dermatitis and psoriasis

Itch is a prominent symptom in many cutaneous disorders, including atopic dermatitis (AD), prurigo nodularis, and psoriasis. Itch is also a common but overlooked concern in patients with hidradenitis suppurativa (HS). Currently, the mechanisms underlying itch in HS remain unclear. To gain a better understanding, we reviewed the literature on pruritus in HS and other itch-predominant disorders, AD, and psoriasis. In HS, psoriasis, and AD, we found that itch often co-localized with pain and occurred more frequently at night. Furthermore, itch was found to negatively affect sleep and increase the risk for comorbid psychiatric disorders in HS, psoriasis, and AD. However, HS-, psoriasis-, and AD-related itch differ in temporality. Itch in AD is often described as chronic, while itch in HS and psoriasis is often described as episodic. HS-associated itch is likely multifactorial, and several mechanisms have been proposed including peripheral sensitization, central sensitization, and neuroinflammation. Prior studies in HS highlight enhanced IgE production and a dense infiltration of mast cells, along with a variety of cytokines and chemokines. Furthermore, alterations in the skin microbiome may contribute to itch in HS. To date, few therapies have been studied to treat itch in HS. Given the efficacy of several biologics and small molecules in treating itch in AD and psoriasis, similar agents may be explored in future HS studies. Alternative therapies to target neurological and psychiatric contributions to itch may include anticonvulsants, cannabinoids, and nonpharmacological treatments. In conclusion, pathomechanisms of itch in HS remain to be fully elucidated. However, we can draw on lessons from other pruritic disorders to begin addressing the symptom of it and identify important questions for future study.

When recombinant proteins go wrong: The hidden pitfall of recombinant protein contamination

Recombinant proteins are critical tools in research; however, their purity is often assumed rather than verified, leading to potential experimental errors. This study aimed to investigate the inflammatory role of recombinant human IL-17F in dermal fibroblasts. Unexpectedly, we discovered with Western blot that recombinant IL-17F from the supplier was contaminated with IL-4, leading to unintended stimulatory effects such as STAT6 phosphorylation and gene induction of CCL26 and IL4R. This contamination led to misinterpretation of data, loss of research time, and erroneous conclusions about IL-17F activity. These findings underscore the critical need for stringent quality control in recombinant protein production and highlight the risks of relying on single-source suppliers. Researchers should remain cautious about potential contamination, ideally validating proteins from multiple suppliers. Our experience illustrates a broader requirement for suppliers to strengthen quality assurance measures, as contaminants can propagate misleading data in the literature and undermine research reproducibility.

Hidradenitis Suppurativa Treatment During Pregnancy and Lactation: Navigating Challenges

Hidradenitis suppurativa (HS), or acne inversa, is a chronic inflammatory skin condition primarily affecting skin folds such as the axilla, groins, and the inframammary, perineal, and perianal regions. It is characterized by painful abscesses, sinus tracts, and scarring. Predominantly affecting young adults, particularly females, HS often emerges during reproductive age, and flares are widely reported during pregnancy and postpartum, underscoring the need to consider management strategies tailored to pregnant or lactating individuals. Moreover, the chronic and relapsing nature of HS, along with challenges related to the safety and compliance of medication use during pregnancy and lactation, as well as various comorbidities and psychological distress, significantly complicate its management in pregnant or lactating women. Treatment options, including topical clindamycin, oral clindamycin-rifampicin, adalimumab, metformin, antiseptic washes, and certolizumab pegol, have accumulated evidence supporting their relative safety in pregnant and lactating women. While certolizumab pegol has shown promising safety data among biologics, it requires more efficacy data in HS. Conversely, while newly approved HS medications such as secukinumab and bimekizumab show promise for the general population, further research is necessary to evaluate their safety profiles in pregnant and breastfeeding individuals. The scant research available on HS in pregnant and lactating women, also shown by our systematic literature review, highlights the need for a comprehensive investigation into the safety, efficacy, and suitability of management strategies.

Management of hidradenitis suppurativa in the inpatient setting: a clinical guide

Hidradenitis suppurativa (HS) is a chronic inflammatory disease that affects the axilla, inframammary folds, buttocks, inner thighs, and anogenital regions. Patients with moderate to severe HS often seek care in the emergency department and may require hospitalization; however, the lack of clear admission criteria and management guidelines presents significant challenges. To address these issues, we conducted a clinical review aimed at hospitalists and consulting dermatologists considering hospital admission for patients experiencing severe HS flares. Admission offers a unique opportunity to optimize care through specialized consultations, pain management, rescue therapy, and surgical planning. Furthermore, multimodal treatments, particularly biologics, are needed to achieve clinical remission in severe disease. Streamlining care during hospitalization for the early initiation of these therapies can significantly improve flare management and overall clinical outcomes for HS patients. This review aims to improve care for HS by providing clear and comprehensive guidance on its management in the inpatient setting.

Hidradenitis Suppurativa: A Review of the Biologic and Small Molecule Immunomodulatory Treatments

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that presents as painful, deep-seated nodules, sinus tracts, and abscesses in about 1% of the population. Although the pathogenesis of HS is not perfectly understood, it is generally recognized to be caused by a combination of genetic, endocrine, environmental, and microbiological factors. The treatment principles of HS focus on decreasing the microbial load with antibiotics and/or modulating the host immune response to reduce inflammation. The treatment of adults with moderate-to-severe HS has significantly changed recently with the development of new biological medications and immunomodulators. While previously the mainstay of treatment of moderate-to-severe HS was adalimumab, a biologic tumour necrosis factor α inhibitor, the evidence for the use of other treatment classes such as interleukin (IL)-17 inhibitors, IL-1 inhibitors, and Janus kinase inhibitors has been growing. The goal of this review article is to review the available evidence that supports the efficacy and safety of biologics and small molecule immunomodulator treatments to treat adults with moderate-to-severe HS.

Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by the formation of nodules, abscesses, and fistulae at intertriginous sites. Pain, pruritus, malodor, and suppuration have a significant impact on quality of life for HS patients. Prevalence figures vary greatly in the literature from 0.05% to 4.1%, and HS is more common in females. The current understanding of the etiology and pathogenesis of HS is incomplete; numerous hypotheses concern the interplay of lifestyle factors, skin microbiota, genetics, and a dysregulated immune system. Due to its phenotypic heterogeneity and multifactorial pathogenesis, HS is a complex disease that can prove challenging to manage. Two approved biologic therapies for the management of HS have led to clinical response in approximately 50% of treated patients. New therapies targeting the interleukin (IL)-1, IL-17, IL-36, and Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathways are in ongoing clinical trials, and preliminary data offer hope for greater clinical efficacy in HS in the future.

Real-world adalimumab survival and discontinuation factors in hidradenitis suppurativa

BACKGROUND AND OBJECTIVES

Survival analyses can provide valuable insights into effectiveness and safety as perceived by prescribers. Here, we aimed to evaluate adalimumab (ADA) survival and the interruption risk factors in a multicentre cohort of patients with hidradenitis suppurativa (HS). Moreover, we performed a subanalysis considering the periods before and after the onset of the COVID-19 pandemic.

METHODS

We conducted a retrospective study including 539 adult patients with HS who received ADA from 1 May 2015 to 31 December 2022. Overall drug survival was analysed using Kaplan-Meier survival curves and compared between the subgroups via stratified log-rank test. Possible predictors for overall drug survival and reasons for discontinuation were assessed using univariate and multivariate Cox regression.

RESULTS

Overall, 50.1% were females with a mean age of 43.5 ± 1 years and a mean BMI of 29.5 ± 6.7. At the start of ADA, 95.29% were biologic-naïve and 24.63% had undergone surgical treatment. During follow-up, 9.46% of patients required dose escalation, while 39.92% interrupted ADA. Concomitant therapy was used in 64.89% of cases. A subanalyses comparing pre- and post-pandemic periods revealed a tendency to initiate ADA treatment at a younger age, among patient with higher BMI and at a lower HS stage after COVID-19 pandemic. Interestingly, ADA demonstrated extended survival compared to previous studies, with a median overall drug survival of 56.2 months (95% CI 51.2 to 80.3). The primary causes for discontinuation were inefficacy (51.69%), followed by adverse effects (21.35%). Female sex, longer delay in HS diagnosis, higher baseline IHS4 score and concomitant spondyloarthritis were associated with poorer ADA survival or increased risk of discontinuation.

CONCLUSIONS

ADA demonstrated prolonged survival (median 56.2 months). While addition of antibiotics did not have a positive effect on survival rate, basal IHS4 proved useful in predicting ADA survival.

Interleukin-17 Inhibitors in the Treatment of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, debilitating, inflammatory dermatosis that significantly impacts patients' quality of life, primarily manifesting as inflammatory nodules, abscesses, and tunnels. The pathogenesis of HS is not fully understood and appears to be multifactorial, involving genetic, immunological, and endocrinological factors, as well as dysbiosis of skin microbiota. Increasing evidence highlights the role of the interleukin (IL)-17 pathway in the inflammatory process and pathogenesis of HS. Consequently, IL-17 inhibitors have emerged as a promising alternative to current therapies. Recently, secukinumab received approval from both the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA), while bimekizumab received approval from the EMA, for the treatment of moderate-to-severe HS in adults, with ongoing clinical trials aiming to further clarify the efficacy and safety of other drugs within this class. IL-17 inhibitors have shown effectiveness in treating moderate-to-severe HS, with safety profiles of drugs such as secukinumab and bimekizumab being comparable to their use in other dermatological conditions. On the other hand, innovative drugs such as sonelokimab and izokibep show promising results and are currently in phase III clinical trials. This review provides a comprehensive overview of current knowledge and scientific advances in HS, focusing on the IL-17 pathway's role and its inhibition as a treatment strategy, alongside examining the most recent and significant clinical studies on various IL-17 inhibitors in the treatment of HS.

Report of successful treatment of follicular occlusion triad with adalimumab and research progress on biologic therapy for follicular occlusion triad

Purpose: This article aims to present a case report of a patient with Follicular occlusion triad (FOT) who achieved successful disease control with adalimumab combined with isotretinoin and provide a comprehensive review of the current research progress on biologic therapies for FOT.

Methods: We report a case of a 22-year-old female patient diagnosed with FOT, who was treated with adalimumab combined with isotretinoin after failing to respond to conventional therapies. A systematic literature review was conducted to summarize the current research progress on biologic therapies for FOT, including TNF-α inhibitors, IL-17 inhibitors, IL-12/IL-23 inhibitors, IL-23 inhibitors, IL-1 inhibitors, and other novel biologic agents.

Results: The patient achieved significant improvement in skin lesions, pain, and quality of life after three months of treatment with adalimumab combined with isotretinoin, without experiencing severe adverse reactions. The literature review revealed that adalimumab and secukinumab are the two FDA-approved biologics for FOT, while others, such as bimekizumab, infliximab, anakinra, and bermekimab, have shown promise in clinical studies.

Conclusions: Biologic therapies have revolutionized FOT management, providing effective options for patients unresponsive to conventional treatments. As our understanding of FOT pathogenesis and the mechanisms of action of biologics grows, further advancements in biologic therapies for FOT are expected.

Real-world effectiveness and safety of bimekizumab for hidradenitis suppurativa: An ambispective observational study

In this original research, we present the results in terms of effectiveness and safety of bimekizumab for hidradenitis suppurativa in real clinical practice. Results indicated significant improvement in all activity scores and patient-reported outcomes at week 16, including a notable decrease in mean IHS4 from 27.1 to 15.6 (p < 0.001), HS-PGA from 5.1 to 3.2 (p < 0.001), VAS pain from 8.3 to 4.7 (p < 0.001) and DLQI from 21.6 to 12.6 (p < 0.001). Bimekizumab, administered every 2 or 4 weeks, was well-tolerated with no discontinuations and no new safety concerns identified. These findings corroborate the drug's effectiveness and favourable safety profile observed in phase 3 clinical trials, supporting its use in real-world clinical practice for treating HS.

Effectiveness of Anti-tumor Necrosis Factor Drugs on Hidradenitis Suppurativa: A Systematic Review

Hidradenitis suppurativa (HS) is a painful and chronic inflammatory skin disease with no consistently effective treatment, affecting a significant portion of the Western population. HS is characterized by painful nodules, abscesses, tunnels, and scarring in body folds. The immunobiology is poorly understood, therefore resulting in a lack of effective therapies. Despite indications of microbial involvement, antimicrobial treatments have shown inconsistent and temporary results. Recent studies have identified dysregulated immune responses as a key factor in HS. This has led to the use of biologic agents, most notably adalimumab, which is currently the only FDA-approved therapy for HS. Due to the limited understanding of immune dysregulation in HS, ongoing clinical trials are adapting treatments from other skin conditions, such as psoriasis. As a result, researchers look to other skin conditions with better-understood pathophysiologies, such as psoriasis, as a starting point for developing treatments for HS. While adaptation can offer some benefits, such as immediate treatment options, the lack of specificity can lead to side effects that are not well tolerated, and long-term efficacy may be uncertain. Therefore, there is a pressing need for a foundational understanding of HS's immune dysregulation. Current ongoing research is exploring other options, such as therapies targeting IL-17, in addition to anti-TNF therapies, which have shown the potential to be more effective. With new options emerging, it is essential to evaluate the current performance of anti-TNF drugs in treating HS. This review was conducted to thoroughly assess the effectiveness of these therapies, offering a detailed analysis to inform future research and clinical practice. The objective is to determine whether anti-TNF drugs continue to be a strong treatment option or if newer therapies might lead to better outcomes for patients.

Anti-IL-17/23 Drugs for the Treatment of Moderate-to-Severe Hidradenitis Suppurativa in Patients With Concomitant Psoriasis: A Multicenter Retrospective Study

INTRODUCTION

Psoriasis and hidradenitis suppurativa (HS) are chronic inflammatory diseases with significant overlap in their immunologic pathways, which involve cytokines such as tumor necrosis factor-alfa, interleukin (IL)-17, and IL-23. Current treatment options for HS are limited, as only adalimumab and secukinumab are approved for severe cases. Given the overlapping pathogenetic features between HS and psoriasis, anti-IL-17 and anti-IL-23 drugs could represent valuable treatments for the management of HS.

OBJECTIVES

We sought to evaluate the effectiveness and safety of anti-IL-17 and anti-IL-23 drugs in patients with HS and concomitant moderate-to-severe plaque psoriasis.

METHODS

We conducted a multicenter retrospective study in 11 Italian Dermatology Units. The effectiveness of the drugs was evaluated by assessing the percentage of patients achieving HS Clinical Response (HiSCR) each week.

RESULTS

We enrolled 41 patients with at least 16 weeks of follow-up, with 17 of them completing 52 weeks of treatment. The most commonly prescribed anti-IL drug was secukinumab (27 patients), followed by ixekizumab (5) and guselkumab (5). The HiSCR was achieved by 39%, 74.3%, and 77.8% of patients after 16, 32, and 52 weeks, respectively. No severe adverse events (AEs) or AEs leading to discontinuation were observed during the study. The most common AE was nasopharyngitis (four patients).

CONCLUSION

In this real-world study, we highlight the effectiveness of anti-IL-23 and anti-IL-17 drugs in the treatment of concomitant plaque psoriasis and severe HS. Longer and larger studies are needed to further evaluate the long-term effectiveness and safety of these treatments in patients affected by HS.

Secukinumab efficacy in patients with hidradenitis suppurativa assessed by the International Hidradenitis Suppurativa Severity Score System (IHS4): A post hoc analysis of the SUNSHINE and SUNRISE trials

INTRODUCTION

The International Hidradenitis Suppurativa Severity Score System (IHS4) is a validated tool that measures inflammatory lesions, including draining tunnels, in hidradenitis suppurativa (HS).

OBJECTIVE

To evaluate secukinumab efficacy using IHS4 in patients with moderate to severe HS.

METHODS

Data from the SUNSHINE and SUNRISE trials, which assessed subcutaneous secukinumab 300 mg every 2 (SECQ2W) and 4 (SECQ4W) weeks in adults with moderate to severe HS, were analyzed. Assessments included changes from baseline in IHS4 and severity classification up to Week 52; IHS4-55, IHS4-75, IHS4-90 responses (55%, 75% and 90% reduction in IHS4) and concordance between IHS4-55 and HS clinical response (HiSCR), at Weeks 16 and 52.

RESULTS

In total, 1084 patients (SECQ2W = 361; SECQ4W = 360; placebo = 363) were analyzed. At Week 16, SECQ2W and SECQ4W demonstrated a numerically higher reduction in IHS4 from baseline versus placebo (adjusted mean [95% CI]: -10.80 [-12.30 to -9.30] and -9.46 [-10.96 to -7.96] vs. -4.92 [-6.43 to -3.41]); the reduction was maintained until Week 52 in both dose regimens. A greater proportion of patients achieved IHS4-55 with SECQ2W (43.4%) and SECQ4W (39.5%) versus placebo (31.5%) at Week 16, with further improvement at Week 52. Similar trends were observed for IHS4-75 and IHS4-90 responses. While no patients had mild disease based on IHS4 (80.7% had severe and 19.3% had moderate HS) at baseline, a greater proportion of patients were categorized as having mild disease at Week 16 in the SECQ2W (25.9%) and SECQ4W (24.0%) groups versus placebo (16.4%); this trend continued up to Week 52 in both dose regimens. Strong concordance (>85%) was observed between IHS4-55 and HiSCR.

CONCLUSIONS

Both SECQ2W and SECQ4W demonstrated efficacy in improving treatment response as measured by IHS4 and reducing disease severity versus placebo at Week 16 and these improvements were sustained through Week 52. These findings support that the dynamic and dichotomous IHS4 can efficiently detect treatment response changes in clinical trial settings.

Evolving understanding of autoimmune mechanisms and new therapeutic strategies of autoimmune disorders

Autoimmune disorders are characterized by aberrant T cell and B cell reactivity to the body's own components, resulting in tissue destruction and organ dysfunction. Autoimmune diseases affect a wide range of people in many parts of the world and have become one of the major concerns in public health. In recent years, there have been substantial progress in our understanding of the epidemiology, risk factors, pathogenesis and mechanisms of autoimmune diseases. Current approved therapeutic interventions for autoimmune diseases are mainly non-specific immunomodulators and may cause broad immunosuppression that leads to serious adverse effects. To overcome the limitations of immunosuppressive drugs in treating autoimmune diseases, precise and target-specific strategies are urgently needed. To date, significant advances have been made in our understanding of the mechanisms of immune tolerance, offering a new avenue for developing antigen-specific immunotherapies for autoimmune diseases. These antigen-specific approaches have shown great potential in various preclinical animal models and recently been evaluated in clinical trials. This review describes the common epidemiology, clinical manifestation and mechanisms of autoimmune diseases, with a focus on typical autoimmune diseases including multiple sclerosis, type 1 diabetes, rheumatoid arthritis, systemic lupus erythematosus, and sjögren's syndrome. We discuss the current therapeutics developed in this field, highlight the recent advances in the use of nanomaterials and mRNA vaccine techniques to induce antigen-specific immune tolerance.

Bimekizumab for the treatment of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a painful, inflammatory dermatosis involving recurrent abscesses, nodules and tunnels in intertriginous regions. Biologics and other immunomodulators have significantly expanded the treatment options available for HS. Bimekizumab is a monoclonal antibody targeting both interleukin-17A and interleukin-17F, key mediators of inflammation, that is already approved for psoriasis, psoriatic arthritis and axial spondylarthritis. It is currently pending FDA review for HS treatment but has already received marketing authorization for this indication in Europe. This review aims to explore drug-specific characteristics of bimekizumab including its mechanism of action, pharmacokinetics and pharmacodynamics and the current state of the literature regarding its use in HS such as safety, efficacy and dosing, while highlighting its implications in clinical practice. Recent Phase II and III trial data demonstrating positive efficacy and safety profiles in the treatment of HS will also be detailed.

Hidradenitis Suppurativa in Elderly Patients: Clinical and Therapeutical Outcomes-A Review of the Literature

The management of hidradenitis suppurativa (HS) in elderly patients presents unique challenges due to its chronic inflammatory nature, heterogeneous clinical presentation and comorbidities. While HS typically affects the anogenital and intertriginous regions, elderly patients may exhibit atypical features such as the involvement of the neck, mammary area and gluteal region. The prevalence of HS in the elderly population is lower and the average age of disease onset is higher than in patients under 65. In contrast, it is unclear whether HS in the elderly has different clinical features. The elderly frequently present multiple comorbidities, including obesity, diabetes, and heart disease, which further complicate management decisions. Therapeutic interventions must consider the frailty and increased risk of multimorbidity and adverse events in elderly patients. While systemic antibiotics remain a mainstay of HS treatment, biologic agents such as TNFα inhibitors and secukinumab offer promising options for refractory cases. However, their safety and efficacy in elderly patients, particularly those with multiple comorbidities, require careful consideration. A comprehensive approach to managing HS in elderly patients involves not only pharmacological interventions but also lifestyle modifications and surgical options where appropriate. Multidisciplinary collaboration between dermatologists, geriatricians and other specialists is essential for tailoring treatment strategies and optimizing long-term outcomes and quality of life in special population.

Hidradenitis Suppurativa: New Targets and Emerging Treatments

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that can be challenging to treat. Biologics and targeted small molecules have become an increasingly popular area of investigation for therapeutic development for moderate-to-severe HS, though only three biologics-adalimumab, secukinumab, and bimekizumab-have received US Food and Drug Administration (FDA) or European Medicines Evaluation Agency approval for treating HS. Promising agents under investigation are targeting interleukin 17A/F, JAK/STAT pathway, interleukin 36, interleukin 1, and more.

Essentials of hidradenitis suppurativa: a comprehensive review of diagnostic and treatment perspectives

Hidradenitis suppurativa, or acne inversa, is a chronic inflammatory skin condition with recurrent inflammatory nodules, abscesses, subcutaneous tracts, and scars. This condition may cause severe psychological distress and reduce the quality of life for affected individuals. It is considered to have one of the most damaging effects on quality of life of any skin disorder as a result of the discomfort and foul-smelling discharge from these lesions. Although the pathophysiology of HS is still unclear, multiple factors, including lifestyle, genetic, and hormonal factors, have been associated with it. The pathogenesis of HS is very complex and has wide clinical manifestations; thus, it is quite challenging to manage and often requires the use of combination treatments that must be tailored according to disease severity and other patient-specific factors. Although lifestyle changes, weight loss, quitting smoking, topical treatments, and oral antibiotics are adequate for mild cases, the challenge for healthcare professionals is dealing with moderate-to-severe HS, which often does not respond well to traditional approaches. This literature review, consisting of an overview of the various assessment tools and therapy strategies available for the diagnosis and treatment of HS from published literature, aims to be a guide for practicing clinicians in dealing with the complexities associated with this disease.

Hidradenitis suppurativa: a new therapeutic approach for an old disease

Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterised by recurrent painful nodules, abscesses, fistulas and scarring. The primary distinguishing factor in the complex, yet still not fully understood, pathogenesis is an inflammation occurring within the hair follicle, followed by an immune response leading to further development of the skin lesions seen in HS. The treatment of patients with HS is very difficult due to the complexity of the lesions and the frequent tendency to recurrence, which also has a negative impact on the psychological state of patients and directly translates into a reduced quality of life. This review article addresses the pathogenesis, clinical presentation of HS and, in particular, explores the new therapeutic options available.

Guidelines How to Integrate Surgery and Targeted Therapy with Biologics for the Treatment of Hidradenitis Suppurativa: Delphi Consensus Statements from an Italian Expert Panel

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent and painful nodules and abscesses in intertriginous skin areas, which can progress to sinus tract formation, tissue destruction, and scarring. HS is highly debilitating and severely impairs the psychological well-being and quality of life of patients. The therapeutic approach to HS is based on medical therapy and surgery. First-line medical therapy includes topical antibiotics, systemic antibiotics, and biologics. Main surgical procedures include deroofing, local excision, and wide local excision. Despite the availability of multiple therapeutic options, the rates of disease recurrence and progression continue to be high. In recent years, the possibility of combining biologic therapy and surgery has raised considerable interest. In a clinical trial, the perioperative use of adalimumab has been associated with greater response rates and improved inflammatory load and pain, with no increased risk of postoperative infectious complications. However, several practical aspects of combined biologic therapy and surgery are poorly defined. In June 2022, nine Italian HS experts convened to address issues related to the integration of biologic therapy and surgery in clinical practice. To this purpose, the experts identified 10 areas of interest based on published evidence and personal experience: (1) patient profiling (diagnostic criteria, disease severity classification, assessment of response to treatment, patient-reported outcomes, comorbidities); (2) tailoring surgery to HS characteristics; (3) wide local excision; (4) presurgery biologic treatment; (5) concomitant biologic and surgical treatments; (6) pre- and postsurgery management; (7) antibiotic systemic therapy; (8) biologic therapy after radical surgery; (9) management of adverse events to biologics; and (10) management of postoperative infectious complications. Consensus between experts was reached using the Estimate-Talk-Estimate method (Delphi Method). The statements were subsequently presented to a panel of 27 HS experts from across Italy, and their agreement was assessed using the UCLA Appropriateness Method. This article presents and discusses the consensus statements.

Efficacy and safety of bimekizumab in patients with moderate-to-severe hidradenitis suppurativa (BE HEARD I and BE HEARD II): two 48-week, randomised, double-blind, placebo-controlled, multicentre phase 3 trials

BACKGROUND

Patients with hidradenitis suppurativa have substantial unmet clinical needs and scarce therapeutic options. We aimed to assess the efficacy and safety of bimekizumab, a monoclonal IgG1 antibody that selectively inhibits interleukin (IL)-17F and IL-17A, in patients with moderate-to-severe hidradenitis suppurativa.

METHODS

BE HEARD I and II were two identically designed, 48-week randomised, double-blind, placebo-controlled, multicentre phase 3 trials. Patients aged 18 years or older with moderate-to-severe hidradenitis suppurativa were randomly assigned 2:2:2:1 using interactive response technology (stratified by worst Hurley Stage at baseline and baseline systemic antibiotic use) to receive subcutaneous bimekizumab 320 mg every 2 weeks; bimekizumab 320 mg every 2 weeks to week 16, then every 4 weeks to week 48; bimekizumab 320 mg every 4 weeks to week 48; or placebo to week 16, then bimekizumab 320 mg every 2 weeks. The primary outcome was an hidradenitis suppurativa clinical response of at least 50%, defined as a reduction in total abscess and inflammatory nodule count of at least 50% from baseline with no increase from baseline in abscess or draining tunnel count (HiSCR50) at week 16. Efficacy analyses included all randomly assigned study patients (intention-to-treat population). Safety analyses included all patients who received at least one full or partial dose of study treatment in the safety set, and of bimekizumab in the active-medication set. These trials are registered at ClinicalTrials.gov, NCT04242446 and NCT04242498, and both are completed.

FINDINGS

Patients for BE HEARD I were recruited from Feb 19, 2020, to Oct 27, 2021, and 505 patients were enrolled and randomly assigned. Patients for BE HEARD II were recruited from March 2, 2020, to July 28, 2021, and 509 patients were enrolled and randomly assigned. The primary outcome at week 16 was met in the group who received bimekizumab every 2 weeks using modified non-responder imputation; higher responder rates were observed with bimekizumab versus placebo in both trials: 138 (48%) of 289 patients versus 21 (29%) of 72 patients in BE HEARD I (odds ratio [OR] 2·23 [97·5% CI 1·16-4·31]; p=0·0060) and 151 (52%) of 291 patients versus 24 (32%) of 74 patients in BE HEARD II (2·29 [1·22-4·29]; p=0·0032). In BE HEARD II, HiSCR50 was also met in the group who were administered bimekizumab every 4 weeks (77 [54%] of 144 vs 24 [32%] of 74 with placebo; 2·42 [1·22-4·80]; p=0·0038). Responses were maintained or increased to week 48. Serious treatment-emergent adverse events were reported in 40 (8%) patients in BE HEARD I and in 24 (5%) patients in BE HEARD II treated with bimekizumab over 48 weeks. The most frequently reported treatment-emergent adverse events to week 48 were hidradenitis in both trials, in addition to coronavirus infection and diarrhoea in BE HEARD I, and oral candidiasis and headache in BE HEARD II. One death was reported across the two trials, and was due to congestive heart failure in a patient with substantial cardiovascular history treated with bimekizumab every 2 weeks in BE HEARD I (considered unrelated to bimekizumab treatment by the investigator). No new safety signals were observed.

INTERPRETATION

Bimekizumab was well tolerated by patients with hidradenitis suppurativa and produced rapid and deep clinically meaningful responses that were maintained up to 48 weeks. Data from these two trials support the use of bimekizumab for the treatment of patients with moderate-to-severe hidradenitis suppurativa.

FUNDING

UCB Pharma.

Emerging innovation in pain medicines

The treatment of pain remains a critical, unmet public health challenge. According to the CDC, in 2021, an estimated 20.9% of US adults (51.6 million people) endured chronic pain, and 6.9% (17.1 million people) endured high-impact chronic pain. Additionally, the impact of the social determinants of health on pain treatment are beginning to emerge. Treating pain addresses its control and relief, enhancing patient outcomes and quality of life. However, current treatment options have limitations, creating a significant need for innovative solutions. This raises the role of innovation in identifying new pain medicines. Thus, the clinical development of novel pain medicines is an unmet need to address public health worldwide.

[Hidradenitis suppurativa]

Hidradenitis suppurativa (HS) is a chronic inflammatory skin and systemic disease that is associated with considerable discomfort and a significant reduction in the quality of life. Despite a significantly increased understanding of the disease, the diagnosis is still delayed for many years. Delayed patient access to suitable treatment often leads to disease progression with increased surgical interventions and the occurrence of possible comorbidities. In recent years, there has been an improved understanding of the pathophysiology and, as a result the authorization of modern therapeutic agents for HS. The treatment of HS is based on three treatment pillars: surgery, antibiotics and biologics. Additionally, risk factors, such as smoking and obesity should be positively influenced. Knowledge of comorbidities and their interdisciplinary treatment is important for the individualized care of patients.

S2k‐Leitlinie zur Therapie der Hidradenitis suppurativa/Acne inversa – Kurzfassung

Die S2k‐Leitlinie der Hidradenitis suppurativa/Acne inversa (HS/AI) soll eine akzeptierte Entscheidungshilfe für die Auswahl/Durchführung einer geeigneten/suffizienten Therapie liefern. Hidradenitis suppurativa/Acne inversa ist eine chronisch‐rezidivierende, entzündliche, potenziell mutilierende Hauterkrankung des terminalen Haartalgdrüsenapparats, mit schmerzhaften, entzündlichen Läsionen in den apokrinen drüsenreichen Körperregionen. Ihre Punktprävalenz in Deutschland ist 0,3%, sie wird mit einer Verspätung von 10,0 ± 9,6 Jahren diagnostiziert. Abnormale Differenzierung der Keratinozyten des Haartalgdrüsenapparats und eine begleitende Entzündung bilden die zentrale pathogenetische Grundlage. Primäre HS/AI‐Läsionen sind entzündliche Knoten, Abszesse und drainierende Tunnel. Rezidive in den letzten 6 Monaten mit mindestens zwei Läsionen an den Prädilektionsstellen verweisen auf eine HS/AI mit einer 97‐prozentigen Genauigkeit. HS/AI‐Patienten leiden an einer deutlichen Einschränkung der Lebensqualität. Zur korrekten Therapieentscheidung sollen Klassifikation und Aktivitätsbewertung mit einem validierten Instrument erfolgen, wie dem International Hidradenitis Suppurativa Severity Scoring System (IHS4). Hidradenitis suppurativa/Acne inversa wird nach der Ausprägung der nachweisbaren Entzündung in zwei Formen eingeteilt: aktive, entzündliche (milde, mittelschwere und schwere nach IHS4) und vorwiegend inaktive, nicht entzündliche (Hurley‐Grad‐I, ‐II und ‐III) HS/AI. Orale Tetrazykline oder eine 5‐tägige intravenöse Therapie mit Clindamycin sind mit der Effektivität von Clindamycin/Rifampicin vergleichbar. Subkutan applizierbares Adalimumab, Secukinumab und Bimekizumab sind für die Therapie der HS/AI zugelassen. Für die vorwiegend nicht entzündliche Erkrankungsform stehen verschiedene operative Verfahren zur Verfügung. Medikamentöse/chirurgische Kombinationen gelten als ganzheitliches Therapieverfahren.

Data wobbles in hidradenitis suppurativa clinical trials and potential contributing factors: a retrospective review

Background

In some hidradenitis suppurativa (HS) clinical trial study arms, there is an unexpected decline in efficacy between the penultimate visit and the prespecified primary endpoint week, which we have termed a "wobble."

Objective

We aimed to establish how often study arms in HS programs wobble.

Methods

In a retrospective review, we identified HS clinical trials listed on ClinicalTrials.gov testing systemic, nonantibiotic medications that utilized Hidradenitis Suppurativa Clinical Response (HiSCR) as an outcome measure. We identified study arms demonstrating greater improvement in a visit prior to the primary endpoint week. Baseline subject characteristics were compared between studies with HiSCR wobble and no HiSCR wobble.

Results

A total of 21 studies (randomized control trial [RCT], n = 14; open-label, n = 7) with 35 study drug arms (RCT, n = 27; open-label, n = 8) and 14 placebo arms were identified. HiSCR wobble occurred significantly more often in RCT compared to open-label study drug arms (11/27 [40.7%] vs 0/8 [0%]). In RCT study arms with HiSCR wobble, baseline draining fistula counts were significantly lower (2.3 vs 3.2), and numerically fewer Hurley stage 3 patients (33.2% vs 42.5%), lower weighted total abscess and nodule counts (12.1 vs 12.6), lower weighted dermatology life quality index scores (12.5 vs 14.5), and a higher proportion of female patients (63.9% vs 58.3%) were observed.

Limitations

Include low number of HS clinical trials and insufficient data reported in many studies to assess for wobble, degree of wobble, and to compare all baseline characteristics.

Conclusion

Nonlinear improvement in study arm response occurs in some HS RCTs. Potential contributing factors include a higher proportion of less severe patients at baseline and more female patients.

S2k guideline for the treatment of hidradenitis suppurativa / acne inversa - Short version

The S2k guideline on hidradenitis suppurativa/acne inversa (HS/AI) aims to provide an accepted decision aid for the selection/implementation of appropriate/sufficient therapy. HS/AI is a chronic recurrent, inflammatory, potentially mutilating skin disease of the terminal hair follicle-glandular apparatus, with painful, inflammatory lesions in the apocrine gland-rich regions of the body. Its point prevalence in Germany is 0.3%, it is diagnosed with a delay of 10.0 ± 9.6 years. Abnormal differentiation of the keratinocytes of the hair follicle-gland apparatus and accompanying inflammation form the central pathogenetic basis. Primary HS/AI lesions are inflammatory nodules, abscesses and draining tunnels. Recurrences in the last 6 months with at least 2 lesions at the predilection sites point to HS/AI with a 97% accuracy. HS/AI patients suffer from a significant reduction in quality of life. For correct treatment decisions, classification and activity assessment should be done with a validated tool, such as the International Hidradenitis Suppurativa Severity Scoring System (IHS4). HS/AI is classified into two forms according to the degree of detectable inflammation: active, inflammatory (mild, moderate, and severe according to IHS4) and predominantly inactive, non-inflammatory (Hurley grade I, II and III) HS/AI. Oral tetracyclines or 5-day intravenous therapy with clindamycin are equal to the effectiveness of clindamycin/rifampicin. Subcutaneously administered adalimumab, secukinumab and bimekizumab are approved for the therapy of HS/AI. Various surgical procedures are available for the predominantly non-inflammatory disease form. Drug/surgical combinations are considered a holistic therapy method.

The use of biologics and JAK inhibitors in the management of moderate to severe Hidradenitis Suppurativa treatment: a scoping review

This scoping review aims to characterize the use of biologics and Janus Kinase inhibitors (JAKi) in the treatment of Hidradenitis Suppurativa (HS), which is a chronic inflammatory condition. A comprehensive literature search was conducted in PubMed/NCBI, Embase, Web of Science databases, and the Clinicaltrials.gov register. The search included interventional trials assessing the use of biologics or JAKi in HS, with no geographic or time restrictions. Secukinumab and adalimumab were identified as the only two drugs approved by the FDA for treating moderate to severe HS in adults. Several other drug classes showed promising results based on clinical studies reviewed. IL-12/23 inhibitor ustekinumab demonstrated improvements in disease severity scores and HiSCR rates in small trials. IL-17 inhibitors such as brodalumab, bimekizumab, and CJM112 showed preliminary positive responses in early-phase clinical studies and case reports. While evidence was mixed, some TNF-α inhibitors such as infliximab provided benefits according to a randomized controlled trial, though etanercept trials yielded non-significant or inconsistent findings. Larger, well-designed studies are required to further establish their efficacy and safety, but biologics and JAKis show potential as alternative treatment options for moderate to severe HS. The findings of this review contribute to the growing interest among patients and to enhancing the understanding of physician's regarding potential alternative therapeutic options for HS and provide a basis for further research in this field.

Biologics for Hidradenitis suppurativa: evolution of the treatment paradigm

INTRODUCTION

Hidradenitis suppurativa (HS) is an autoinflammatory skin disease with a high unmet need for effective medical management. Clinically, it is characterized by inflammatory nodules that may progress into abscesses, draining tunnels and extensive scarring, mainly affecting apocrine gland-bearing areas.

AREAS COVERED

Treatment options include topical and systemic medications and a variety of surgical procedures. The anti-TNF-α antibody adalimumab and the anti-IL-17 secukinumab are the only two approved biologics for HS, showing moderate efficacy. HS research is a rapidly growing field, with a wide range of agents leveraging distinct mechanisms of action currently under development. Drugs targeting the IL-17 and Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathways are the most advanced in both ongoing and completed Phase 3 studies, promising deeper levels of response. Use of other, off-label biologics is also discussed.

EXPERT OPINION

A therapeutic algorithm is proposed based on comorbidities and existing evidence. Patient-tailored combinations between biologics and other biologics or small molecules will hopefully allow clinicians to target most events in HS pathophysiology in a complementary way while obtaining a meaningful effect on their devastating manifestations.

Brodalumab for moderate-severe hidradenitis suppurativa: An open-label multicentric cohort study in real clinical practice

INTRODUCTION

The use of biological therapy is becoming increasingly common in patients with hidradenitis suppurativa (HS). Levels of serum TNF-alfa and IL17 support the role of an immune system dysregulation in the pathogenesis of HS. Brodalumab targets the receptor A of IL-17, thus having a promising role in the treatment of HS.

MATERIAL AND METHODS

A multicenter retrospective observational open-label study was conducted in two tertiary hospitals. Adults with moderate to severe HS under treatment with brodalumab 210 mg at week 0, 1, 2 and then every 2 weeks were included and assessed at weeks 0 and 16 which was the median follow-up time. Demographic and disease-related variables as well as response parameters (HiSCR and IHS4) and safety data were recorded and analysed.

RESULTS

A total of 16 patients (75% males) were included in our study. 50% of patients presented an inflammatory phenotype and mean BMI was 28.37. HiSCR was achieved in 50% of patients and mean IHS4 decreased from 24.13 to 16.81 (p = 0.002). No differences were found between those who achieved HiSCR and those who did not. Grade 2 adverse events were reported in three patients with no fatal outcomes and treatment discontinuation was advised in four patients.

CONCLUSIONS

Brodalumab seems to be effective and safe in patients with moderate to severe HS, even in those that did not respond to adalimumab, which, at the moment, is the only widely approved biologic for this indication. Thus, it stands as an interesting option for the treatment of HS.

Successful Treatment with Bimekizumab of a Psoriatic Patient Undergoing Hemodialysis: A Case Report and Review of the Literature

Background/Objectives: Treating psoriasis patients requires the consideration of potential underlying complications like latent viral infections and chronic kidney disease, which may influence therapy selection. Case presentation: A patient with end-stage kidney disease (ESKD) undergoing hemodialysis (HD) was successfully treated with bimekizumab, an IgG1 humanized monoclonal antibody inhibiting interleukin (IL)-17A and IL-17F. This case appears to be the first documented instance of effective anti-IL-17A/IL-17F antibody treatment in a psoriasis patient undergoing HD, with a sustained positive response for eight months. Discussion: Studies indicate the comparable pharmacokinetics, efficacy, and safety of certain psoriasis drugs in patients with chronic kidney disease (CKD) and those with normal renal function. The positive clinical outcome observed following treatment with bimekizumab aligns with the existing literature on this topic. However, further studies are needed to objectively evaluate the pharmacokinetics, efficacy, and safety of this drug in this specific setting. Conclusions: This documented case represents the first known use of bimekizumab to treat psoriasis in patients undergoing dialysis, suggesting its potential effectiveness and safety in this population.

An evaluation of secukinumab for the treatment of moderate-to-severe hidradenitis suppurativa

INTRODUCTION

Until recently, biological therapy for hidradenitis suppurativa was limited to anti-tumor necrosis factor (TNF) blockade with adalimumab (ADA). However, not all patients respond to treatment with ADA. This highlighted the need for more therapeutic options. Interleukin (IL)-17/T-helper 17 (Th17) axis may play an important role in the pathophysiology of HS. Recently, the IL-17A inhibitor secukinumab, which targets IL-17A specifically and prevents it from interacting with the IL-17 receptor, has been FDA-approved for HS.

AREAS COVERED

Secukinumab, represents a novel therapeutic strategy in HS management. An overview of structural and pharmacological characteristics is provided. Described efficacy in clinical trials and case reports and safety data from is presented.

EXPERT OPINION

As response to anti-TNFas is lost over time, secukinumab has provided an alternative HS treatment option in clinical practice. Overall, secukinumab has shown good efficacy and a favorable side effect profile in HS clinical trials but may be avoided in patients with inflammatory bowel disease. Long-term and real-life data on the use of secukinumab are essential for improving decision-making in HS therapy.

Alterations to the Hidradenitis Suppurativa Serum Proteome with Spleen Tyrosine Kinase Antagonism: Proteomic Results from a Phase 2 Clinical Trial

Hidradenitis suppurativa is a disease in great need of novel therapies. Given the heterogeneous nature of the disease and the variable response to therapies, biomarkers are essential to predict response to therapies and increase our understanding of disease pathogenesis. Our recent phase 2 clinical trial of spleen tyrosine kinase antagonism using fostamatinib in hidradenitis suppurativa demonstrated a 75% clinical response, with the greatest benefit in individuals with elevated serum inflammation and IgG. In this study, we present results of an in-depth serum proteomic analysis in this patient cohort identifying downregulation of IL-12B as well as B-cell-associated proteins CCL19 and CCL20 and IFN-γ-mediated proteins CXCL10 and CX3CL1. Clinical responders demonstrated greater reduction in serum IL-17A, IL-6, IL-8, and CX3CL1 compared with clinical nonresponders. Baseline levels of CCL28 were associated with clinical response to fostamatinib therapy at week 12. Overall, this suggests that fostamatinib, by targeting B-cell receptor and Fc receptor activity in B cells, monocytes, and macrophages, has a significant molecular impact on the inflammatory serum proteome of hidradenitis suppurativa. In addition, potential therapeutic biomarkers may aid in patient selection for targeted therapy.

Rethinking Hidradenitis Suppurativa Management: Insights into Bacterial Interactions and Treatment Evolution

Hidradenitis suppurativa (HS), or acne inversa, is a chronic inflammatory dermatological condition characterized by painful and recurrent nodules and purulent abscesses. HS can have a devastating impact on the quality of life of patients. This condition is commonly localized to the axilla, groin, perineal, and inframammary regions, and can develop fistulas and sinus tracts over time. Its pathogenesis remains elusive and is best characterized at the moment as multi-factorial. Additionally, questions remain about the role of cutaneous dysbiosis as a primary HS trigger or as a secondary perturbation due to HS inflammation. This article features works in relation to HS and its interplay with bacterial microflora. We address current treatment approaches and their impact on HS-related bacteria, as well as areas of therapeutic innovation. In the future, disease-modifying or remittive therapy will likely combine an advanced/targeted anti-inflammatory approach with one that effectively modulates cutaneous and deep tissue dysbiosis.