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Treatment – Biologics

Hidradenitis suppurativa (HS) is a chronic, painful inflammatory skin disease. There is no cure, but treatments are available to help manage the condition. Since there is no cure, the goals of treatment are to reduce symptoms, relieve pain, and heal wounds to prevent infection.1

There are different treatments used for HS symptoms, including biologic disease-modifying anti-rheumatic drugs (DMARDs). Adalimumab (Humira®), a biologic DMARD, is the first treatment approved by the U.S. Food and Drug Administration (FDA) specifically for moderate to severe HS in adults. Other biologics, which are approved by the FDA for other conditions, are used for HS off-label. Off-label is when doctors prescribe a medicine for a condition that it is not approved to treat.2,3

How do biologics work?

Biologic DMARDs are drugs made from substances produced by the body. They fight specific targets whose actions contribute to disease. Biologics are especially useful because they affect only 1 part of the immune system, instead of curbing the entire system.3,4

In HS, biologics block tumor necrosis factor-alpha (TNF-α) or interleukin (IL). These blocked substances are secreted by the immune system and cause inflammation.5

Biologic DMARDs used for HS are usually given by injection or intravenously (IV).

Which are used for HS?

There are different types of biologics used to treat HS. These include:

  • TNF-α blockers
  • Interleukin blockers

TNF-α blockers for HS

  • Adalimumab (Humira®) – Extensive research has shown that adalimumab controls symptoms of moderate to severe HS, reduces pain, and improves quality of life6,7
  • Infliximab (Remicade®) – Research shows this drug to be effective in controlling symptoms and pain for moderate to severe HS. However, some people relapse despite treatment, and others after treatment stops.5,8,9
  • Golimumab (Simponi®, Simponi Aria®) and etanercept (Enbrel®) – Research is limited or inconsistent on using golimumab and etanercept for HS. More research is needed.2,8
  • Other TNF-α blockers – There is a lack of evidence on how effective other TNF-α blockers are in HS. These include bimekizumab, certolizumab pegol, guselkumab, and rituximab.1,5

Interleukin blockers for HS

  • Anakinra (Kineret®) – In research studies, anakinra worked better than a placebo (inactive substance) in reducing disease severity and relieving the pain of HS. Because of inconsistent results and limited testing, anakinra is recommended only if other blockers fail to improve HS.2
  • Ustekinumab (Stelara™) – An IL-12/IL-23 inhibitor, ustekinumab is used mostly to treat psoriasis. It produced varied responses in tests against HS, and it needs more research.10

What are the possible side effects?

Common side effects of biologic DMARDs include:2,8,11

  • Irritation at the injection or infusion site
  • Infections
  • Nausea or vomiting
  • Rash

Sometimes infections can be serious, so it is important to see your doctor if you think you have an infection while you are taking these drugs. Biologic DMARDs also have a higher risk of viral, bacterial, and/or fungal infections that can be fatal.2,8,11

Other more serious side effects include:2,8,11

  • Allergic reactions
  • Heart failure
  • Disorders of the nervous system
  • High blood pressure
  • Kidney problems

These are not all the possible side effects of biologic DMARDs. Talk to your doctor about what to expect or if you experience any changes that worry you.

Things to know

Biologic DMARDs may not be right for you. You should not take these medicines if you have:12

  • Active infection
  • Chronic liver disease
  • Immunodeficiency syndromes
  • Leukopenia
  • Bone marrow hypoplasia

In most cases, biologics should not be taken by women who are pregnant or breastfeeding. Talk to your doctor if you are pregnant, plan to become pregnant, or if you are breastfeeding.2,8,11

You should discuss the risks and benefits of biologics with your doctor, as well as any other steps you should take to avoid side effects. Close monitoring of biologic DMARD effectiveness and side effects is necessary when taking these drugs.

Before taking biologics, tell your doctor about any other drugs, vitamins, or supplements you are taking. This includes over-the-counter drugs.

Biologic DMARDs are just 1 part of HS treatment. You should discuss the risks and benefits of these drugs with your doctors. Other approaches may include different drugs, surgery, diet and lifestyle changes, and alternative medicine.

Written by: Ina Fried and Heather Morse | Last reviewed: December 2020
  1. Seyed Jafari SM, Hunger RE, Schlapbach C. Hidradenitis suppurativa: current understanding of pathogenic mechanisms and suggestion for treatment algorithm. Front Med (Lausanne). 2020 Mar 4;7:68. doi:10.3389/fmed.2020.00068.
  2. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part II: Topical, intralesional, and systemic medical management. J Am Acad Dermatol. 2019;81(1):91‐101.
  3. Biological and biosimilar medicines (biosimilars). National Health System. Available at https://www.nhs.uk/conditions/biological-and-biosimilar-medicines/. Accessed 8/12/2020.
  4. Luther E. Biological treatments. Topics A-Z. DermNet NZ. Available at https://www.dermnetnz.org/topics/biologics/. Accessed 8/12/2020.
  5. Constantinou CA, Fragoulis GE, Nikiphorou E. Hidradenitis suppurativa: infection, autoimmunity, or both? Ther Adv Musculoskel Dis. 2019 Dec 30;11:1-14. doi:10.1177/1759720X19895488.
  6. Kimball AB, Okun MM, Williams DA, et al. Two phase 3 trials of adalimumab for hidradenitis suppurativa, N Engl J Med. 2016 Aug 4;375(5):422-434. doi:10.1056/NEJMoa1504370.
  7. Mac Mahon J, Kirthi S, Byrne N, et al. An update on health-related quality of life and patient-reported outcomes in hidradenitis suppurativa. Patient Relat Outcome Meas. 2020;11:21-26. doi:10.2147/PROM.S174299.
  8. Zouboulis CC, Desai N, Emtestam L, et al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol. 2015 Jan;29(4):619-644. doi:10.1111/jdv.12966.
  9. Ranaweera A. Anakinra. Topics A-Z. DermNet NZ. 2011. Available at https://www.dermnetnz.org/topics/anakinra. Accessed 8/12/2020.
  10. Ranaweera A. Ustekinumab. Topics A-Z. DermNet NZ. 2011. Available at https://www.dermnetnz.org/topics/ustekinumab. Accessed 8/12/2020.
  11. Oakley A. Tumour necrosis factor inhibitors. Topics A-Z. DermNet NZ. Available at https://www.dermnetnz.org/topics/tumour-necrosis-factor-inhibitors/. Accessed 8/12/2020.
  12. Benjamin O, Bansal P, Goyal A, Lappin SL. Disease modifying anti-rheumatic drugs (DMARD). StatPearls. Available at https://www.ncbi.nlm.nih.gov/books/NBK507863/ Accessed 1/29/20.