Early Biologic Therapy for Hidradenitis Suppurativa Supported by Majority of Specialists, Survey Shows

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A recent multinational survey of hidradenitis suppurativa (HS) specialists suggests broad support for initiating biologic therapy earlier in the disease course, with many clinicians reporting that current antibiotic-first regulatory requirements may delay optimal treatment and risk missing a “window of opportunity” for disease control.

The data come from a questionnaire administered to 55 specialists in HS treatment. The findings were published in the Journal of the European Academy of Dermatology and Venereology.

Most clinicians prescribe antibiotics despite expecting limited benefit

In the structured survey of 55 invited European HS specialists, 43 participated (77% of experts; 80% of future opinion leaders) representing 19 countries. Nearly all respondents (95%) reported adherence to licensing rules requiring a 10–12-week antibiotic trial before biologic therapy. However, 81% stated they often prescribed antibiotics despite not expecting adequate clinical response.

Doxycycline was the most commonly selected first-line antibiotic (47%), followed by clindamycin (21%), clindamycin-rifampicin (16%), other tetracyclines (9%), and additional regimens (7%). More than half of clinicians (52% of experts; 56% of future opinion leaders) reported patient-reported flares during the mandated antibiotic period.

Clinicians frequently escalate to biologics before 12 weeks

When flares occurred during antibiotic therapy, 58% of respondents said they switched to biologic monotherapy, while 74% preferred combining biologics with antibiotics. Most experts required two to three flares to justify early escalation, while younger opinion leaders were more likely to escalate after more than one flare.

Among patients who initially responded to antibiotics, 60% of clinicians discontinued treatment after the standard course, but 26% continued therapy—some for 4–6 months or until flare or intolerance. About half of specialists estimated relapse within 1–3 months of antibiotic cessation.

Concern about missing optimal treatment window

HS diagnostic delay and progression to irreversible lesions, including draining tunnels, remain critical concerns. In the survey, 48% of experts and 70% of future opinion leaders believed the required 3-month antibiotic course may risk losing the therapeutic window needed to prevent structural disease progression.

Strong support for earlier biologic use, especially in severe early-stage disease

Overall, 79% of participants favored short-term biologic therapy over antibiotics for patients with severe Hurley stage I disease. Preference for biologics was higher among future opinion leaders (85%) than experts (74%). The most commonly preferred treatment duration was 12 weeks, with an option to extend to 24 weeks.

Preliminary phenotypic criteria for early biologic initiation

Participants identified several clinical scenarios in which biologics may be appropriate as first-line therapy, though overlap in responses precluded phenotype-specific recommendations. Frequently cited scenarios included:

• Frequent flares (≥3 in 12 weeks)
• Rapid progression in Hurley staging
• Moderate disease with multi-site involvement (IHS4 ≥4 affecting upper and lower body)
• Syndromic HS or HS with inflammatory comorbidities (e.g., Crohn disease, arthritis)
• Hurley I severe disease (IHS4 ≥11)
• Hurley II–III disease with draining tunnels or multiple area involvement
• Pediatric onset with family history and persistent inflammation
• Disease involving inguinal, anogenital, gluteal, or visible areas

These preliminary findings will undergo further refinement in a Delphi consensus process proposed by the investigators.

"The findings underscore the need for a consensus statement defining upgrade criteria for biologics as a first-line therapy, potentially improving patient outcomes and reducing healthcare burdens," researchers concluded.

Source: Nikolakis G, Alpsoy E, Zouboulis CC, et al. Towards the development of upgrade criteria for the treatment of hidradenitis suppurativa with biologics. J Eur Acad Dermatol Venereol. Published online November 13, 2025. doi:10.1111/jdv.70118