Chair & Presenter, Vivian Y. Shi, MD, FAAD, and Jennifer Hsiao, MD, prepared useful Practice Aids pertaining to hidradenitis suppurativa for this CME activity titled “Hope on the Horizon for Hidradenitis Suppurativa: Leveraging Emerging Biologics to Improve Quality of Life.” For the full presentation, downloadable Practice Aids, and complete CME information, and to apply for credit, please visit us at https://bit.ly/3c2uXCE. CME credit will be available until December 5, 2023.

1. Hidradenitis Suppurativa Diagnosis
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If patient has chronic history of1-3
• Nodules or abscesses
• Sinus tracts
• Purulent discharge
• Pain
Also evaluate for1,4,5
• Blackheads
• Atrophic scarring
• Follicular prominence
As these may be signs of quiescent HS
Also beware of differential diagnoses
• Folliculitis
• Furuncles, carbuncles
• Acne
• Epidermal inclusion cyst
• Actinomycosis
• Tuberculosis
• Granuloma inguinale
And …
• Has comorbidities (ie, Crohn disease, psoriasis, etc)
• Is a smoker
• Has a family history of HS
Chronically occurring in
• Intertriginous areas
Then, suspect HS
• Biopsy may not be needed

2. Hidradenitis Suppurativa Diagnosis
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Hidradenitis Suppurativa Diagnosis1,4,5
Chronicity; relapsing/remitting
Inquire about
• Length of symptoms
• Prior diagnoses
• Pain
• Discharge
• Smoking status
• Weight
• Family history of HS
• Comorbidities (ie, Crohn disease, psoriasis, etc)
Commonly appears in axillae, anogenital,
inframammary areas, but can appear elsewhere
Abscesses or
nodules
Sinus tracts
Quiescent disease
• Blackheads
• Atrophic scarring
• Follicular prominence
Purulent
discharge

3. Hidradenitis Suppurativa Diagnosis
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Differential Diagnosis5,6,7
Early-Stage Hidradenitis Suppurativa Late-Stage Hidradenitis Suppurativa
• Folliculitis
• Furuncles, carbuncles
• Acne
• Epidermal inclusion cyst
• Pilonidal cyst
• Perirectal abscess
• Erysipelas
• Actinomycosis
• Granuloma inguinale
• Lymphogranuloma
venereum
• Cat scratch disease
• Cutaneous Crohn disease
• Pilonidal disease
• Tuberculosis
1. https://www.aad.org/public/diseases/a-z/hidradenitis-suppurativa-symptoms. 2. Lee EY et al. Can Fam Physician. 2017;63:114-120. 3. Scuderi N et al. Skin Appendage Dis. 2017;3:95-110.4. Čagalj AM et al. Int J Mol Sci. 2022;23:3753. 5. Micheletti R. Semin Cutan Med Surg.
2014:33:S51-S53. 6. Dufour DN et al. Postgrad Med J. 2014;90:216-221. 7. Alikhan A et al. J Am Acad Dermatol. 2009;60:539-561.

4. Hidradenitis Suppurativa Management Algorithm1,2
Full abbreviations, accreditation, and disclosure information available at PeerView.com/RJF40
Hurley Stage 1
Mild
(nodules and abscesses)
Hurley Stage 2
Moderate (nodules, abscesses,
and scars or tunnels)
Hurley Stage 3
Severe (nodules, abscesses,
and connecting tunnels)
Lifestyle Modification
and General Treatment
Medical Treatment
Surgical and Laser Treatment
• Smoking cessation
• Body weight reduction
• Advise wearing loose clothing to avoid friction with skin
Hormonal therapies
Retinoids
Topical antibiotics or disinfection (eg, clindamycin [1%] twice daily for 12 wk)
Intralesional steroids for short-term control of acute and recalcitrant lesions
Zinc gluconate
Systemic Antibiotics: Tetracyclines (eg, doxycycline 50-100 mg BID)
Systemic Antibiotics: Clindamycin 300 mg BID and rifampicin 300 mg BID for 12 wk
Other biologics: secukinumab, ustekinumab, anakinraa
TNF-α Inhibitors: Adalimumab for 12 wk followed by assessment
(wk 0 160 mg subQ, wk 2 80 mg subQ, then weekly 40 mg subQ) or
infliximab 5 mg/kg IV on wk 0, 2, 6, and Q8W thereafter
Local Procedures for Localized Stationary and Recurrent Nodules and for
Abscesses: excision; carbon dioxide laser evaporation of diseased tissue;
drainage of fluctuating abscesses
Local Procedures for Sinus Tracts: deroofing of sinus tracts; sinus tract
excisions; carbon dioxide laser evaporation of diseased tissue
Wide local excisions with healing by secondary intention or primary closure/flap/graft
Other Possible Systemic Therapies: Dapsone 25-200 mg daily; acitretin 0.2-0.5 mg/kg daily;
prednisone 40-60 mg daily for 3-4 d then taper; cyclosporine 3-5 mg/kg daily
• Advise antiseptic wash to keep skin clean to reduce odor (eg, triclosan)
• Refer to psychosocial support as needed
• Pain management
a
Not yet FDA-approved for HS.
1. Adapted from Jafari SMS et al. Front Med (Lausanne). 2020 Mar 4;7:68. 2. Alikhan A et al. J Amer Acad Derm. 2019;811:91-101.

5. Comparative Dosing, Efficacy, Safety, and MOA of Biologic and
Small Molecule Therapies for Hidradenitis Suppurativaa
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Adalimumab1,2
TNF
inhibitor
PIONEER I
and
PIONEER II
• Period 1: 40 mg
weekly for 12 wk
• Period 2: weekly or
every other wk for
24 wk
Through wk 168
300 mg Q2W or Q4W
through wk 16
300 mg Q2W or Q4W
through wk 16
• Bimekizumab: 640
mg wk 0, 320 mg
Q2W
• Adalimumab: 160
mg wk 0, 80 mg wk
2, 40 mg every wk
for wk 4-10
• PIONEER I: HiSCR at wk 12: 41.8%
adalimumab vs 26.0% PBO
• PIONEER 2: HiSCR at wk 12: 58.9%
adalimumab vs 27.6% PBO
• HiSCR at wk 16 (Q2W): 45.0%
secukinumab vs 33.7% PBO
• Q4W: 41.8% secukinumab
• HiSCR at wk 16 (Q2W): 45.0%
secukinumab vs 31.2% PBO
• Q4W: 41.8% secukinumab
• HiSCR all responders at wk
12: 60% bimekizumab and
adalimumab vs 22% PBO
• HiSCR90 responders: 30%
bimekizumab vs 18%
adalimumab vs 0% PBO
• HiSCR at wk 168: 52%
adalimumab and 57% responders
+ partial responders
Phase 3 RCT 307, 327
No differences
between groups
No differences
between groups
No new safety
signals
No new safety
signals
TEAEs similar
among groups
151
>500
>500
84
Phase 3 OLE;
uncontrolled
Phase 2 RCT vs
adalimumab
and PBO
Phase 3 RCT
Phase 3 RCT
PIONEER III
SUNSHINE
SUNRISE
N/A
IL-17A
inhibitor
IL-17A/17F
inhibitor
Secukinumab3,4
Bimekizumab5
Agent Class/MOA Trial Name Trial Type N Dosing Efficacy Safety

6. Comparative Dosing, Efficacy, Safety, and MOA of Biologic and
Small Molecule Therapies for Hidradenitis Suppurativaa
Full abbreviations, accreditation, and disclosure information available at PeerView.com/RJF40
a
Only adalimumab is FDA-approved for HS.
1. Kimball AB et al. N Engl J Med. 2016;375:422-434. 2. Zouboulis CC et al. J Amer Acad Derm. 2019;80:60-69. 3. Kimball AB et al EADV 2022. Abstract LB-3549. 4. https://www.emjreviews.com/dermatology/abstract/secukinumab-in-moderate-to-severe-hidradenitis-suppurativa-primary-
endpoint-analysis-from-the-sunshine-and-sunrise-phase-iii-trials-j0301225. 5. Glatt S et al. JAMA Dermatol. 2021;157:1279-1288. 6. Gottlieb A et al. J Invest Dermatol. 2020;140:1538-1545. 7. https://clinicaltrials.gov/ct2/show/NCT04988308. 8. Grant A et al. J Am Acad Dermatol. 2010;62:205-217.
9. Tzanetakou V et al. JAMA Dermatol. 2016;152:52-59. 10. Blok JL et al. Br J Dermatol. 2016;174:839-846.
Agent
Bermekimab6,7
Infliximab8
Anakinra9
Ustekinumab10
Il-1α
inhibitor
TNF
inhibitor
IL-1
antagonist
IL-12/23
inhibitor
Phase 2 (open-label):
anti-TNF–naïve vs failed;
no PBO
Phase 2
Phase 2
Phase 2 (open-label)
Injection-site
reactions
30% decrease in lesion
count in naïve group vs
60% in failed group;
HiSCR at wk 12
~60% both groups
_
_
_
_
42
38
20
12
400 mg weekly
• Wk 0, 2, 6: 5 mg/kg
• Wk 8: crossover; Q8W
through wk 22
• Wk 22 and 30:
maintenance regimen
26.7% of infliximab
patients had ≥50%
decrease in HSSI vs 5%
with PBO
Infusion-site
reactions; infections
Injection-site pain;
mild infections
Upper respiratory
tract infections
Disease activity score
decreased in 67% in
anakinra patients vs
20% with PBO
47% achieved HiSCR50
at wk 40
100 mg subQ once
daily for 12 wk
45mg subQ if <90kg
and 90mg if >90kg at
wk 0, 4, 16, and 28
Class/MOA Trial Name Trial Type N Dosing Efficacy Safety