Real-World Considerations of Candidacy for Biologics in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, progressive inflammatory skin disease that is often recalcitrant to multiple treatments. In determining biologic candidacy for patients with HS, we propose a paradigm shift away from Hurley staging and towards consideration of other variables. Biologics represent a long-term treatment option for HS that may serve as a disease-modifying agent. These medications are typically initiated in patients with moderate to severe disease, which, based on inclusion criteria in clinical trials, is often defined as Hurley stage II or III disease, at which point irreversible tissue damage has already occurred. In real-world clinical settings, these considerations include treatments tried and failed, predicted disease trajectory, disease characteristics beyond lesion type, impact of disease on patients' functional status and quality of life, and patient comorbidities, venturing away from the limitations of Hurley stage designations. Future clinical trials may benefit from inclusion of recalcitrant Hurley stage I patients, which may then re-shape treatment guidelines and insurance coverage and improve patient access to biologic treatments.