Towards the development of upgrade criteria for the treatment of hidradenitis suppurativa with biologics

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BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized primarily by dysregulated innate immunity and abnormal keratinocyte differentiation. Over the past two decades, the treatment paradigm has evolved from antibiotics to targeted biologics, such as anti-TNF-α and anti-IL-17A/A-F inhibitors. However, antibiotic therapy remains a prerequisite for biologic initiation despite a lack of comparative studies evaluating their efficacy. OBJECTIVES: This study aimed to assess current prescription patterns for systemic HS therapies among European HS specialists, evaluate unmet needs in antibiotic and biologic use and explore expert opinions on criteria for biologic upgrade as a first-line therapy. METHODS: A structured questionnaire was distributed to 55 HS specialists, the majority of whom were members of the European Hidradenitis Suppurativa Foundation (EHSF), comprising HS experts and future opinion leaders. Responses underwent statistical analysis to assess trends in antibiotic versus biologic prescription, treatment efficacy and potential improvements in therapeutic decision-making. RESULTS: A total of 43 participants (76.6% of invited experts, 80% of invited opinion leaders) responded. While 95% adhered to licensing regulations mandating 10-12 weeks of antibiotics before biologics, 81% acknowledged prescribing antibiotics despite anticipating inadequate responses. More than half reported patient-reported flares during antibiotic treatment. The majority (77%) supported earlier biologic initiation in cases of persistent flares, and 79% favoured short-term biologic therapy over antibiotics for early-stage HS. Participants identified specific phenotypic attributes such as rapidly progressing disease, extensive involvement and comorbidities as factors warranting earlier biologic intervention. CONCLUSIONS: Current treatment practice may delay optimal intervention, potentially leading to missed therapeutic windows. A significant proportion of respondents expressed a preference for earlier biologic intervention, especially in cases of severe disease or frequent flares. 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.

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