What are treatment options for a 55-year-old woman with hidradenitis suppurativa (HS) who has failed adalimumab (Humira) therapy?

Treatment Options After Adalimumab Failure in Hidradenitis Suppurativa

For a 55-year-old woman with hidradenitis suppurativa who has failed adalimumab therapy, the recommended next-line biologic is infliximab 5 mg/kg at weeks 0,2,6, and every 2 months thereafter, with consideration of surgical deroofing or radical excision depending on disease extent and anatomical involvement. 1, 2

Second-Line Biologic Therapy

Infliximab is the guideline-recommended second-line biologic after adalimumab failure:

• Dosing regimen: 5 mg/kg intravenously at weeks 0,2,6, then every 2 months for at least 12 weeks 1
• Higher doses and more frequent intervals may be considered for severe refractory cases 1
• This recommendation is supported by the American Academy of Dermatology as the standard escalation pathway 1

Alternative Biologic Options

If infliximab is not suitable or fails, consider these alternatives:

Secukinumab (IL-17A inhibitor):

• Demonstrates response rates of 64.5-71.4% in adalimumab-failure patients at 16-52 weeks 1
• Suggested for patients 6 years and older with conditional strength and moderate quality evidence 3
• Can be used in combination with infliximab for treatment-refractory disease, targeting different inflammatory pathways 1

Ustekinumab (IL-12/23 inhibitor):

• Suggested for patients 6 years and older with conditional strength and moderate quality evidence 3
• Represents an alternative pathway targeting different cytokines than TNF-alpha 3

Non-Biologic Systemic Options

Acitretin (retinoid):

• Recommended by the British Journal of Dermatology as an alternative for patients unresponsive to adalimumab 1
• Dosing: 0.3-0.5 mg/kg/day 1
• Critical caveat: Teratogenicity must be considered in women of reproductive age; requires strict contraception and monitoring 4
• Feasible for long-term treatment 4

Dapsone:

• Suggested as an alternative option for adalimumab non-responders 1
• Starting dose: 50 mg daily, titrating up to 200 mg daily 1
• Requires G6PD testing before initiation and monitoring for hemolytic anemia 1

Combination antibiotic therapy (clindamycin + rifampicin):

• Clindamycin 300 mg twice daily with rifampicin 300-600 mg daily for 10-12 weeks 1, 5
• Response rates of 71-93% documented in systematic reviews 1
• Can be used as adjuvant therapy in severe disease or during surgical planning 1
• Important limitation: High recurrence rate after discontinuation 4

Ertapenem (IV carbapenem):

• 1g daily for 6 weeks as rescue therapy or during surgical planning for severe disease 1
• Reserved for severe flares requiring intravenous antibiotics 1

Surgical Interventions

Surgical deroofing:

• Recommended for recurrent nodules and tunnels 1, 5
• Particularly effective when biologic therapy fails, with long-term remission achievable 6
• Less extensive than radical excision but effective for localized disease 1

Radical surgical excision:

• Recommended for extensive disease with sinus tracts and scarring 1, 5
• Often necessary for lasting cure in advanced disease 1, 5
• Wound closure options include secondary intention healing, skin grafts, or flaps 1
• Critical consideration: Width of excision influences therapeutic outcome 1

Treatment Algorithm After Adalimumab Failure

1. Assess disease extent and Hurley stage:

   • Document inflammatory lesion count, draining tunnels, and scarring 1, 5
   • Measure baseline pain using Visual Analog Scale 5
   • Assess quality of life using DLQI 5

2. For predominantly inflammatory disease (Hurley II-III without extensive scarring):

   • Initiate infliximab 5 mg/kg at weeks 0,2,6, then every 2 months 1
   • Reassess at 12 weeks using HiSCR (≥50% reduction in inflammatory lesions with no increase in abscesses or draining fistulas) 1, 5

3. For extensive disease with sinus tracts and scarring:

   • Refer to hidradenitis suppurativa surgical multidisciplinary team 5
   • Consider surgical deroofing or radical excision as primary intervention 1, 6
   • Biologics can be used as adjuvant therapy perioperatively 1

4. If infliximab fails or is contraindicated:

   • Consider secukinumab or ustekinumab as third-line biologics 3, 1
   • Consider acitretin 0.3-0.5 mg/kg/day (if not of childbearing potential) 1
   • Consider dapsone 50-200 mg daily 1

Essential Adjunctive Measures

Regardless of treatment choice, address these factors that impact outcomes:

• Smoking cessation: Tobacco use predicts poor treatment response and worse outcomes 5
• Weight management: Obesity strongly associates with disease severity 5
• Pain management: NSAIDs for symptomatic relief 1, 5
• Wound care: Appropriate dressings for draining lesions 5
• Comorbidity screening: Depression, anxiety, cardiovascular risk factors (BP, lipids, HbA1c), inflammatory bowel disease 1, 5

Critical Pitfalls to Avoid

• Do not continue ineffective biologics beyond 12-16 weeks without reassessment or escalation 1, 5
• Do not rely solely on antibiotics for severe disease with established sinus tracts and scarring, as surgical intervention is often necessary for lasting cure 1, 5, 6
• Do not overlook surgical options in favor of sequential biologic trials when extensive scarring and tunnels are present, as surgery may provide more durable outcomes 6
• Do not prescribe acitretin without ensuring adequate contraception in women of reproductive age due to severe teratogenicity 4
• Avoid non-specialized surgical interventions (simple incision and drainage), as these are generally unsuccessful and non-durable 6

Monitoring Treatment Response

• Reassess at 12 weeks using HiSCR, pain VAS, and DLQI 1, 5
• For infliximab, if no clinical response by 12 weeks, escalate to alternative biologic or surgical intervention 1
• Monitor for biologic-related adverse events including infections, infusion reactions, and malignancy 2