Choosing a first biologic for HS, as recommended by Jennifer Hsiao, M.D. | Fall Clinical Derm 2026

Dermatologists treating hidradenitis suppurativa (HS) now have three FDA-approved biologics to choose from. Deciding which one to start tends to come down to what patients want, what other health conditions they have and what their insurance will cover, according to Jennifer Hsiao, M.D., dermatologist and researcher at the University of Southern California and member of the HS Foundation.

The three drugs work in different ways. For instance, Humira (adalimumab) blocks tumor necrosis factor-alpha, while Cosentyx (secukinumab) blocks interleukin-17A (IL-17A) and Bimzelx (bimekizumab) blocks both IL-17A and IL-17F. Hsiao said a patient's age is one early factor in the choice, since the approved age ranges differ among the three.

In this process, she weighs what patients bring into the exam room. Some arrive having heard something about a specific drug and refuse to consider it. When other options are available, it may not make sense to push that drug at that visit. Other health conditions a patient has also play a role, she said.

Access is the final piece, and it is often where treatment stalls. Hsiao said timing matters because a patient's willingness to start therapy may not last through a long approval process.

“So if a patient is interested, willing to start a medication, I really want to get a medication into that patient's hands as soon as possible,” Hsiao said. “I feel like with delays, patients may be like, ‘you know what, this is more trouble than it's worth.’ You might miss kind of a window of time when they were open to starting therapy.”

Insurance formularies can also shape how quickly that happens. Hsiao said strong bridge and patient assistance programs can help fill the gap. However, she said the larger goal is to catch patients during that window, ideally when they have early moderate disease. Starting one of the three biologics at that point could help slow the disease's progression, or at least help patients feel better sooner, she said.