AAD and HS Foundation Issue First Joint Hidradenitis Suppurativa Guidelines. Step Therapy Is Named the Largest Barrier.
The 37 recommendations, published Oct. 20, strongly recommend adalimumab, bimekizumab, infliximab and secukinumab for moderate to severe disease. The academy says evidence does not support insurer step therapy, which delays access to treatment.
The American Academy of Dermatology (AAD) and the Hidradenitis Suppurativa Foundation issued their first joint hidradenitis suppurativa guidelines on Oct. 20, with 37 recommendations, four strongly recommended biologics and step therapy named the largest barrier to care.
The guidelines appeared online in the Journal of the American Academy of Dermatology the same day the academy announced them. A work group of 13 experts, 12 of them board-certified dermatologists, wrote them. The AAD says more than 3 million people in the United States have been diagnosed with the disease. The recommendations apply to adults, adolescents and children aged 9 and older, and the work group used the GRADE approach with patient partners, Dermatology Times reported.
Which drugs get a strong recommendation?
Adalimumab, bimekizumab, infliximab and secukinumab are strongly recommended for moderate to severe disease, the AAD said. According to Dermatology Times, the evidence was rated moderate certainty for adalimumab, bimekizumab and secukinumab and low certainty for infliximab.
The trial data behind them, as Dermatology Times summarized the guideline: adalimumab 40 mg weekly, seven randomized trials in 733 patients, risk ratio 1.92 for HiSCR50 at week 12 (95% CI, 1.57 to 2.36); bimekizumab 320 mg every two weeks, three trials in 784 participants, risk ratio 1.67 for HiSCR50 at week 16 (95% CI, 1.31 to 2.13); and secukinumab 300 mg every two or four weeks, two trials in 724 participants, risk ratio 1.35 for both regimens. For infliximab, the authors cited unmet need in refractory disease, with the most favorable outcomes reported at 10 mg/kg every four weeks.
What is conditional, and what is advised against?
Conditional recommendations cover upadacitinib, short-term systemic steroids, topical clindamycin, resorcinol and ruxolitinib, doxycycline or tetracycline, clindamycin with rifampin, ertapenem, spironolactone, continuing adalimumab around surgery, and office procedures including deroofing, incision and drainage, excision, laser hair removal, botulinum toxin and intralesional triamcinolone, the AAD said.
The guidelines conditionally recommend against acitretin, isotretinoin, etanercept, guselkumab, risankizumab, vilobelimab, avacopan, methotrexate or azathioprine as primary treatment, and radiotherapy in children and adolescents. The evidence was judged insufficient for oral contraceptives, finasteride, weight reduction, GLP-1 drugs and specific diets.
Most of the recommendations are conditional, and head-to-head biologic trials are still missing. The firmest line in the document is about payer policy, not drug choice.
What do the guidelines say about step therapy?
The AAD release calls step therapy the largest barrier to impactful HS care and says the evidence does not support it because it delays access to appropriate treatment. Dermatology Times reports the authors found no evidence of clinical benefit and linked step therapy with treatment delays, reduced access to guideline-concordant care and worse outcomes.
The work group also asked for head-to-head trials across biologic classes, noting that three published network meta-analyses reached different conclusions on relative response rates, per Dermatology Times.
What practices should do now
Prior authorization staff can now cite a society guideline when a plan requires failed antibiotics or other steps before a strongly recommended biologic. A guideline does not bind a payer, and appeals still turn on plan policy and documentation. Our look at the quiet math of prior authorization covers how that time adds up.
Add the guideline citation to your appeal template, record disease severity and prior therapies the same way at every visit, and ask payer contacts whether their HS step requirements predate this document.
Reported, fact-checked and edited by The Script Pad's editorial staff.
This article is for professional education and does not replace clinical judgment. Treatment decisions should be based on the individual patient and current guidelines.
