Hidradenitis Suppurativa: Painful Nodules and Biologic Therapy Explained

Hidradenitis suppurativa isn't just a skin rash. It’s a chronic, painful condition that turns hair follicles into deep, recurring abscesses that leak pus, scar badly, and can make sitting, walking, or even wearing a shirt unbearable. Think of it as an internal firestorm in your armpits, groin, or under your breasts - not caused by poor hygiene, not contagious, and not something you can sweat out. It affects 1 to 4% of people worldwide, mostly women between 20 and 29, and for decades, doctors had little more than antibiotics and surgery to offer.

What Causes Those Painful Nodules?

It starts with a clogged hair follicle. The skin around it thickens, keratin builds up, and the follicle bursts. That triggers a massive immune response. Your body doesn’t fight off an infection - it attacks its own tissue. Cytokines like TNF-alpha, IL-17, and IL-23 go into overdrive, turning a small bump into a deep, painful nodule that can grow into tunnels under the skin called sinus tracts. These aren’t just pimples. They’re chronic wounds that heal poorly, reopen, and leave behind thick scars. Many patients describe the pain as constant, throbbing, and worse during menstruation or stress.

Why Biologics Changed Everything

Before 2015, treatment was a cycle of antibiotics, hormonal pills, weight loss advice, and surgery - often repeated over years. Surgery could remove affected tissue, but it didn’t stop the inflammation from coming back elsewhere. Then came adalimumab (Humira), the first biologic approved by the FDA for HS. It didn’t just treat symptoms - it targeted the root cause: TNF-alpha, the main driver of inflammation.

Biologics are made from living cells, not chemicals. They’re like precision missiles aimed at specific parts of your immune system. Unlike broad-spectrum drugs that suppress your whole immune response, biologics shut down just the overactive signals causing the damage. That’s why they work so well for HS.

The Three Biologics on the Market

Today, there are three FDA-approved biologics for HS, each with different targets and results:

• Adalimumab (Humira): Blocks TNF-alpha. Given as a weekly or every-other-week injection. In clinical trials, about 42% of patients saw at least half their lesions improve within 12 weeks. It’s been used the longest, so we know more about its long-term effects.
• Secukinumab (Cosentyx): Targets IL-17A, another key inflammation signal. Approved in early 2024. In trials, 45% of patients hit the 50% improvement mark by week 16. Many report faster relief from pain and fewer new abscesses.
• Bimekizumab (BIMZELX): The newest, approved in June 2024. It blocks both IL-17A and IL-17F - two closely linked signals. In one trial, 67% of patients saw major improvement at 16 weeks. That’s the highest rate seen so far.

These aren’t just numbers. Real patients report life-changing results. One woman on Reddit said her abscesses, which used to burst weekly, stopped completely after 6 weeks on secukinumab. Another man on MyHSteam said he could finally wear a T-shirt again after 12 years.

How Do They Compare?

Here’s how the three main biologics stack up:

Comparison of Biologic Therapies for Hidradenitis Suppurativa

Biologic	Target	Dosing	HiSCR50 at Week 12-16	Cost (Monthly, US)
Adalimumab (Humira)	TNF-alpha	40 mg weekly or every other week	41.8%	$5,800
Secukinumab (Cosentyx)	IL-17A	300 mg weekly for 5 weeks, then every 4 weeks	44.5%	$6,200
Bimekizumab (BIMZELX)	IL-17A and IL-17F	640 mg loading, then 320 mg every 4 weeks	66.9%	$6,900

Higher efficacy doesn’t always mean better choice. Adalimumab still works best for patients with heavy scarring and deep tunnels. Secukinumab and bimekizumab shine when the main problem is inflamed nodules and abscesses. Bimekizumab’s dual action gives it the edge in speed and depth of response - but it’s also the most expensive.

What Happens Beyond the Skin?

HS isn’t just a skin disease. It’s linked to heart disease, diabetes, and depression. That’s because the same inflammation damaging your skin also affects your blood vessels and metabolism.

Studies show patients on biologics don’t just get clearer skin - their blood lipid profiles improve. Triglycerides drop by over 15%, and HDL (good cholesterol) rises by nearly 9% within 6 months. That’s not a side effect - it’s proof the treatment is calming systemic inflammation. One dermatologist put it simply: “When the skin improves, the body’s overall burden of inflammation drops. That’s a win for your heart, too.”

Who Gets Biologics - and Who Doesn’t?

Not everyone qualifies. Doctors use the Hurley staging system:

• Stage I: Single or few abscesses, no tunnels. Usually treated with antibiotics or lifestyle changes.
• Stage II: Recurrent abscesses, some tunnels. Biologics are often recommended here.
• Stage III: Widespread abscesses, many interconnected tunnels. Biologics are the standard, but surgery may be needed first.

Before starting a biologic, you’ll need tests: tuberculosis screening, hepatitis B and C checks, and a heart function review. These drugs can reactivate old infections or worsen heart failure. If you’ve had cancer or multiple serious infections, you may not be a candidate.

And timing matters. Experts agree: the earlier you start biologics, the better. Once deep tunnels and scarring form, biologics can stop new lesions - but they can’t undo existing damage. Surgery may still be needed to remove scarred tissue.

Real Patient Challenges

The benefits are real - but so are the hurdles.

• Cost: Even with insurance, many patients pay $800-$1,200 a month out of pocket. Medicaid approval rates are less than half of private insurance.
• Side effects: Injection site reactions are common. Some report upper respiratory infections. Serious infections (like pneumonia or sepsis) happen in about 1 in 10 patients - rare, but life-threatening.
• Long-term commitment: Biologics don’t cure HS. You need to keep taking them. Stopping often leads to flare-ups within weeks.

Patients who succeed often combine biologics with lifestyle changes: quitting smoking (a major trigger), losing weight (even 10% helps), and managing stress. One patient on r/HS said, “The biologic gave me back my life. But I still have to watch what I eat and avoid tight clothes.”

What’s Coming Next?

The pipeline is full. Three new biologics are in late-stage trials:

• Guselkumab (targets IL-23): Shows 58% improvement in early results.
• Spesolimab (targets IL-36): Could help those who don’t respond to IL-17 blockers.
• TAK-279 (TYK2 inhibitor): A new oral option - no injections.

Researchers are also working on blood tests to predict who will respond to which drug. A 2024 study found a 12-gene pattern that predicts adalimumab response with 85% accuracy. That could mean less trial and error.

Combination therapy is another frontier. Early data shows pairing bimekizumab with surgical removal of scar tissue boosts success rates to nearly 90% - much higher than either alone.

Bottom Line

Hidradenitis suppurativa used to be a sentence. Now, it’s a manageable condition. Biologics aren’t perfect - they’re expensive, require ongoing treatment, and carry risks. But for the first time, they offer real, lasting relief. If you have moderate to severe HS, talk to a dermatologist who specializes in it. Don’t wait until your skin is covered in scars. The window to prevent irreversible damage is narrow - but it’s open.