Biologic Therapies in Hidradenitis Suppurativa: A Narrative Review of Current and Emerging Treatments

Background Hidradenitis suppurativa (HS) is a chronic, profoundly debilitating inflammatory skin disease characterized by deep-seated nodules, abscesses, and discharging sinus tracts. Its complex pathogenesis is driven by a dynamic interplay between a disrupted skin microbiome and an aberrant host immune response, resulting in the massive overexpression of pro-inflammatory cytokines, notably TNF-α, IL-1, IL-17, and IL-36. Aim To critically evaluate the clinical evidence for approved, off-label, and investigational biologic therapies for moderate-to-severe HS. Materials and Methods This narrative review was based on a search of PubMed, Google Scholar, Embase, Cochrane Library, and ClinicalTrials.gov for English language sources published between January 2016 and August 2026. The synthesis included 103 sources comprising publications, registry records, regulatory information, and selected conference reports. Clinical evidence on biologic therapies was supplemented by background literature on HS epidemiology, pathogenesis, and conventional treatment, including relevant earlier publications. Preclinical evidence was used only to explain mechanisms. Results Current evidence most robustly supports the inhibition of TNF-α and IL-17, with adalimumab, secukinumab, and bimekizumab representing the approved biologic treatment options for moderate-to-severe disease. Investigational approaches utilizing dual inhibition, such as sonelokimab (IL-17A/F) and lutikizumab (IL-1α/IL-1β), demonstrate promising clinical potential. Controlled studies of guselkumab, risankizumab, bermekimab, and spesolimab did not consistently demonstrate benefit for their primary endpoints, indicating that a strong pathophysiological rationale does not necessarily translate into therapeutic efficacy. Conclusions TNF-α and IL-17 inhibition are established biologic treatment strategies for moderate-to-severe HS. Differences between studies limit comparisons of efficacy, while long-term safety and optimal treatment sequencing require further investigation. Clinical and molecular predictors of response may help guide individualized treatment.