LOSS OF EFFICACY OF ADALIMUMAB IN HIDRADENITIS SUPPURATIVA: FOCUS ON ALTERNATIVES.

The loss of efficacy of adalimumab, one of the most commonly used biologics for the treatment of hidradenitis suppurativa/acne inversa, is not news to the scientific community, and it should be noted that the number of cases not responding to this agent has been progressively increasing in recent years. We present a 45-year-old patient with hidradenitis suppurativa/acne inversa (Hurley II-III) with a complaint duration of 3 years who has been on adalimumab 40 mg weekly for 9 months. The lack of improvement in the clinical condition as well as the progression of the disease within the ongoing biologic therapy led to the need for repeated hospitalizations and the additional introduction of intravenous treatment with a regimen of antibiotics (Ertapenem, Metronizadol, Ceftriaxone), zinc, colchicine, and pain relievers. During these hospitalizations, a partial improvement was found, which was not durable and required the parallel administration of antibiotics, colchicine and zinc in combination with adalimumab in an outpatient regimen. Several attempts at surgical treatment/incision in non-specialized units were also made, and these too remained generally unsuccessful or with a nondurable, unsatisfactory clinical outcome. Due to the subsequent consecutive worsening of the symptomatology, the patient was admitted for evaluation of the clinical condition and optimization of treatment. Surgical treatment was performed by surgical deroofing under general anaesthesia, concurrent with discontinuation of adalimumab/antibiotic application and long-term remission was achieved. Surgical deroofing has also been shown to be an effective therapeutic option in the loss/lack of efficacy of adalimumab in patients with hidradenitis suppurativa (Hurley II-III). In the case of therapeutic resistance or worsening of symptomatology in patients with acne inversa within adalimumab therapy, other advanced alternatives such as golimumab, anakinra, etanercept are available. The efficacy of these second-line agents is also questionable due to the development of resistance to them as well, which in turn necessitates the frequent switch to third-line agents such as: Ustekinumab, Tildarkizumab, Certolizumab or Ixekizumab. The future will show to what extent this "trust" could be justified and whether in practice the surgical approach will once again displace the so-called "modern options" as the reasonable next basic and reliable alternative. The disadvantage of modern biological therapy is mainly due to the loss of efficacy/development of resistance over time, multiple side effects and frequent recurrence after discontinuation of treatment. In contrast, in the case of specific, stage-oriented, specialized surgical treatment of hidradenitis suppurativa/ acne inversa, in the form of surgical deroofing, for example, the results are long-lasting and in the case of recurrences: the latter are much more easily managed by dermatosurgery/surgery again. The effect achieved after this type of manipulation is essential for the patients' quality of life and guarantees to a large extent also prevention of the development of keratinocyte tumours in the areas affected by chronic inflammation. Precisely because of the aforementioned facts, in a serious number of patients this type of treatment could be considered as a priority. The rethinking of the guideline and the staging of surgical modalities as first-line therapy could, in a serious number of patients, have a positive effect. Swap for surgery seems to be a good alternative.