Three Oral Candidates Could Change Hidradenitis Suppurativa Care

By Daniel Okafor

Three oral candidates—povorcitinib, upadacitinib and remibrutinib—could become first- or second-line treatments for hidradenitis suppurativa (HS) if approved.

In the Dermatology Times episode “Where Oral Therapies Fit in the HS Treatment Algorithm,” clinician panel members Dr. Bush and Chao mapped where three drugs described as near approval might fit. The segment was a clinical panel discussion rather than a patient cohort study, and it reported no efficacy endpoint.

Where could the three oral drugs fit?

Dr. Bush said any of the three could serve as first-line or second-line therapy. Because response to the three candidates cannot be predicted in advance, she favored letting patients choose between an oral option and an injectable one. Neither route would be assigned by default.

Chao plans a similar approach in his own clinic. He will present oral and injectable options side by side as equal first-line choices. For him, that is a practical way to match treatment to patient preference when comparative response is uncertain.

Chao also challenged a common claim that GLP-1 medications have made patients broadly comfortable with injections. In his view, patients “remain just as resistant to injections as ever.” He believes that persistent resistance makes oral alternatives genuinely attractive.

Takeaway: Oral and injectable treatments could begin as parallel choices when individual response cannot be predicted.

Can broader access prevent advanced HS?

Dr. Bush’s immediate request was rapid approval and insurance coverage. She also wants clinicians to use the oral therapies earlier, before patients reach advanced and disabling disease stages.

The need is not theoretical. Dr. Bush said some HS patients “are truly disabled by the condition today.” In her view, more available tools could keep patients from reaching severe, disabling disease and interrupt a pattern of delayed effective care.

Chao set a more specific personal goal. He wants to prevent any patient from progressing beyond early stage 2 disease. He sees no reason patients should still advance to later-stage or stage 3 disease as the available treatment compendium expands.

The panel’s broader argument was that earlier use across the board could change the disease trajectory for the majority of patients who now face years of delay before receiving truly effective care. More choices create a chance to intervene before disability and later-stage disease accumulate.

Takeaway: Earlier access could keep more patients from reaching disabling stages of HS.

What does the psoriasis precedent show?

During the earlier era of psoriasis treatment, clinicians presented several approved drugs together, including methotrexate and adalimumab, allowing patients and clinicians to consider parallel choices from the outset.

She hopes HS therapies will follow a similar path toward early access. The intent is not to force oral drugs into a fixed position after biologics. It is to make a broader range of treatments available before severe disease develops.

That approach also reframes escalation. Rather than waiting for a standard sequence to fail, the panel favors offering more tools early and preserving the option to step up when needed. The goal is to prevent later-stage or stage 3 disease, not merely to manage it once it arrives.

Takeaway: The psoriasis precedent supports early, parallel choice instead of a rigid treatment sequence.

What should clinicians do now?

The panel’s positions can be distilled into four actions.

• Treat povorcitinib, upadacitinib and remibrutinib as potential first- or second-line choices if approved.
• Present oral and injectable therapies as equal first-line options, as Chao plans in his clinic.
• Pair rapid approval with insurance coverage and earlier use.
• Aim to prevent progression beyond early stage 2 disease and avoid later-stage or stage 3 disease.

The final episode, “Improving Early Identification and Escalation of HS,” closes with practical advice for recognizing and escalating HS sooner. That advice completes the discussion: treatment options matter only when clinicians identify disease early enough to use them and do not delay escalation.

If the three oral candidates secure approval and coverage, they could give patients more ways to begin effective treatment before HS advances into severe, disabling disease.

Takeaway: With approval and coverage, three oral options could help clinicians treat HS earlier and prevent avoidable disability.