Treatment Sequencing With Biologic Switching, Staged Excision, and Split-Thickness Skin Grafting for Extensive...

Treatment of extensive multiregional hidradenitis suppurativa requires sequencing biologic therapy and surgery when active inflammation and irreversible structural disease coexist. A 58-year-old Japanese man with Hurley Stage III disease had inadequate overall control with adalimumab. At the assessment before medial-thigh surgery, the International Hidradenitis Suppurativa Severity Score System score was 48. Because he sought prompt relief from painful drainage and daily wound care, bilateral scarred and tunnel-bearing lesions were excised and reconstructed by staged split-thickness skin grafting while adalimumab was continued. Local control was achieved, but disease persisted elsewhere, prompting a switch to bimekizumab. Inflammatory lesion counts decreased, but Hidradenitis Suppurativa Clinical Response was not achieved at week 16 and extensive gluteal scars and draining tunnels remained. Bilateral gluteal excision and staged grafting were therefore performed during continued bimekizumab treatment, without postoperative infection, bleeding, or graft failure. Six months after reconstruction, the severity score was 9 and the clinical response criterion was met, reflecting both decreased inflammatory activity during bimekizumab treatment and surgical removal of structural lesions. Gluteal local control persisted through 15 months. This case illustrates sequencing biologic switching and regional surgery according to inflammatory activity, persistent structural disease, and the need for prompt symptom relief.