A groundbreaking study presented at the Society for Pediatric Dermatology Annual Meeting reveals that adalimumab shows superior drug survival compared to infliximab in pediatric patients with hidradenitis suppurativa, marking a significant departure from findings in adult populations where the opposite has been observed.
The research, conducted by investigators at Duke University School of Medicine, examined factors associated with drug survival of these two TNF-α inhibitors in pediatric hidradenitis suppurativa patients. The findings challenge existing treatment paradigms and suggest age-specific considerations may be crucial for optimizing biologic therapy selection.
Contrasting Pediatric and Adult Treatment Responses
The study's most striking finding was the superior performance of adalimumab over infliximab in pediatric patients, which directly contrasts with previous research in adults. According to the researchers, this difference may be attributed to pediatric patients developing antidrug antibodies to infliximab earlier than adult patients.
"A study in 2021 conducted by Trotta et al that compared the development of antidrug antibodies to infliximab and adalimumab in adult and pediatric patients with rheumatologic conditions found that pediatric patients developed antidrug antibodies to infliximab earlier than adult patients," explained the research team. "The development of earlier antidrug antibodies to infliximab may be one of the reasons for the difference we observed."
Impact of Prior Biologic Exposure
The study demonstrated that biologic survival was significantly higher in biologic-naïve pediatric patients compared to those who had previously received biologic therapy. This finding has important implications for treatment sequencing and highlights the critical importance of sustained insurance coverage and timely access to dermatologic care.
The development of antidrug antibodies to TNF-α inhibitors like adalimumab and infliximab can diminish therapeutic efficacy when patients discontinue and reinitiate these medications. To combat this issue, physicians often prescribe methotrexate concurrently with TNF-α inhibitors.
Additionally, patients switched from one biologic to another may have more severe or extensive disease that didn't respond adequately to initial treatment. The researchers noted that gluteal involvement was associated with lower drug survival in their study, suggesting that disease location and severity may influence treatment outcomes.
Addressing Diagnostic Delays Through Education
Parallel to their drug survival research, the Duke team developed an educational module aimed at raising awareness and destigmatizing hidradenitis suppurativa among children. This initiative addresses a critical healthcare gap, as the average diagnostic delay for hidradenitis suppurativa is 10 years.
The educational program focuses on teaching children to identify core signs and symptoms: "recurrent painful lumps under the skin in areas where the skin can rub together (under the breasts, under the armpits, around the buttocks, where your legs meet your body, and the lower abdomen/pubic region). These lumps can drain pus and leave scars."
Factors Contributing to Diagnostic Challenges
Several factors contribute to the lengthy diagnostic delays in pediatric hidradenitis suppurativa. The condition is frequently misdiagnosed as other cutaneous diseases such as acne, folliculitis, ingrown hairs, abscesses, and cellulitis. Contributing factors include lack of awareness among both patients and healthcare professionals, long wait times for pediatric dermatology consultations, and reluctance to seek medical care due to stigma surrounding the condition's involvement of sensitive body areas.
The educational initiative specifically emphasizes that hidradenitis suppurativa is not contagious and is not caused by poor personal hygiene, addressing common misconceptions that contribute to patient stigma and delayed care-seeking.
Clinical Implications and Future Directions
Based on their findings, the researchers suggest that earlier diagnosis of hidradenitis suppurativa and initiation of adalimumab therapy may be associated with superior adalimumab survival in pediatric patients. However, they emphasize that further research is needed to investigate whether early biologic management improves quality of life by minimizing disease-associated morbidity and mortality.
Future research directions include comparing drug survival between brand name TNF-α inhibitors and biosimilar drugs in both pediatric and adult patients. As novel biologic therapies targeting different pathways, such as IL-17, IL-12/IL-23, and Janus kinase inhibitors, become available for hidradenitis suppurativa treatment, comparative effectiveness studies will be essential.
The researchers conclude that identifying differences in drug survival and efficacy between pediatric and adult patients will help physicians better tailor treatment recommendations based on patient age and disease severity, ultimately improving outcomes for this challenging condition.
