Upadacitinib for Severe Refractory Hidradenitis Suppurativa After Failure of Multiple Systemic Therapies: A Case Report.

Hidradenitis suppurativa (HS) is a chronic inflammatory dermatosis characterized by recurrent nodules, abscesses, draining sinus tracts, and substantial impairment in quality of life. Management of severe, refractory HS remains challenging, particularly in patients with inadequate response to systemic antibiotics and biologic therapies. Increasing evidence supports the involvement of the Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathway in HS pathophysiology, highlighting JAK inhibitors as potential therapeutic alternatives. We report the case of a 64-year-old man with severe Hurley stage III HS involving axillary, inguinal, intergluteal, abdominal, and truncal regions, with extensive inflammatory activity, chronic pain, and marked functional limitation. Relevant comorbidities included folliculitis decalvans, chronic kidney disease stage G3b, anemia, hypoalbuminemia, and malnutrition. The patient had an inadequate response to multiple prolonged systemic antibiotic regimens, adalimumab therapy for six years with subsequent secondary failure, and secukinumab, which was discontinued because of clinical worsening. Due to progressive disease and the absence of effective therapeutic alternatives, treatment with upadacitinib 15 mg once daily was initiated after careful risk-benefit assessment and informed consent. Progressive and sustained clinical improvement was observed, including a reduction in inflammatory lesions, pain, purulent drainage, and functional impairment. The International Hidradenitis Suppurativa Severity Score System (IHS4) decreased from baseline values of 127-145 points to 20 points during follow-up. Treatment was well tolerated, and no significant adverse events were documented. This case highlights the potential role of upadacitinib as a therapeutic alternative in severe, refractory HS after failure of conventional systemic and biologic therapies and supports the need for further studies to better define the efficacy and safety of JAK inhibitors in the management of HS.