Hidradenitis suppurativa (HS) is a highly prevalent and morbid inflammatory skin disease with limited treatment options. The major cell types and inflammatory pathways in skin of HS patients are poorly understood. In addition, it is currently unknown which patients will respond to TNFα blockade. Herein, we comprehensively elucidate and functionally define the immune cell infiltrate and major inflammatory pathways in HS skin, before and after anti-TNFα therapy. We discovered that clinically and histologically healthy appearing skin (i.e., nonlesional skin) is dysfunctional in HS patients with a relative loss of immune regulatory pathways. At the cellular level, HS skin lesions were characterized by quantitative and qualitative dysfunction of type 2 dendritic cells (cDC2s), relatively reduced regulatory T cells (Tregs), an influx of memory B cells and a plasma cell/plasmablast infiltrate predominantly in end-stage fibrotic skin. At the molecular level, there was a relative bias towards the IL-1 pathway and type 1 T cell responses when compared to both healthy skin and skin from psoriasis patients. Anti-TNFα therapy significantly attenuated B cell activation with minimal effect on other inflammatory pathways. Finally, we identified an immune activation signature in skin prior to anti-TNFα treatment that correlated with subsequent lack of response to this modality. Taken together, our results reveal the fundamental immunopathogenesis of HS and provide a molecular foundation for future studies focused on stratifying patients based on likelihood of clinical response to TNFα blockade.
Margaret M. Lowe, Haley B. Naik, Sean Clancy, Mariela Pauli, Kathleen M. Smith, Yingtao Bi, Robert Dunstan, Johann Gudjonsson, Maia Paul, Hobart W. Harris, Esther A. Kim, Uk Sok Shin, Richard Ahn, Wilson Liao, Scott L. Hansen, Michael Rosenblum