Decoding the Prescribing Decisions for Hidradenitis Suppurativa

Conversational Chart Audits via Patient Scribe

A Patient Scribe report across nine dermatology cases — what the conversation captured that a traditional patient chart would have missed, and what it means for commercial strategy in HS.

About This Report

Patient Scribe is ZoomRx’s AI-powered conversational chart audit platform. Instead of asking physicians to select from predetermined categories, Patient Scribe conducts a voice-first conversation — capturing clinical reasoning in the physician’s own words, probing when something unexpected surfaces, and structuring the output without compressing the underlying logic.

This report presents findings from Patient Scribe conversations with dermatologists managing Hidradenitis Suppurativa patients. What those conversations surfaced that a traditional PCA would have missed entirely is the subject of what follows.

WHAT THIS REPORT COVERS

• 9 patient charts collected from dermatologists via Patient Scribe
• Drugs in scope: Bimzelx · Cosentyx · Humira · Topicals · Antibiotics
• Patient profiles ranging from biologic-naive to third-line biologic switch
• Hurley Stages 2 and 3; moderate to severe disease presentations

Patients span across biologic-naive initiations, mid-therapy switches, access-driven substitutions, and one patient not yet on a biologic despite physician recommendation.

What a Traditional PCA Would Have Captured

Below is a direct comparison for two of the nine cases: what a checkbox-based PCA would have recorded versus what the Patient Scribe conversation actually revealed.

 The checkbox captures the outcome. The conversation captures the story behind it.  

What Patient Scribe Revealed

Across conversations, four distinct insight categories emerged that a traditional patient chart audit (PCA) would have flattened, missed, or misclassified.

1. Access Is Silently Overriding Clinical Preference

In two of nine cases, the prescribing physician’s stated clinical preference was Bimzelx but a different drug was dispensed. Insurance coverage, not clinical judgment, was the deciding factor. A traditional PCA records the prescription. It does not record the drug that was actually preferred.

• P1: Physician considered Bimzelx and Humira alongside Cosentyx. Selected Cosentyx based on patient access: “High patient access with Cosentyx dictated [the choice].” Bimzelx’s coverage barrier is invisible in the structured record - the dataset simply shows a Cosentyx initiation.
• P2: Physician explicitly acknowledged Bimzelx’s higher efficacy, then prescribed Cosentyx anyway: “Sometimes [Bimzelx] can be a problem with insurance coverage. So we wanted to start with Cosentyx as a first-line biologic and maybe move to Bimzelx.” The intent to move to Bimzelx and the access barrier preventing it do not appear in any checkbox.
  

 “Bimzelx could even have higher efficacy, because of coverage Cosentyx was picked. Although I think both medications work well to decrease inflammation in Hidradenitis.”
— Dermatologist, HS patient audit (P2)

2. The Urgency Signal — Scarring Drives Decisions More Than Hurley Stage

In HS, clinical urgency is not simply a function of Hurley stage. Across these conversations, physicians named the irreversibility of structural damage — scarring, sinus tract formation, permanent tissue changes — as the primary urgency driver, often independent of formal severity classification.

• P4: Patient rated moderate on exam. Physician urgency: 7 out of 10 — driven by the patient’s own distress about pain and inability to function, not the clinical score. “The patient was a little bit more concerned herself about the active areas and the pain and the inability to function.” The urgency was patient-reported, not clinician-scored.
• P5: Urgency named explicitly as “due to the scarring nature” — not because a Hurley threshold was crossed, but because the physician understood the permanence of what was happening if treatment was delayed.
• P7: “Very urgent” — Hurley Stage 3, draining sinuses and abscesses, scarring already present. Goal: reduce active sinuses before further structural damage compounds.
• P3: Urgency framed around active scarring risk despite not yet initiating a biologic. Physician anticipates the patient will eventually need one: “Long term we probably will end up on a biologic.” The scarring clock is already running.

 “Starting a biologic was urgent — due to the scarring nature, due to the overall severity of the patient.”
— Dermatologist, HS patient audit (P5)

3. Physician Confidence — Personal Experience Outweighs Trial Data

When asked what drove the biologic decision, physicians across this dataset cited two distinct sources of confidence: published efficacy data and personal clinical experience with the drug on previous HS patients. The two are not equivalent. Physicians with firsthand experience described it with specificity - speed of onset, anatomical response, patient-reported improvement - that trial summaries do not capture. When both were present, personal experience was the stronger anchor.

• P7: Personal experience named as the primary driver — listed before data: “Due to my personal experience using Bimekizumab on some of my other HS patients, and its efficacy data.” Experience first. Data second.
• P8: “Based on clinical data and just past clinical experience, I felt like Bimzelx typically has a fast onset of efficacy and durability of response.” Both cited, but experience provided the clinical specificity that data alone could not.
• P2: Cosentyx chosen in part because of physician familiarity from psoriasis patients, existing rep relationship, and available samples — all experiential factors invisible in the structured record.

 “I have used Bimzelx on quite a few other HS patients. I find that it works pretty fast. Some patients feel a difference within as soon as two weeks - improved pain, decreased inflammation, decreased number of draining sinuses and nodules.”
— Dermatologist, HS patient audit (P7)

4. The Switch Story — What “Inadequate Efficacy” Actually Means

Seven of nine patients had prior treatment experience before the current drug. In each case, a traditional PCA would record a switch reason - typically “inadequate response” or “multiple biologic failures.” What the conversation reveals is the texture underneath: which anatomical locations were still active, how long partial control was tolerated, what procedural interventions were attempted, and the cumulative reasoning that made the switch feel inevitable.

• P6: On Humira for approximately two years with partial control. Active lesions persisting specifically in the inguinal folds at follow-up visits. The inadequacy was anatomically specific and tracked over multiple visits. Kenalog injections and deroofing procedures were attempted before escalating the biologic. The structured record shows one switch. The conversation shows a clinical timeline of incremental failure.
• P9: Eight distinct treatment failures — antibiotics, topicals, Kenalog, Spironolactone, birth control, Humira, Cosentyx, Prednisone. Lesions present since teenage years. The switch to Bimzelx was not a clinical decision. It was an inevitability. A checkbox records: multiple biologic failures.

“They were on Humira and while they had some control, they were still getting some active painful lesions in their inguinal folds. So I switched them to Bimzelx in order to get better efficacy.”
— Dermatologist, HS patient audit (P6)

“It was more just this was the next logical step after all the failures patient already had.”
— Dermatologist, HS patient audit (P9)

Patient Cases and Commercial Implications

Four implications, each followed by the patient cases that validate it.

Access is the hidden barrier

COMMERCIAL IMPLICATION 
Two physicians preferred Bimzelx clinically — and dispensed Cosentyx instead. Neither case registers as a lost opportunity in prescribing data; both look like routine Cosentyx initiations. One physician has already declared intent to move to Bimzelx once the coverage barrier is resolved. That conversion is not waiting on clinical persuasion. It is waiting on patient services and formulary support. Without the conversation, neither the preference nor the path to resolve it is visible. 

PATIENT 1 — 45M, MODERATE-SEVERE STAGE 2–3, COMMERCIAL → COSENTYX

Axilla and gluteal cheeks. Obesity. First biologic. Bimzelx and Humira in consideration.

“High patient access with Cosentyx dictated” the prescription. Severity and drainage drove urgency. Bimzelx was the preferred option — access made it unavailable.

PATIENT 2 — 33F, MODERATE, COMMERCIAL → COSENTYX (BIMZELX DEFERRED ON COVERAGE)

Chest folds, inguinal folds. Multiple cysts, scarring. Obesity. Prior topicals, antibiotics, Kenalog, I&D.

Physician explicitly preferred Bimzelx for higher efficacy. Cosentyx chosen on coverage. Physician plans to transition to Bimzelx once access allows. “The risk of scarring made it more imperative to start a more aggressive treatment.”

Initiation follows patient signals 

COMMERCIAL IMPLICATION 
One patient does not appear in any prescribing dataset at all — yet the physician has already identified the biologic, discussed it with the patient, and expects it to be necessary long-term. Patient hesitance, not clinical judgment, is the barrier. For the two biologic-naive initiations, the tipping point was patient-reported functional distress and scarring risk — not a Hurley threshold. Messaging anchored in permanence and functional impact maps to this moment of decision more directly than staging-based language. 

PATIENT 3 — 24F, MODERATE-SEVERE STAGE 3, COMMERCIAL → NO BIOLOGIC YET

Bilateral axilla, groin, buttock. PCOS, pre-diabetic. Oral + topical antibiotics, corticosteroid PRN.

Physician has already discussed Bimzelx and Cosentyx with the patient. Biologic deferred because the patient is concerned about side effects and injectables. Physician expects biologics long-term. The scarring clock is running.

PATIENT 4 — 23F, MODERATE STAGE 2, COMMERCIAL, BIOLOGIC-NAIVE → BIMZELX

Axillary skin and inner thighs. Hurley Stage II. Obesity, anxiety. Brief antibiotic and topical course prior.

Physician urgency 7 out of 10 — moderate on exam. Patient had reached out herself after antibiotics failed. Inability to work, drainage, and odor were the named triggers.

PATIENT 5 — 25M, MODERATE STAGE 3, COMMERCIAL, BIOLOGIC-NAIVE → BIMZELX

New patient. Obesity, smoking. Oral + topical antibiotics only prior.

Urgency driven by scarring risk, not Hurley classification. Physician was acting to prevent structural permanence. “Their moderate to severe status warranted biologic therapy — this patient needed the best systemic therapy available.”

The switch narrative

COMMERCIAL IMPLICATION 
“Inadequate response” and “multiple biologic failures” are accurate answers - but incomplete ones. The conversation reveals the texture that changes how you respond commercially: what made a physician tolerate two years of partial control before switching, and at what point in the treatment sequence Bimzelx entered. In both cases below, the opportunity to intervene earlier was present and invisible to Rx data.

PATIENT 6 — 34F, MODERATE, COMMERCIAL, HUMIRA (~2 YRS) → BIMZELX

Axillae and inguinal folds. Obesity, smoker. Kenalog injections and deroofing prior to switch.

Two years on Humira with active lesions persisting in the inguinal folds. Kenalog injections and deroofing attempted before escalation. The structured record shows one switch. The conversation explains why it took two years to get there.

PATIENT 9 — 45F, SEVERE STAGE 3, MEDICAID, HUMIRA + COSENTYX → BIMZELX

Armpits, groin, under breasts. Lesions since teenage years. 8+ treatment failures.

Eight distinct treatment failures before Bimzelx. The switch was not an active clinical choice — it was an inevitability. Patient arrived motivated and hopeful despite an exhaustive history. “The hope was that Bimzelx would target the process rapidly and effectively.”

Experience Is the Real Driver

COMMERCIAL IMPLICATION 
Physicians who have prescribed Bimzelx in HS are already thoroughly convinced — grounded in specific patient-level observations that no trial publication replicates. The physicians defaulting to Cosentyx on access and familiarity acknowledge Bimzelx’s clinical superiority but lack firsthand experience. These are two distinct segments. The highest-value intervention is connecting them: experienced Bimzelx prescribers as peer voices for access-defaulting physicians, through structured case sharing rather than promotional outreach.

PATIENT 7 — 34F, SEVERE STAGE 3, MEDICAID → BIMZELX

Axilla and groin. Multiple draining sinuses, abscesses, scarring. Obesity, metabolic syndrome. Topicals, Doxycycline, Spironolactone all failed.

Physician confidence built on firsthand experience: onset within two weeks, specific reduction in draining sinuses and nodules. Personal experience named before efficacy data. “It’s very painful for her to even sit because it’s affecting her groin area.” The functional picture drove the urgency, not the stage.

PATIENT 8 — 43M, SEVERE STAGE 3, COMMERCIAL → BIMZELX

Axilla, groin, buttocks. Monthly flare-ups. Sinus tracts, scarring. Depression. Topical + oral antibacterials only prior.

Fast onset and durable response validated by clinical experience, not trial data alone. “She was having a lot of pain and drainage with multiple inflammatory nodules at different body sites — I wanted something with really good fast clinical efficacy where she was getting relief, but also sustained relief.”

Conclusion

The structured data is not wrong. It is structurally incomplete in ways that matter commercially. Two Cosentyx prescriptions that look routine in prescribing data were actually deferred Bimzelx prescriptions — invisible without the conversation. One patient not yet on a biologic represents a conversion waiting on patient education, not clinical indication. These are not edge cases. They are the commercial reality that checkbox formats were never designed to surface.

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