Everything You Should Know About Hidradenitis Suppurativa

The main symptom of HS is a painful skin breakout that commonly occurs on any of the following areas:

• armpits
• groin
• anus
• inner thighs
• under the breasts
• between the buttocks

Signs of an HS breakout include:

• red, pimple-like bumps
• pain
• deep nodules or cysts
• boils
• nodules that leak or drain

Over time if HS is left untreated, symptoms can worsen, and you may develop:

• tunnels, which are tracts or channels that connect lumps and form under your skin
• painful, deep breakouts that go away and come back
• bumps that burst and leak a foul-smelling pus
• scars that thicken
• scars that form as persistent breakouts
• infections

Lesions can come and go, but some people always have breakouts on their skin.

The following factors may worsen the condition:

• stress
• hormonal changes
• heat
• smoking tobacco products
• being overweight

Hidradenitis suppurativa vs. pimples, boils, and folliculitis

The HS bumps are often mistaken for pimples, boils, or folliculitis.

You can recognize an HS breakout because it typically causes bumps on both sides of your body that tend to return in specific locations, such as your armpits and groin.

What you eat may have an effect on your HS. Some foods may trigger flare-ups, while others can help prevent them.

While there’s currently no recommended diet for people with the disease, small studies and anecdotal evidence suggest that some may find relief by avoiding the following foods:

• dairy products, including cow’s milk, cheese, butter, and ice cream, because they may raise the levels of some hormones
• sugary foods, such as candy, soda, and boxed cereals, which may increase blood glucose and cause inflammation
• brewer’s yeast, found in products such as beer, wine, and soy sauce, because it may cause an immune system reaction in people predisposed to wheat intolerance

Some foods may help relieve the symptoms of HS, including:

• foods high in fiber, such as fruits, vegetables, and oats, which may aid in balancing hormone and blood sugar levels
• foods containing omega-3 fatty acids, such as salmon, sardines, and walnuts, because they may aid in reducing inflammation

Zinc supplements may help boost the immune system. Get more information about diet and its effect on HS.

While there’s no cure for HS, effective therapies are available. Treatment can:

• improve pain
• reduce the severity of breakouts
• promote healing
• prevent complications

Your doctor may recommend the following treatments:

• Antibiotics. These oral and topical medications can reduce inflammation, treat bacterial infections, and stop new breakouts. Your doctor may prescribe tetracyclines or a combination of clindamycin (Cleocin) and rifampin (Rifadin).
• Biologics. Biologic drugs work by suppressing your immune system. Adalimumab (Humira) is currently the only HS treatment approved by the Food and Drug Administration (FDA). Others, such as infliximab (Remicade), etanercept (Enbrel), and golimumab (Simponi), may be used as well in what is known as off-label drug use.
• Steroids. Oral or injected steroids can reduce inflammation and improve your symptoms. Low doses of corticosteroids and systemic steroids, such as prednisone, may be prescribed for people with moderate to severe symptoms. Long-term use may lead to serious side effects.
• Pain medications. Over-the-counter (OTC) pain relievers, such as acetaminophen (Tylenol) and lidocaine (ZTlido), a topical anesthetic, may help relieve discomfort caused by skin breakouts.
• Hormones. Some studies have shown hormone therapy may be as effective as antibiotics for women with HS. Antiandrogen therapy to reduce the effects of hormones, such as testosterone, may be successful. The diabetes drug metformin (Glucophage) may help people who also have metabolic syndrome. Metformin is used off-label.
• Retinoids. These medications, often prescribed for treating acne, are developed from vitamin A and may be administered orally or topically. Your doctor may prescribe acitretin (Soriatane) or isotretinoin (Amnesteem, Claravis). Retinoids are used off-label.
• Acne washes or topical medications. While these products may not clear your symptoms on their own, they may be a useful addition to your treatment regimen.
• Zinc. Some people report improvement in symptoms when they take zinc supplements.
• Laser hair removal (LHR). LHR treatment early in the disease course can halt disease progression.

Surgical options

If you have severe, recurring HS, surgery may be performed to drain or remove lesions that grow deep in your skin.

After surgery, the disease may return to the same or a different area of your body.

Surgical options include the following:

• unroofing, which cuts away the skin that covers tunnels
• limited unroofing, which removes one nodule, which is also called punch debridement
• electrosurgical peeling, which removes damaged skin tissue

Other procedures to clear lesions include radiation and laser therapy.

The bottom line

Your treatment plan will depend on the severity of your condition. You may need to try more than one therapy or change treatments over time. Learn more about treatments for HS.

Doctors commonly use the Hurley clinical staging system to assess the severity of HS and determine a treatment plan. The three Hurley stages are:

• Stage 1: single or multiple lesions (nodules and abscesses) with little scarring
• Stage 2: single or multiple lesions with limited tunnels and scarring
• Stage 3: many lesions across an entire area of the body, with extensive tunnels and scarring

Other tools that may be used to determine the severity of your HS include the following:

• Sartorius Hidradenitis Suppurativa Score, which counts and assigns scores to lesions based on tunnels, scarring, and their distance from each other
• Visual Analog Scale (VAS), which measures pain
• Dermatology Life Quality Index (DLQI), a 10-question questionnaire
• Hidradenitis Suppurativa Impact Assessment, a questionnaire that assesses the impact of HS
• Hidradenitis Suppurativa Symptom Assessment, a questionnaire that assesses HS symptoms
• Acne Inversa Severity Index (AISI), a measurement tool that assesses the severity of HS symptoms

Doctors aren’t sure what causes HS. What’s known is that HS isn’t contagious and isn’t caused by poor hygiene or any type of infection.

A family history is reported in one-third of people with the condition, suggesting that there may be a genetic link.

Some studies have looked at mutations in specific genes and found a connection to HS, but more research is needed.

Other possible causes of HS include the following:

• an overactive immune system
• being overweight
• smoking tobacco products
• having another inflammatory disease of the immune system, especially inflammatory bowel disease (IBD)
• having acne
• abnormal sweat gland development

HS usually occurs shortly after puberty, so hormones are also likely involved in the development of the condition.

Getting diagnosed early on is important to help make sure you receive effective treatment. This may prevent scarring and limitations of mobility, which can occur after ongoing breakouts.

If you suspect you have HS, it’s a good idea to see a dermatologist. They’ll examine your skin closely and may swab some of your lesions if they’re leaking fluid.

You should see a dermatologist if you develop breakouts that:

• are painful
• don’t improve within a few weeks
• appear in several locations on your body
• return often

There’s no cure for HS, but it’s possible to manage the disease so you can maintain your quality of life.

Your doctor may prescribe topical and oral medications to help reduce inflammation and relieve your pain.

You may have to make regular visits to your doctor for treatment. In some cases, you may need injectable medications that only your doctor can administer.

Flare-ups of HS can last for a couple of weeks. You may experience more pain during these flare-ups. It’s important to take any prescribed medications to help relieve this discomfort and resolve the flare.

Although flare-ups are generally unpredictable, possible triggers may include:

• stress
• hot weather
• foods containing dairy or sugar

Some people experience flare-ups before their menstrual periods.

When nodules burst and the fluid inside them leaks out, an unpleasant odor may be released. Gently washing the area with an antiseptic soap can remove the smell.

In some cases, wearing loose clothing that doesn’t rub against the nodules can also help.

Find out what you should ask your doctor about living with HS.

Risk factors that may increase your chances of developing HS include:

• being assigned female at birth
• taking certain medications
• being overweight or having obesity
• having a family history of HS
• being between ages 20 and 39 years
• having severe acne, arthritis, IBD (such as Crohn’s disease), metabolic syndrome, or diabetes
• being a current or past smoker
• having a lower socioeconomic status

According to research, HS occurs more frequently in African American people compared with other ethnic groups. One reason for this may be health inequities.

If you have HS, it’s important to be screened for other conditions, such as:

• diabetes
• depression
• skin cancer

You may be at higher risk for these.

Untreated or severe cases of HS can cause complications, such as:

• Scarring. Scars can form where breakouts heal and then reappear. They can thicken over time.
• Immobility. Painful sores and scars may restrict your movement.
• Infection. Areas of your skin that drain or ooze can become infected.
• Lymph drainage problems. Bumps and scars typically occur on areas of your body that are near lymph nodes. This can affect lymph drainage, which may cause swelling.
• Skin changes. Certain areas of your skin may darken or appear pitted.
• Depression. The skin breakouts and unpleasant odor from drainage can lead to self-induced social isolation. As a result, some people may become depressed.
• Fistulas. The healing and scarring cycle that’s associated with HS breakouts can cause hollow passages, known as fistulas, to form inside your body. These can be painful and may require surgery.
• Skin cancer. Although very rare, some people with advanced HS have developed a type of skin cancer known as squamous cell carcinoma on areas of the skin where they had recurrent breakouts and scarring.

To better manage HS, making some key changes in your lifestyle may be helpful and necessary.

Quitting smoking

Up to 90 percent of people with HS are current or former cigarette smokers. Nicotine may create plugs on the skin’s follicles.

If you’re currently a smoker, consider talking with your doctor about smoking cessation and other supportive resources that are available to help you make an informed decision that’s right for you.

Maintain a moderate weight

According to a 2019 article, more than 75 percent of people with HS have overweight or obesity.

Some research has shown that people who worked toward achieving and maintaining a moderate weight experienced improved symptoms or remission.

Try bleach baths

Taking bleach baths may help remove bacteria that colonize on your skin. To make a bleach bath:

1. Add approximately 1/3 teaspoon of 2.2 percent household bleach for every 4 cups of water in your bath.
2. Soak in the bath for 10–15 minutes, keeping your head above water.
3. After your bath, rinse in warm water and pat yourself dry with a towel.

Living with HS can be challenging, but effective therapies may help reduce pain and improve your condition.

Improved treatment options may soon be available as scientists continue to conduct research, in preparation for developing new breakthroughs.