It’s the ultimate catch-22: Hidradenitis suppurativa (HS), a chronic inflammatory skin condition characterized by lesions that form under the skin, starts in the hair follicles. So you'd think having less hair would help. But once HS develops, the hair-removal process can become a real pain.
To fully understand this conundrum, here is a quick recap of how hair normally grows from the skin: It all starts at the root (aka a bulb under the surface of skin made of a bunch of hair follicle cells), which is at the very bottom of the follicle. Blood vessels feed the root with nutrients so that more cells are created. As the bulb is fed, hair forms and gets pushed up through the skin, passing an oil gland along the way to help the process run smoothly.
With HS, however, inflammation develops around the upper portion of the hair follicle, which likely leads to rupture and sometimes blockage of the follicular opening. Experts aren’t definitively sure why, but this hair growth disruption and malfunction creates painful nodules and abscesses that may leave behind “tunnels” under the skin. Hair removal techniques vary in how they interrupt the normal process of hair growth and can potentially trigger trauma and inflammation in some patients. If you have HS, you need to be extra careful on how you deal. We tapped the experts to find out which forms of hair removal are best for folks with HS. Keep reading for the rundown.
The Technique: Waxing
The first step in waxing, which is typically done in a salon or spa, is to slather hot wax onto the skin. Next, a piece of cloth is pressed and adhered over the wax. The hair removal tech then pulls off the piece of cloth, with the wax and hairs stuck to it. In a normal situation, waxing leaves the skin smooth and fuzz-free for four to six weeks.
The HS Verdict: Waxing is a major no-go because it can exacerbate the HS and result in even more irritation and lesions, says Sejal Shah, M.D., a dermatologist who teaches at Mount Sinai St. Luke’s Roosevelt Hospital Center in New York City. Plus, it can put one at greater risk for infection because if it’s not done properly and the whole hair isn’t removed, a sharp fragmented hair can get trapped in the skin and leave an opening for bacteria to get inside.
“It ultimately does more harm than good as the hot wax can inflame the symptoms and further irritate the skin,” says Adam Friedman, M.D., professor of dermatology at George Washington University in Washington, D.C., explains.
Currently, no studies have evaluated the effects of waxing on HS. Since all patients with HS are different it is possible that some patients with HS can wax without any problems, but caution is recommended.
The Technique: Shaving
When you shave, you’re cutting the hair away from the surface of skin using a razor and an emollient product, such as shaving cream. Unlike waxing, shaving doesn’t remove the hair from the root, which is why hairs tend to grow back quickly and sometimes thicker-looking.
The HS Verdict: When it comes to shaving with HS, Dr. Friedman says it’s one of the safer options out there. But you still must be extremely careful when doing so, as he explains that any injury to the skin—say, a razor nick—can result in a new lesion or possible infection. “I recommend my patients with HS take basic measures, such as cleaning the area with antibacterial soap first, to avoid worsening the disease,” says Dr. Friedman. “This helps prevent bacteria from being pushed into the skin, which causes more irritation,” he adds. Dr. Friedman recommends Hibiclens Liquid, which is also commonly referred to as chlorhexidine wash. He says you can also use a bacterial hand soap to cleanse the area but would avoid using alcohol as it can be harsh and irritating on the skin.
Another tip: Use a gel-to-foam shave gel rather than a traditional foaming formula as it’s less irritating, says Dr. Friedman. You can even use a thin layer of moisturizer before shaving, too, because this softens the skin around the follicle and helps protect it. “Anything you can do to limit how the blade catches the skin will be beneficial,” he explains.
Shaving has also not been properly studied with regard to its impact on HS. Some patients may be sensitive to shaving trauma to the skin so it is important for individuals to be mindful of it as a personal trigger if they notice a pattern of flaring after shaving.
The Technique: Laser Hair Removal
Laser hair removal uses light energy, which is converted to heat when it interacts with the pigment in hair, to literally damage the hair follicles and inhibit or postpone future hair growth. People who want significantly less hair growth—to the point where they can stop shaving—tend to be fans of this method as some can achieve permanent hair reduction. Following each treatment the hair is typically completely removed, and about 10-15% is permanently destroyed. The remaining 85-90% grows back about 3-4 weeks later. As more treatments are performed this permanent reduction becomes more significant. It can take more than 10 treatments to have less than 5% of the starting hair, but most studies show that even partially reducing the hair with 4 treatments leads to improvement in disease activity. There can be some discomfort during treatment, but it is performed with patients that are awake and there is no recovery needed after.
The major downside to laser hair removal is that it can cost roughly $200-$300 per session and is near impossible to get covered by insurance—even if you have HS—as it’s considered cosmetic and not medically necessary.
The HS Verdict: While it’s the costliest of the bunch, dermatologists say that laser hair reduction is your best bet if you have HS, partly because it goes beyond basic hair removal. “I generally recommend that patients consider laser hair removal as there are studies that show this modality can not only remove the hair but also treat the condition and prevent recurrences,” explains Dr. Shah.
For instance, it’s shown to be an ideal treatment option for those with moderate and localized HS because it’s a minimally invasive method of removal that’s able to reduce the number of hair follicles lesions that act as potential sites of inflammation. It also doesn’t come with any worrisome complications that could make the condition worse, and it offers a rapid post-treatment recovery. What’s more, Dr. Friedman says it can be helpful at managing the disease because lasers have a pre- and post-cooling option that soothes active lesions before and after treatment, and may prevent new ones from forming.
One caveat when it comes to laser-hair removal: Not everyone is the most ideal candidate. For instance, Dr. Friedman says it’s not as suitable for those with blonde and gray hair because there’s no pigment to absorb the energy from the laser. For those with dark skin tones, he says there are specific technologies, like the long-pulse Nd: YAG laser, that are safe because the wavelength can kill off dark, coarse hairs without destroying the skin’s pigment. Both experts recommend visiting a dermatologist to have the procedure done, as they’re most likely clinically trained and will be able to tell you whether it’s a viable option for you.
The Technique: Trimming
Trimming is a hair removal technique that generally involves using scissors or an electric body trimmer to tame extra-long or unruly hairs. Similar to shaving, it’s not going to pluck the hair from the root but rather just cut it close to the surface of the skin, so the hair is less noticeable. Trimming tends to be more common in males who want a way to manage their facial hair without shaving, but it’s safe and easy enough for anyone to do.
The HS Verdict: Dr. Shah is a fan of trimming as it’s less invasive. “Trimming the hair with electric trimmers or fine scissors is usually a safe option,” she says, adding that you should still use an antibacterial cleanser with some slip to it before and afterward to keep the area free of infection-causing bacteria.