Board-certified dermatologists and hidradenitis suppurativa patients share their favorite grooming and odor control products.

Odor Control

The best bras and underwear for HS patients that won’t hurt or irritate sensitive skin, even during a flareup.

HS Bras and Underwear

woman wearing silver underwear sitting on floor

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When you have a painful skin condition, the only thing you want next to your body are soft fabrics and painless seams. These intimates pass the test.

The Comfiest Bras and Underwear that Won't Irritate Your HS

Comfortable Bras and Underwear that Won't Irritate Your HS

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Hidradenitis suppurativa can be a smelly condition. These HS-safe finds help soothe skin while controlling odor.

The Top HS Odor Fighters

Top Grooming and Odor Control Products for HS

But First, Why Does HS Smell?

Head-to-Toe Cleanser: Hibiclens Skin Cleanser ($20, [amazon.com](https://www.amazon.com/Hibiclens-Antimicrobial-Antiseptic-Cleanser-Cleansing/dp/B00EV1D79A))

Lotion-Booster: Young Living Tea Tree Oil ($35, [youngliving.com](https://www.youngliving.com/en_US/products/tea-tree-essential-oil))

Skin Cooler: Vicks Vapoprub ($10, [amazon.com](https://www.amazon.com/Vicks-VapoRub-Ointment-1-76-Ounces/dp/B000GCHOEM))

Chemical-Free Deodorant: Lavanila “The Healthy Deodorant" ($12, [lavanila.com](https://www.lavanila.com/products/the-healthy-deodorant-pure-vanilla))

Gentle Shaver: Philips Norelco OneBlade Hybrid Electric Trimmer and Shaver ($35, [amazon.com](https://www.amazon.com/Philips-Norelco-OneBlade-QP2520-90/dp/B01D328BG6))

Skin-Softening Deo: The Mama Au Deodorant ($11, [themamaau.com](https://themamaau.com/products/bentonite-manuka-honey-natural-deodorant))

On-the-Go Wipes: Burt's Bees Sensitive Skin Wipes ($5, [amazon.com](https://www.amazon.com/Burts-Bees-Sensitive-Cleansing-Towelettes/dp/B008HBMQTM))

Sweat Stopper: Primally Pure Charcoal Deodorant ($16, [primallypure.com](https://primallypure.com/products/charcoal-deodorant))

Getting a Handle on HS

Vincent Nguyen and Starla Mathis

HS is not an easy condition to live with: It's painful. It's often embarrassing. And it can even be disfiguring. Even worse, most people have no idea what it even is. We'll answer all of your questions so you can be sure to get the treatment, advice, and support you need.

Getting a Handle on Hidradenitis Suppurativa

The truth is that it’s hard to avoid hidradenitis suppurativa complications. Also true? You can minimize these complications, and maybe even prevent further progression.

HS Complications

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The truth is that it’s hard to avoid hidradenitis suppurativa complications. Also true? You *can* minimize these complications, and maybe even prevent further progression.

9 Common HS Complications (and How to Calm Them)

- __Scarring and HS:__ *Journal of the American Academy of Dermatology*. (2016). “A qualitative study of hidradenitis suppurativa: Scars matter, not just active disease.” [ncbi.nlm.nih.gov/pmc/articles/PMC5516792/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5516792/)
- __Depression and HS:__ *Journal of Investigative Dermatology*. (2018). “Patients with Hidradenitis Suppurativa Have a High Psychiatric Disease Burden: A Finnish Nationwide Registry Study.” [jidonline.org/article/S0022-202X(17)31856-0/fulltext](https://www.jidonline.org/article/S0022-202X(17)31856-0/fulltext)
- __HS and Comorbidities:__ *Clinical, Cosmetic and Investigational Dermatology*. (2017). “Hidradenitis suppurativa: from pathogenesis to diagnosis and treatment.” [ncbi.nlm.nih.gov/pmc/articles/PMC5402905/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5402905/)


9 Common HS Complications (and How to Keep Them From Getting Worse)

Infection

Scarring

Immobility

Genital Swelling

Skin Discoloration

Skin Pitting

Skin Cancer

Comorbidities

Depression

*If you've been diagnosed with hidradenitis suppurativa (HS), you're probably wondering, "What can I do to feel normal again?” The good news is that this chronic (meaning lifelong) skin condition can be managed so you reduce the pain and discomfort of the oozing bumps that appear under the skin, usually in the armpits, genitals, groin, buttocks, or under breasts. But there’s no cure for this disease—or even an explanation as to what is causing those lumps to appear in the first place. Annoying, we know. So the goal of treatment will vary depending on your stage. If you’ve got a mild case, you’ve got a good shot at reducing flares until they’re no longer coming back. If your case is more advanced, then the goal is to manage the pain and the constant draining of pus and other fluids, as well as slow down the disease’s progress so it’s no longer controlling your life. Wherever you are in your HS treatment journey, you’re sure to have questions. We’re here to answer them.*

## What Is HS, Again?

While doctors still don’t understand what causes the painful, recurrent lesions to form, the best guess at the moment is that there seems to be some kind of defect in the hair follicles on your body. In HS, inflammation develops around follicles and causes them to eventually break open. This releases the hair shaft and normal bacteria from the follicle under the skin, which leads to more inflammation. For some reason—maybe because of faulty genes or some type of environmental trigger like hormones or chemicals—your immune system gets reprogrammed to attack these ordinarily friendly bacteria. The resulting inflammation makes it easier for bacteria to proliferate, which causes more inflammation and pus-filled nodules that look like boils.   

Left to run their course, these nodules grow, swell, and burst over the span of a week or two, spilling foul-smelling blood and pus from deep in the skin, staining your clothes. All you know is that these lesions hurt like heck and take a long time to heal. In mild cases, or early in the disease, people tend to have solitary nodules mainly in one area. Stage 1 is nodules coming and going without scar or tunneling. Stage 2 is when the presence of one or a few widely separated tunnels in one or multiple body areas, and 3 widespread and/or interconnected tunnels or scarring in one or multiple body regions. Stage 1 can be in multiple body areas, and stage 3 can be in only one body area. 


Learn more about symptoms, diagnosis, and what it's really like to live with HS. 

Get All the Details on Hidradenitis Suppurativa

## What Is the Best Treatment for HS?

It depends. Doctors try a combination of medical treatments and sometimes surgery depending on the type of nodules you have, how severe they are, and where they're cropping up on your body—with the understanding that what works for one person may not work for you. What’s more, HS doesn’t just affect your skin. It’s an inflammatory condition, which means there are a wide range of illnesses that often occur with it (called comorbidities)—like inflammatory bowel disease (IBD); spondyloarthritis (SpA), a form of arthritis that causes back pain; anxiety and depression; and metabolic syndrome, a cluster of risk factors that include obesity, high blood pressure, and high cholesterol that ups your risk of diabetes, strokes, and heart disease. That’s why it’s important to get a whole team of pros that can help you get everything under control—your body, skin, and soul.

## What Medications Are Available for HS?

You will probably be on several of these medications, including the topicals, as you and your dermatologist find a way to manage your HS. Expect some trial and error. Medications can work at first, then stop working after a while, which may mean trying another, stronger one in that group (antibiotics, say). Or you may hit upon the perfect combo from the get-go. Sometimes the research on how well some of these medications perform is based on small studies and anecdotal evidence (meaning reports from patients and doctors), or your doctor’s own personal experience with HS patients. It’s tough but try to be patient—eventually you and your team of docs will find the right meds (or close to it) for you. 

### Topicals for Hidradenitis 

Your doctor will probably suggest you use an antiseptic body wash as well as antibacterial ointment on your nodules to control inflammation and reduce the number of bacteria on your skin. If you only have a few nodules in one area of your body, then these ointments and soaps can reduce flares to the point of remission, especially if you have [laser hair removal](https://www.healthcentral.com/article/hair-removal-techniques-for-hidradenitis-suppurativa) beforehand.

__Antiseptic washes:__ They usually contain antibiotics chlorhexidine or benzoyl peroxide (which seems to be particularly effective), and you’ll use one every day on the parts of your body affected by HS. They can break up the sticky layer of bacteria that attaches to the nodules, called a [biofilm](https://www.healthcentral.com/article/biofilms-and-hs). Available over the counter, they can help control the smell from the nodules as they drain, and also prevent flare-ups. 

Common washes include:

- Oxy 10, PanOxyl Creamy Wash (benzoyl peroxide)
- Hibiclens, Betasept (chlorhexidine)

__Antibiotics:__ If your nodules are painful and swollen, then your doctor will prescribe an antibiotic ointment or lotion to put on twice a day. Topical antibiotics are used during acute flares to reduce pain and inflammation, whether you have a mild or moderate case. The most effective antibiotic lotion is clindamycin (Cleocin).

__Keratolytics:__ These exfoliants help break up and loosen skin cells to reduce the size and pain of nodules in stage 1 and 2 cases of HS. Resinol (resorcinol) is commonly prescribed.  

### Systemic Medications for HS

Your doctor may put you on one or several systemic medications—meaning oral or IV drugs that affect your whole body, not just the nodules themselves (like the topicals do). These include antibiotics, hormonal therapy (birth control pills, say) and biologics. Each does different things, but the goal of each is to reduce flares and pain—and, depending on which stage you’re in—even put the disease into remission. Which drug you take depends too on your other conditions. For instance, if you have polycystic ovary syndrome (PCOS) or some sort of hormonal imbalance, a doctor will probably put you on an androgen-blocker since that hormone seems to play a role in both conditions.  

### Antibiotics

Bacteria may not cause HS, but they can make it worse, and oral antibiotics are given to help diminish their numbers when you have multiple active nodules. Doctors also prescribe them to reduce inflammation and stabilize the condition, and, when you have a severe case of HS, to keep the pain and draining pus from getting worse before starting surgery or a more heavy-hitting med like a biologic. 

Your dermatologist may start you on one antibiotic, usually in the __tetracycline__ family (doxycycline or minocycline), if your HS is mild but topical antibiotics aren’t controlling it well. For more moderate or severe cases, you may take a combo of __clindamycin with rifampicin__ for at least 10 weeks—French researchers found that 300 mg of clindamycin along with 300 mg of rifampicin twice a day together improved the symptoms and quality of life for 82% of the HS patients in the study. 

Antibiotics come with caveats, though. Unlike ordinary bacterial infections, the antibiotics don’t clear up the condition forever. At best, they manage it until you stop taking the meds. Second, you take strong doses of these drugs for weeks and sometimes months, which can give you such side effects as diarrhea, nausea, and yeast infections. And finally, doctors are wary of using them long term, as bacteria can become resistant to them. Both surgery and biologics are better solutions in the long run.

Commonly prescribed antibiotics include:

- Sumycin, Brodspec, Tetracon (tetracycline) 
- Adoxa, Monodox, Periostat (doxycycline)  
- Dynacin, Minocin, Myrac (minocycline) 
- Cleocin (clindamycin)
- Cipro, Ciloxin, Cetraxal (ciprofloxacin) 
- Rifadin, Rimactane (rifampin)
- Flagyl (metronidazole)

### Hormone Therapy

Even though people with HS tend to have normal hormone levels, experts believe that androgens, the male sex hormones that include testosterone, play a role. The clues: Some female HS patients also have PCOS (another condition driven by abnormal hormones); HS usually begins after puberty (most often in your 20s and 30s) and seems to taper off after 50 when menopause hits (but not always). That’s why your doctor may put you on an androgen-blocker if your flare-ups get worse right before or during your period or you have irregular cycles. 

If you’re a guy losing hair in what’s called male-patterned balding (thinning on the crown with a receding hairline), you might also be a good bet for hormone therapy—it’s a sign your hair follicles are sensitive to DHT, a type of testosterone. While there’s not a lot of evidence backing their use in hidradenitis, androgen-blockers can improve or even clear up mild to moderate cases, either by themselves or in combination with other medications (like topicals). 

Anti-androgens include:

- Birth control pills, with a high estrogen-to-progesterone ratio given only to women
- Aldactone or CaroSpir (spironolactone), blood pressure medications, usually given to women 
- Propecia or Proscar (finasteride), meds used to shrink the prostate in men (used to re-grow thinning scalp hair to help normalize the use of these drugs for something other than treatment of prostate issues) 

### Retinoids

These oral acne-fighting meds can shrink oil glands and reduce the number of bacteria in both the oil glands and on the skin, and dermatologists have been prescribing them for people with acne for years. But the evidence for how they work on HS is mixed. Nearly two-thirds of HS patients had no response when they took the retinoid isotretinoin, according to one review study. Acitretin, another retinoid, might be a better bet for improving outbreaks and pain, even though the evidence behind it is based on small sample-size studies. And if you’re a woman between the ages of 20 and 40, you may not want to take retinoids at all, as they can cause birth defects if you get pregnant.

The most commonly prescribed retinoids are:

- Amnesteem, Claravis, Sotret, Absorica (isotretinoin) 
- Soriatane (acitretin) 

### Metformin

This drug treats high blood sugar, and your dermatologist may prescribe it if you show signs of prediabetes—or the potential to develop it—like if you have a high BMI and your lab tests come back showing higher-than-normal glucose levels. The goal with metformin is two-fold. It’ll reduce insulin resistance and lower your risk of developing type 2 diabetes and, later, heart disease. And the drug can also decrease the number of nodules and may even put you in remission. How so? Uncontrolled insulin levels can fuel inflammation, so reducing its levels can also affect flares. In one small study, two-thirds of HS patients showed improvement and 19% of those went into remission. Common brand names include __Fortamet__, __Glucophage__, __Glucophage XR__, __Glumetza Riomet__. 

### Biologics

Biologics are used in a variety of autoimmune disorders to control different types of proteins that fuel inflammation. People with HS produce too much TNF-alpha (among other inflammatory proteins), so biologics called TNF-inhibitors, like __Humira__ (adalimumbab) and __Remicade__ (infliximab), block these proteins to slow down inflammation and prevent the disease from progressing. Dermatologists tend to prescribe TNF-inhibitors in moderate-to-severe cases that haven’t been helped by other medications or to decrease the number of inflamed lesions before surgery. 

Only Humira has been approved to treat HS, which means insurance would likely pay for the weekly injections, which you give yourself. But Remicade, given via an IV at the doctor’s office, has been used off-label to good results, according to study that found that after eight weeks of being treated with Remicade, patients had at least a 50% improvement in their HS symptoms and quality of life.    




For our "Just One More Question...!" video series, Dr. Christopher Sayed sat down with us to answer some of the most common questions he hears from his patients with hidradenitis suppurativa.

HS Just One More Question

Dr. Christopher Sayed on All Things HS

## Surgery and Laser Treatments

Doctors will use lasers (and sometimes old-school scalpels) to help control HS. In milder cases, removing hair from the armpits and groin can reduce your HS to the point of remission. In more serious cases, surgery may be the only way to control the pain and suffering when you have many tunnels.

### Laser Hair Removal 

Using a laser to zap hair at its roots so it grows more slowly can keep outbreaks from recurring in some parts of your body. In fact, it can reduce these outbreaks by about 70% in the groin area to roughly 75% in the armpits, say experts. This is especially true if you still have a mild case of HS, but hair removal is also helpful in moderate-to-severe cases as well if you don’t have tunnels. You’ll need to go once a month for at least three months and continue using the antiseptic washes and antibiotic lotions to keep nodules at bay.

### Surgery

If your lesions have formed tunnels—inflamed areas under your skin connecting the nodules—your doctor will probably recommend surgery to remove the damaged tissue. What kind of procedure you have, though, depends on the stage of the disease. 

For moderate cases (a single tunnel in one affected area ), your provider performs a procedure called *deroofing*, an in-office procedure. You’ll be given a local anesthetic or topical anesthetic (sometimes a numbing cream followed by an injection) and then the doctor will open up the tunnel to scrape out the deep-red, jelly-like material made up of white blood cells, bacteria, and tissue. As the tunnel heals, it closes up and forms a scar, preventing nodules from erupting there again, at least in the majority of cases. 

For multiple, interconnected tunnels in patients who have a severe case that’s not improving with medication, doctors use a laser or scalpel to remove skin, hair follicles, and oil glands from these tunnels. This is a bigger operation, requiring general anesthesia and sometimes a hospital stay. 

After the operation, the wound is either closed with stitches or skin grafts or left to heal on its own, with dressings and ointments. About half of all HS patients find that the outbreaks no longer occur in those areas operated on—even though they may have outbreaks in other places. But even better, the pain level from the active lesions will go down from nine or 10 to a two or three.


## Other Types of Therapy That May Help

__Watching what you eat.__ Consuming fewer carbs and more protein can help reduce inflammation for everyone—and it may help you shed pounds, lowering the risk of other diseases associated with HS like heart disease and type 2 diabetes as well as improving HS symptoms, according to some studies. But besides losing weight, banning certain foods from your diet may also help with HS flares.

There’s some evidence that dairy-free diets improve symptoms for patients as does avoiding yeast-products, like beer, cider, and miso. Staying away from nightshades—tomatoes, bell peppers, eggplant, and white potatoes—has worked for others, perhaps because these plants contain solanine, a chemical which may increase inflammation. If you want to try modifying your diet, keep a log of foods to see which ones trigger or make symptoms worse.

__Easing your pain.__ Pain is ever-present when you have HS, which is why you need a way to manage it when it gets out of hand. Your provider will probably want you to start with soothing creams and gels that contain 5% lidocaine and pain relievers like acetaminophen and ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs). 

If your lesions still hurt, then your doctor will prescribe an SNRI like duloxetine, an antidepressant that reduces pain signals to the brain, or gabapentin, an anti-convulsant that affects pain caused by nerve damage. For pain after surgery or if nothing else helps, you may take opioids like tramadol, but always under your provider’s watchful eye.

Some common pain relievers include:

- Tylenol and other brands (acetemenophine) 
- Advil and other brands (ibuprofen) 
- Aleve and other brands (naproxen)
- Lidoderm and other brands (lidocaine)
- Gabarone, Neurontin (gabapentin)
- Cymbalta (duloxetine)
- Ultram (tramadol)

__Taking supplements.__ People swear by turmeric, which is an anti-inflammatory, but the evidence that it can help HS flares is all anecdotal. There is slightly more scientific evidence backing zinc supplements. Taking 90 mg of zinc every day if you have a mild or moderate HS may decrease nodules to the point of remission, according to one small pilot study. That’s because zinc plays a big role in your immune system’s ability to fight off harmful substances and repair damaged cells; low levels may contribute to lesions and slow healing.

__Caring for your wounds.__ Whether you have one open lesion or tracts of them, you will have to become a pro at tending to your wounds so they can heal more quickly. Of course, your dermatologist can show you how, since providers have an array of products, like specialized dressings made from highly absorbent material. The best dressings are made up of three layers—the contact layer next to the open lesion, the absorbent layer that soaks up the pus and fluids, and a barrier layer to keep bacteria out. For smaller open lesions, try a sanitary pad with the adhesive side attached to your clothing, as some HS patients have done.  


Your primary care doctor may be able to diagnose your HS, but they’ll more than likely refer you to a dermatologist for further testing and treatment. At your first appointment, the dermatologist will examine your skin and ask a bunch of questions (be prepared!). If the bumps are leaking fluid, the derm may also swab a sample for testing. But, remember, hidradenitis suppurativa is chronic, so you’ll likely have regular follow-up appointments along the way.

What kind of doctor should I see for hidradenitis suppurativa?

Doctors use lasers to zap hair at its roots and help reduce outbreaks of hidradenitis suppurativa. Patients say laser hair removal feels like being repeatedly snapped with a small rubber band on the skin. It’s not the best feeling, but it’s also not the worst. Afterwards, it may feel like you have a mild sunburn. The sting is common and will go away in a day or two.

What does laser hair removal feel like?

In addition to following the treatment protocol that your doctor gives, you can watch what you eat (fewer carbs and more protein reduces inflammation), manage discomfort with an OTC pain reliever (try Tylenol, Advil, or Aleve), and incorporate supplements (there is some scientific evidence for taking zinc daily to help fight off harmful substances and repair damaged cells).

What can I do at home to help heal my HS?

It depends. For moderate cases (a single tunnel in one affected area ), you’ll have a procedure called *deroofing*, an in-office procedure with a local anesthetic (a numbing cream followed by an injection). For multiple, interconnected tunnels in patients who have a severe case that’s not improving with medication, doctors use a laser or scalpel to remove skin, hair follicles, and oil glands from these tunnels. This is a bigger operation, requiring general anesthesia and sometimes a hospital stay.

What should I expect with HS surgery?

HS Treatment FAQ

HS Treatment

This guide includes doctor-approved info and advice on hidradenitis suppurativa treatments, including laser hair removal and surgery.

More Info on Hidradenitis Suppurativa

From treatment options and complications to lifestyle changes and comorbidities, here’s the ultimate guide to everything you want to know about hidradenitis suppurativa.

Hidradenitis Suppurativa

Iltefat H. Hamzavi, M.D.

Senior Staff Physician

Jennifer L. Hsiao, M.D.

Health Sciences Assistant Clinical Professor Medical Dermatology

Joslyn R. Sciacca Kirby, M.D.

Director

We went to some of the nation’s top experts in hidradenitis suppurativa to bring you the most up-to-date information possible.

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We've got the doctor-approved details on hidradenitis suppurativa causes, symptoms, treatments, and a jillion other facts and tips that can make life with HS easier.

Let's Talk About Hidradenitis Suppurativa

Hidradenitis Suppurativa Symptoms, Causes, Diagnosis, Treatments, and More

We went to some of the nation's top experts in hidradenitis suppurativa to bring you the most up-to-date information possible.

woman getting laser hair removal on underarm

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You have some seriously effective options for managing symptoms—and a darn good chance at reaching remission, too.

Let's Talk About Treatment for HS

- __Antibiotics and HS__: *Dermatology* (2009). “Combination therapy with clindamycin and rifampicin for hidradenitis suppurativa: a series of 116 consecutive patients.” [ncbi.nlm.nih.gov/pubmed/19590173](https://www.ncbi.nlm.nih.gov/pubmed/19590173)

- __Antibiotic Resistance in HS Patients__: *Journal of the American Academy of Dermatology* (2017). “Patterns of antimicrobial resistance in lesions of hidradenitis suppurativa.” [sciencedirect.com/science/article/abs/pii/S0190962216306156](https://www.sciencedirect.com/science/article/abs/pii/S0190962216306156)

- __Treatments__: *Journal of Clinical and Aesthetic Dermatology* (2018). “Hidradenitis Suppurativa: Causes, Features, and Current Treatments.” [ncbi.nlm.nih.gov/pmc/articles/PMC6239161/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239161/)

- __Therapeutic Advances in Chronic Disease__" *Therapeutic Advances in Chronic Disease.*(2019). “Topical, systemic and biologic therapies in hidradenitis suppurativa: pathogenic insights by examining therapeutic mechanisms.” [ncbi.nlm.nih.gov/pmc/articles/PMC6399757](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6399757)

- __Retenoids, Biologics, and HS__: *British Journal of Dermatology.* (2013). “Systemic therapy with immunosuppressive agents and retinoids in hidradenitis suppurativa: a systematic review.” [ncbi.nlm.nih.gov/pubmed/23106519](https://www.ncbi.nlm.nih.gov/pubmed/23106519)

- __Acitretin use with HS__: *British Journal of Dermatology.* (2011). “Long-term results of acitretin therapy for hidradenitis suppurativa.” [ncbi.nlm.nih.gov/pubmed/20874789](https://www.ncbi.nlm.nih.gov/pubmed/20874789)

- __Humira and HS__: *Clinical and Experimental Dermatology.* (2019). “Clinical response rate and flares of hidradenitis suppurativa in the treatment with adalimumab.” [doi.org/10.1111/ced.14127](https://doi.org/10.1111/ced.14127)

- __Remicade and HS__: *Journal of the American Academy of Dermatology.* (2010). “Infliximab therapy for patients with moderate to severe hidradenitis suppurativa: A randomized, double-blind, placebo-controlled crossover trial.” [jaad.org/article/S0190-9622(09)00782-8/fulltext](https://www.jaad.org/article/S0190-9622(09)00782-8/fulltext) 

- __Hormone Therapies in HS__: *Dermatology Online Journal.* (2017). "Hormonal therapies for hidradenitis suppurativa: Review." [escholarship.org/uc/item/6383k0n4](https://escholarship.org/uc/item/6383k0n4)

- __Overall Treatment and HS__: *Mayo Clinic Proceedings.* (2015). “Hidradenitis Suppurativa.” [mayoclinicproceedings.org/article/S0025-6196(15)00711-9/fulltext#sec7.3](https://www.mayoclinicproceedings.org/article/S0025-6196(15)00711-9/fulltext#sec7.3)

- __Metmorfin and HS__: *Journal of Dermatological Treatment.* (2019). “Metformin use in hidradenitis suppurativa.” [tandfonline.com/doi/abs/10.1080/09546634.2019.1592100](https://www.tandfonline.com/doi/abs/10.1080/09546634.2019.1592100)

- __Deroofing and HS__: *Journal of the American Academy of Dermatology.* (2010). “Deroofing: A tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions." [jaad.org/article/S0190-9622(09)02288-9/fulltext](https://www.jaad.org/article/S0190-9622(09)02288-9/fulltext)

- __Diet Changes and HS__: *Surgery.* (2013). “New perspectives in the treatment of hidradenitis suppurativa: surgery and brewer's yeast-exclusion diet." [surgjournal.com/article/S0039-6060(13)00165-7/fulltext](https://www.surgjournal.com/article/S0039-6060(13)00165-7/fulltext)

- __Weight Loss and HS__: *Journal of Cutaneous Medicine and Surgery.* (2019). “Weight Loss and Dietary Interventions for Hidradenitis Suppurativa: A Systematic Review.” [journals.sagepub.com/doi/abs/10.1177/1203475419874412](https://journals.sagepub.com/doi/abs/10.1177/1203475419874412)

- __Zinc and HS__: *Dermatology.* (2007). “Hidradenitis suppurativa and zinc: a new therapeutic approach. A pilot study.” [ncbi.nlm.nih.gov/pubmed/17460404](https://www.ncbi.nlm.nih.gov/pubmed/17460404) 


Christopher Sayed, M.D.

Medical Reviewer

Guide to Hidradenitis Suppurativa Treatments

Let's Talk About Treatment for Hidradenitis Suppurativa

With any chronic health condition, the number-one goal is to have it diagnosed and treated early to prevent it from progressing or causing lasting damage. It makes sense, but that doesn't typically happen when it comes to the painful, little-known skin disease hidradenitis suppurativa (HS). Frustrating fact: It often takes many visits to doctors just to get a correct diagnosis. A multinational survey published in a July 2019 issue of the *Journal of the American Academy of Dermatology* (*JAAD*) found that 64% of patients visited five or more physicians before receiving a formal diagnosis of HS. The mean delay in diagnosis? Ten *years*. 

For a condition that causes so much pain along with feelings of embarrassment and isolation, why is HS so often missed?

The simplest explanation: The lumps that appear, typically in areas like the armpits and groin where skin rubs together, may look like something else. "There is still under-recognition of what HS is. It's often mistaken for a routine boil or abscess," explains Victoria Shanmugam, M.D., director of the Hidradenitis Suppurativa Clinic and director of rheumatology at The George Washington University in Washington, D.C. 

So what is HS then? It's a chronic, painful, non-contagious skin disease, with a few distinct characteristics, according to the Hidradenitis Suppurativa Foundation: 

- __Recurrence__ Boils that return over and over. They typically begin as a single lesion, usually due to a blocked hair follicle and/or inflamed sweat gland, which develops into a hard lump filled with pus. They can progress and form tunnels under the skin, leaving people with painful clusters that seep fluid, according to the National Organization for Rare Disorders. (Important note: HS is not actually rare! It affects 1 in 100 people.)
- __Location__ Characteristic locations for those boils are areas where you have hair and/or sweat glands: the armpit, under the breasts, folds of the stomach, the groin, genital area, buttocks, and sometimes behind the ears and the nape of the neck.
- __Symmetry__ You’ll have symptoms on both sides of your body at the same time.
- __Associated conditions__ HS is commonly associated with other health conditions (called comorbidities) including metabolic syndrome, diabetes, heart disease, polycystic ovarian syndrome, a higher body mass index (though HS can affect a person of any weight), and more.

Whether HS is *missed* or *misdiagnosed*, the delay in properly diagnosing this chronic inflammatory skin disorder causes a ripple effect of issues. First, not having a proper diagnosis means ongoing suffering that can shortchange your quality of life. In fact, lesions can make it painful to even walk or lift your arms because they often show up in the groin and armpits. 

According to the *JAAD* study, nearly half of patients report their symptoms have an extreme impact on their life, and nearly 15% say they’re disabled because of it. What's more, misdiagnosis can set the stage for progression of HS and complications, from infection to scarring to depression. 

The latest research also suggests that people with HS have an increased risk of developing squamous-cell skin cancer in longstanding HS lesions, notes Jennifer Hsiao, M.D., an assistant clinical professor at UCLA Dermatology. 

## Why HS Gets Misdiagnosed

Initially, patients with symptoms of HS may see a primary-care physician or an ob-gyn, or go to urgent care or the emergency room to have their painful lesions, which can erupt with pus and bleed, evaluated. If the symptoms are viewed as an isolated incident, patients may receive temporary treatment—lancing and draining of the boil and a prescription for antibiotics—for what seems like a simple abscess, cyst, or boil and sent on their way, without any recommended follow-up care.  But eventually, lesions just flare again, often weekly or monthly. 

One reason for this lack of awareness: "HS is one of the things that hasn’t made it into the medical school curriculum," says Chris Sayed, M.D., an associate professor of dermatology at the UNC School of Medicine in Chapel Hill. (For the record, HS is a clinical diagnosis that's made by a doctor based on a visual examination of the lesions or lesion patterns on a patient’s skin; no blood test or diagnostic test is available to make the diagnosis. It affects three times as many women as men.) 

In other instances, patients themselves may contribute to the delay in diagnosis. "Because HS lesions are often in hidden places on the body like the armpits or the groin, patients may be hesitant to discuss them with a health-care provider or they may hope they'll just go away on their own," Dr. Hsiao says. In some cases, they might—but they will recur.   

## What Happens When Docs Miss HS 

However it happens, a delay in HS diagnosis can compromise someone's social life, sex life, and work or professional life. If HS is poorly controlled, it can lead to more skin pulling and "tunnels" that connect painful, beneath-the-skin lumps. These tunneling tracts in particular can release an odorous discharge that can make an HS sufferer feel reluctant to go out in public. 

There's also a risk for scars, which can be hard and appear rope-like.  "The longer you have the disease, the more scarring you'll have with recurring lesions, and that's something we can’t reverse," says Martina Porter, M.D., a dermatologist and co-director of the Clinical Laboratory for Epidemiology and Applied Research in Skin (CLEARS) at Beth Israel Deaconess Medical Center in Boston. "The scarring can be really bad, especially in the armpits, under the breasts, in the groin area, under the thighs, and behind the neck and ears."  (Support from fellow HS patients can help relieve the resulting emotional burden and isolation HS sufferers feel; a list of in-person and online support networks is available at the site [Hope for HS](https://hopeforhs.org/).) 

People with undiagnosed or poorly controlled HS may need to have lesions drained if they progress to the point where they impair mobility, or they may need to have surgery to remove a portion of scar tissue. "This is a disease that leads to progression over time if it's not treated effectively," says Dr. Sayed. 

Bottom line: Even if your lumps or sores embarrass you, don't delay getting help, or persisting for a proper diagnosis. "If you suspect you have HS [based on what you’ve read about it], it's important to see a physician who's familiar with the condition as soon as possible," says Dr. Sayed. You may be able to find a referral to a specialist near you through the [Hidradenitis Suppurativa Foundation](https://www.hs-foundation.org/hs-specialty-clinics/). If you can't, Dr. Sayed recommends doing some internet research and printing information about HS, including images, then bringing this to your physician. 

Though it can't be cured, the good news is HS is a treatable condition, with a whole range of medicines, including biologics, available to help you manage and reduce flares, so you can focus on living your life. Says Dr. Porter: "We're in a time where we have more treatment options than ever to manage the disease, and the earlier we can diagnose people, the better off they'll be."


red alarm light-iStock-1166460347

Doctors and patients often miss hidradenitis suppurativa, which leads to unnecessary suffering and scarring.

HS Misdiagnosis Dangers

Doctors and patients easily miss hidradenitis suppurativa, but the sooner this painful skin condition’s diagnosed, the sooner you can relieve your suffering.

The Dangers of HS Misdiagnosis

- __HS and the delay in getting diagnosed__:  Sixty-four percent of patients see five doctors before HS diagnosis. [ncbi.nlm.nih.gov/pubmed/31279015](https://www.ncbi.nlm.nih.gov/pubmed/31279015)

- __HS, a definition__: National Organization for Rare Disorders. (n.d.) "Hidradenitis Suppurativa." [rarediseases.org/rare-diseases/hidradenitis-suppurativa/](https://rarediseases.org/rare-diseases/hidradenitis-suppurativa/)

- __HS and its prevalence__: HS is three times more common in women than men. [pmj.bmj.com/content/90/1062/216](https://pmj.bmj.com/content/90/1062/216)


Aaron S. Farberg, M.D.

Doctors and patients easily miss hidradenitis suppurativa, but the sooner this painful skin condition’s diagnosed, the sooner you can end your suffering.

Anyone diagnosed with hidradenitis suppurativa (HS) will have plenty of questions—especially if, like most people, you've never heard of the disease. So let's get the basic definition out of the way: Once thought to be rare (more on that in a bit), HS is a chronic inflammatory illness that can cause painful lumps, open sores, and permanent scarring, often in the armpits, groin, buttocks, and under the breasts (really any place where the skin rubs together). Now, let's get to the other answers you need most: 

## Is HS My Fault?

No, it is not your fault. And for the record, HS does not develop because of “bad hygiene,” as doctors sometimes incorrectly (and even cruelly) imply. That sort of guilt-tripping “is deeply unfair, because none of us fully understands where HS comes from,” says Rashmi Unwala, M.D., a dermatologist at the Cleveland Clinic in Ohio. 

## What Do We Know About the Causes of HS Then?

“We're still trying to understand the fundamental mechanisms behind HS,” says Haley Naik, M.D., an assistant professor of dermatology at the University of California, San Francisco, where she established an HS clinic. We do know that people with HS experience inflammation around their hair follicles, often in intertriginous locations. When those follicles rupture, skin cells and bacteria that usually live on the skin peacefully get trapped in places they don't belong. The result: The body’s immune system kicks into gear, triggering an even bigger inflammatory response that leads to pus-filled HS boils.

There are some known risk factors that can up the odds of HS:

- It typically occurs in places where skin rubs against skin, like under the arms, the vulva, or in the folds of skin in people who are overweight.
- Hormone levels might also fuel the condition, including having high levels of insulin and/or androgens, which begin to soar during puberty, spurring pubic and under-arm hair growth among other functions. In fact, many cases develop after puberty kicks into high gear.
- [As many as 30% to 40% of patients have a family history of the disease](https://rarediseases.info.nih.gov/diseases/6658/hidradenitis-suppurativa), according to the Genetics and Rare Diseases Information Center at the National Institutes of Health.  
- Numerous studies have found higher rates of HS among smokers, and one recent paper published in *Dermatology Reports* found that 67% of participants were current smokers who’d smoked for an average of eight years before onset. As with basically anything having to do with smoking, the less you do it, the better off you’ll be. If you need help quitting, visit the [American Lung Association](https://www.lung.org/stop-smoking/i-want-to-quit/) for advice and support.

## Is HS Rare?  



green chairs in a stadium with one yellow chair

green chairs in a stadium with one yellow chair-ricardo-gomez-angel-KmKZV8pso-s-unsplash

No, HS is not rare—although, for decades, it was treated as such. Seeing the disease as rare “was probably due, in part, to misdiagnosis or under-diagnosis,” says Dr. Naik, “but also because of the shame and stigma a disease like HS can bring about. People didn't seek medical attention right away.” That the onset of HS often occurs around puberty, when young people can be intensely self-consciousness about their bodies, could help account for the under-diagnosis, as well.

Today’s estimates indicate that roughly 1% of Americans are affected. That might sound insignificant: But as Dr. Naik notes, for a condition of this severity—HS can be a disfiguring disease—that's a pretty huge number. To put it in perspective, roughly the same number of Americans are diagnosed with HS as are diagnosed with IBD (either Crohn's disease or ulcerative colitis), and fewer are diagnosed with more widely known illnesses, like multiple sclerosis (less than .5%).

## Is HS an STD? 

When you have itchiness or painful, cyst-like bumps or, in late stages of the disease, excruciating, draining open sores in sensitive areas like the groin and anus, “Is HS an STD?” is a perfectly reasonable question. But the answer is no. “In some cases, if these patients visit a physician unfamiliar with HS, that might be exactly what they're told—that they have a sexually transmitted disease,” like herpes or HPV, says Dr. Naik. Such misdiagnoses can, and do, delay helpful and proper treatment while compounding the embarrassment and shame HS so often sparks in people. Bottom line: HS is neither infectious nor contagious, and it’s not sexually transmitted.

## What Are the Stages of HS?

“There are three clinical stages to HS,” says Dr.  Unwala. In each stage, the symptoms are distinctive (though early diagnosis and treatment can help manage those symptoms, especially at the earlier stages):

- In Stage I, you may notice small (perhaps the size of a pea), sometimes itchy, usually quite painful bumps in the armpits, groin, near the breasts, and (more commonly in men than in women) around the anus. These might resemble hard cysts or prominent razor bumps.
- In Stage II, inflammation and infection have increased, and multiple abscesses may keep appearing on the skin. Pus-filled tunnels or tracts also form beneath the skin; eventually the abscesses can rupture, resulting in open sores.
- In Stage III, advanced tunnels form, often connecting multiple lesions. At this point, the damage is permanent, says Dr. Unwala. “The tissue has been blown out, and multiple areas have scarring.”  An entire armpit, for example, might be inflamed, she says, with large boils that are not only agonizingly painful, but also emit a bad smell from the draining pus and fluid.

## Are There Treatments for HS?



person squirting cream into hand-collins-lesulie-7lFGxDph5KQ-unsplash

The good news: Yes, there are, and the earlier you can start treatment, the better your outcome is likely to be, says Dr. Naik. For early and moderate cases of HS, doctors have a range of options to battle infection, keep new boils in check, and manage pain.

In the earliest stage, topical antibiotic creams (such as clindamycin or gentamicin) are often used to help manage symptoms.

For moderate and severe HS, when topical creams are deemed no longer sufficient, your doctor might prescribe oral or injected antibiotics; corticosteroid injections to ease pain and inflammation; or the biologic drug Humira (adalimumab), which targets and effectively blocks a specific protein believed to cause inflammation. (It's currently the only FDA-approved biologic for HS, though more are in the pipeline.)

Finally, the more severe stages of the disease can often require surgery, as well. This can range from out-patient procedures involving tissue removal—allowing the “tunnels” beneath the skin to drain (a method called “unroofing”)—to more complicated surgeries in which large sections of damaged skin are removed and replaced by reconstructive skin grafts.

The most successful treatment usually requires a multidisciplinary approach: medicine, surgery, and lifestyle changes (quitting smoking, losing weight, exercising more), according to study in the journal *Clinical, Cosmetic and Investigational Dermatology*.

## Who Is Most Likely to Develop HS?

Hidradenitis suppurativa affects three times as many women as men, and though researchers still aren’t exactly sure why, it’s likely that hormones play a role. Recent studies suggest that, in the United States, HS disproportionately affects African Americans, and African-American women, especially. Do they know why this is the case? Not yet. As with so much of HS, more studies are also needed to determine why certain racial or ethnic groups might be more prone to developing HS.

## Can Diet Help HS? (Or Make It Worse?)



two women on picnic-toa-heftiba--TTI1k1mVAY-unsplash

Honestly, either is possible. And big surprise, there’s not a whole lot of data to help us understand what changes may make a difference. In one survey of more than 200 patients, most people had limited at least one food group, and of those, about 86% had cut out multiple groups, according to the report in *Dermatology*. The top targets: gluten, dairy, refined sugar, tomatoes, and alcohol. About 30% said their symptoms improved—but a few said they worsened.

Sugars, milk, cheese, and other dairy products can raise insulin levels, which in turn can trigger an overproduction of androgens, a type of hormone that appears to be a factor in HS, according to the Mayo Clinic. Similarly, avoiding foods with gluten, particularly those that include yeast to rise (bread, pizza dough, etc.) may also help lesions heal.

The key to figuring out what your food triggers might be? Keep food diary and track your symptoms. Working with a registered dietician can also help. 

## Is There a Cure? 

Not at the moment—but it’s the goal! As doctors and researchers look for answers, the best strategy for people with the disease is smart, careful management that can keep symptoms under good control for many patients.

“We're hopeful that in the short term, we’ll be able to find more targeted therapies to help people live without pain, without the development of new lesions, and without the need to undergo huge surgeries,” says Dr. Naik. "In the next 10 years or so, I think hitting that goal is certainly possible. But the long-term goal, make no mistake, is a cure.”




question marks painted on trees-evan-dennis-i--IN3cvEjg-unsplash

A diagnosis of hidradenitis suppurativa (HS) will likely spark a lot of questions, since it isn't that well known. We have some answers for you.

9 Top Qs About Hidradenitis Suppurativa

- __HS in Certain Areas of the Body:__ National Organization for Rare Disorders. (2012). “Hidradenitis Suppurativa.” [rarediseases.org/rare-diseases/hidradenitis-suppurativa/](https://rarediseases.org/rare-diseases/hidradenitis-suppurativa/)
- __The Stages of HS:__ Hidradenitis Suppurativa Foundation. (n.d.). “What Is Hidradenitis Suppurativa?” [hs-foundation.org/what-is-hs/](https://www.hs-foundation.org/what-is-hs/)
- __HS Prevalence in Women vs. Men:__ *Postgraduate Medical Journal*. (2014). “Hidradenitis Suppurativa: A Common and Burdensome, Yet Under-Recognized, Inflammatory Skin Disease.” [https://pmj.bmj.com/content/90/1062/216](https://pmj.bmj.com/content/90/1062/216)
- __Smoking and HS:__ *Dermatology Reports*. (2019). “Secondary Prevention of Hidradenitis Suppurativa.” [pubmed.ncbi.nlm.nih.gov/31728176-secondary-prevention-of-hidradenitis-suppurativa/](https://pubmed.ncbi.nlm.nih.gov/31728176-secondary-prevention-of-hidradenitis-suppurativa/)
- __HS and Diet (1):__ *Dermatology*. (2019). “Prevalence and Impact of Dietary Avoidance Among Individuals With Hidradenitis Suppurativa.” [pubmed.ncbi.nlm.nih.gov/31678977-prevalence-and-impact-of-dietary-avoidance-among-individuals-with-hidradenitis-suppurativa/](https://pubmed.ncbi.nlm.nih.gov/31678977-prevalence-and-impact-of-dietary-avoidance-among-individuals-with-hidradenitis-suppurativa/)
- __HS and Diet (2):__ Mayo Clinic. (2018). “Hidradenitis Suppurativa and Diet: What's Recommended?” [mayoclinic.org/diseases-conditions/hidradenitis-suppurativa/expert-answers/hidradenitis-suppurativa-diet/faq-20182593](https://www.mayoclinic.org/diseases-conditions/hidradenitis-suppurativa/expert-answers/hidradenitis-suppurativa-diet/faq-20182593)

Hidradenitis Suppurativa (HS): Answers to Your Top Questions

It may not be the most common skin disease (it affects about 1 percent of the global population) or the easiest to roll off the tongue. But if you suffer from hidradenitis suppurativa (HS), you don’t need anyone to tell you that it’s definitely one of the most painful. “HS is characterized by large, inflamed boils in areas like the armpits, groin, and breast area,” says Rashmi Unwala, M.D., a dermatologist at the Cleveland Clinic in Cleveland, OH. If that doesn’t sound like a world of hurt, now add this: Those boils can often burst, leading to a tunneling effect under the skin, inside of which biofilms can form.

Biofilms, slimy layers of bacteria that adhere to wet surfaces, are highly resistant to antibiotics—a worrisome prospect for HS sufferers who rely on long-term courses of the drugs to keep their condition under control. In fact, a recent study by the *European Academy of Dermatology and Venereology* found that biofilms significantly reduced people’s sensitivity to tetracycline and clindamycin, two standard antibiotics in the treatment of HS.

While scientists are still learning about the role biofilms play in the development of HS, there are some key findings that anyone dealing with this challenging disease should know.

## #1. HS Itself Is Still a Mystery

The questions surrounding HS, from what causes it to which medical discipline should "own" it, are all too familiar to those struggling with the disease. Small consolation, but it’s a headscratcher for researchers, too. "There's a logical reason we don't know a lot about HS," says Haley Naik, M.D., an assistant professor of dermatology at the University of California, San Francisco and founder of the UCSF HS Clinic. "For as long as we've known it exists, there's been a dearth of studies and funding focused on it. The amount of research published on HS over the past 20 years is minuscule in comparison to that published on other prevalent inflammatory skin conditions. It is a truly neglected disease."

## #2. It’s Quite Sweaty

HS, which typically first appears after puberty, is most likely to occur in areas of your body with where skin-on-skin friction occurs, like your armpits, under the breasts, and genital region. Scientists believe the skin lesions begin to form due to inflammation around hair follicles that become tender and swollen. These can then fill with pus and blood and may be extremely painful. Obesity and smoking appear to factor into the development and severity of HS , though many patients of normal weight that have never smoked also develop the disease. There may also be a genetic component to the disease, as 30% to 40% of people with HS also have a family member with the condition.

## #3. The Biofilm Factor Is a Hot Debate

While research suggests that there is a meaningful connection between HS and biofilms, the exact sequence of events is up for discussion. “We now have a handful of studies that have looked at biofilms and HS,” says UCSF's Dr. Naik, “and I think we can say with pretty good certainty that biofilms exist in sinus tracts [the pus-filled 'tunnels' beneath the skin in HS sufferers], because these tracts are filled with bacteria, and of course they'll try to protect themselves by making this material that we commonly call biofilms.” 

But are they the cause or the result of this inflammatory condition? “We need to do more work on what's the chicken, and what's the egg,” she acknowledges. “Does the inflammatory response come first, and the bacteria are secondary? Or do the bacteria end up somewhere they're not supposed to be, and that incites the robust inflammatory response?” Some data indicate that biofilms are not present in early lesions but form later to play a role in disease maintenance. Either way, once they are in place, it throws a wrench into treatment.

## #4. Biofilms Mess with Antibiotics

Biofilms are actual structures made up of proteins, fats, and other materials. They are gooey substances, like the mucus in your nose, bacteria discharges these materials and form the biofilm to protect themselves, protecting the germs from anything trying to remove it—namely, antibiotics. In the case of HS, this structural slime effectively seals the bacteria inside the tunnels that have formed under your skin, preventing antibiotics from reaching them to kill them off, according to researchers at the Centre of Biomolecular Sciences, University of Nottingham in the UK.

## #5. Biofilms—They're Not Just for Humans!

Wrapping your mind around what biofilms actually are can be tricky, in part because the variety, both bacterial and fungal, is so vast. In fact, biofilms don’t even have to occur on people—they have been known to form on industrial products like drain pipes and medical devices, as well as plants. The slime-encapsulated bacteria colonies are at the heart of many chronic infections and conditions ranging from urinary-tract and middle-ear infections to gingivitis. (You know that slimy gunk that forms on your teeth when you haven’t brushed them all day? That’s a biofilm!). And biofilms also contribute to more serious illnesses like endocarditis.

## #6. Technology Is Getting Better at Spotting Them

Not every person with HS will develop biofilms. But—as with virtually everything about hidradenitis suppurativa—treatment outcomes may improve if biofilms are identified early, since it indicates to doctors that antibiotics may not work as well, and other approaches to treating HS could be more effective. There are numerous methods of detecting biofilms in HS, including tissue-culture plates (staining cells with crystal violet dye); a bioluminescent technique based on the signals of certain metabolically active cells; scanning electron microscopy, used to study the structure and number of bacteria in a colony; and confocal scanning laser microscopy, which provides a three-dimensional view of the microbial community. These cutting-edge detection techniques have greatly improved the medical community’s understanding and ability to identify the presence of biofilms.

## #7: Research Is Ramping Up

There is currently no single treatment available to remove biofilms in people with HS. That’s partly because the variety of existing biofilms is huge (so there will never be a one-size-fits-all plan), and partly because biofilms have evolved over eons with the express purpose of protecting their precious cargo, so they’re not going down without a fight. Still, researchers are increasingly discovering approaches that show promise. For example, scientists at the University of South Florida in Tampa have found that a compound that they dubbed "darwinolid," found in an Antarctic sea sponge, appears to be effective in preventing the formation of a biofilm for methicillin-resistant *Staphylococcus aureus*—or as the rest of us know it, a staph infection that can cause pneumonia or even heart failure. Another potential tactic might be to use biologic agents, electrical impulses, or other means to disrupt, block, or scramble the chemical signals that cells within a biofilm use to communicate with one another.

## #8: Treatment Is Still Evolving

Bottom line? The exact relationship between hidradenitis suppurativa and biofilms remains unclear, even as researchers seek new approaches for disrupting—and even preventing their development in those living with HS. Because treating biofilms directly is still an ongoing area of research, for now the majority of treatment options focus on HS itself. These include antibiotics (with the understanding that at some point the effectiveness might diminish) as well as the FDA-approved biologic drug Humira (adalimumab).

Another approach involves "unroofing," or removing skin tissue in the affected area to expose the tunnels beneath the skin and allow pus to drain, thereby relieving the pressure that is such a painful part of the disease for so many patients. In advanced stages, your doctor might suggest surgical removal of the affected areas, a procedure that in some cases include prolonged wound healing and skin grafting. 

While HS remains a challenging condition to live with, the ongoing research into biofilms may one day yield more effective treatment strategies for those dealing with the disease. Until then, talk with your doctor about the best plan to keep yourself one step ahead of HS.

shirtless man in pain with armpit-sam-burriss-zHSX9o2 B7Y-unsplash

The development of slick layers of bacteria called biofilm can threaten the effectiveness of antibiotics to fight HS lesions. Find out why the problem exists and what you can do about it.

Biofilms & HS

Dealing with the painful skin condition is tough, but slick layers of bacteria known as biofilms can make it even tougher. Here's what scientists are discovering about the interaction between the two.

8 Facts You Need to Know About Biofilms and HS

- __Reduced sensitivity to antibiotics:__ *Journal of the European Academy of Dermatology and Venereology*. (2019). “Biofilm production and antibiotic susceptibility of staphylococcus epidermidis strains from hidradenitis suppurativa lesions.” [ncbi.nlm.nih.gov/pubmed/30022542](https://www.ncbi.nlm.nih.gov/pubmed/30022542)
- __Biofilms and endocarditis:__ *Seminars in Thoracic and Cardiovascular Surgery*. (2016). “Current hypotheses in cardiac surgery: Biofilm in infective endocarditis.”  [ncbi.nlm.nih.gov/pubmed/27568136](https://www.ncbi.nlm.nih.gov/pubmed/27568136)
- __What are biofilms:__ British Society for Immunology. (n.d.) “Biofilms and Their Role in Pathogenesis.” [immunology.org/public-information/bitesized-immunology/pathogens-and-disease/biofilms-and-their-role-in](https://www.immunology.org/public-information/bitesized-immunology/pathogens-and-disease/biofilms-and-their-role-in)
- __Detection of HS:__ *Virulence*. (2018). “Strategies for Combating Bacterial Biofilms.” [ncbi.nlm.nih.gov/pmc/articles/PMC5955472/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5955472/)
- __Biofilms and resistance:__ *Cold Spring Harbor Perspectives in Medicine*. (2013). “Bacterial Biofilms: Development, Dispersal, and Therapeutic Strategies in the Dawn of the Postantibiotic Era.”  [ncbi.nlm.nih.gov/pmc/articles/PMC3683961](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683961)
- __Biofilms and HS:__ *FEMS Immunology & Medical Microbiology*. (2012). “Considering Hidradenitis Suppurativa as a Bacterial Biofilm Disease.” [academic.oup.com/femspd/article/65/2/385/683422](https://academic.oup.com/femspd/article/65/2/385/683422)

Biofilms and Hidradenitis Suppurativa: 8 Facts You Need to Know About

8 Must-Know Facts About Biofilms & Hidradenitis Suppurativa

Treatments for hidradenitis suppurativa (HS) aren’t limited to antibiotics and anti-inflammatory drugs. They can also include home remedies such as honey and aloe. We've got a roundup for you here.

Home Remedies for HS

woman-soaked-in-water-with-bubbles-2306205

While you're waiting for your prescription meds to kick in, these strategies may help ease the pain and discomfort that comes with hidradenitis suppurativa.

Simple Home Remedies to Soothe HS

- __Prevalence of HS:__ UPMC/University of Pittsburgh Schools of the Health Sciences.  "Hidradenitis Suppurativa Surgery: Frequently Asked Questions.” [upmc.com/services/plastic-surgery/services/hidradenitis-suppurativa/faq](https://www.upmc.com/services/plastic-surgery/services/hidradenitis-suppurativa/faq)
- __Aloe Vera:__ *Journal of Clinical and Diagnostic Research*. (2016). “Antibacterial Effect of Aloe Vera Gel against Oral Pathogens: An In-vitro Study.” [ncbi.nlm.nih.gov/pmc/articles/PMC5198455/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198455/)
- __Bleach Baths:__ American Academy of Dermatology. (n.d.). “Hidradenitis Suppurativa: Diagnosis and Treatment.” [aad.org/diseases/a-z/hidradenitis-suppurativa-treatment](https://www.aad.org/diseases/a-z/hidradenitis-suppurativa-treatment)
- __Honey:__ *Oxidative Medicine and Cellular Longevity*. (2018). “Honey as a Potential Natural Antioxidant Medicine: An Insight Into Its Molecular Mechanisms of Action.” [ncbi.nlm.nih.gov/pmc/articles/PMC5822819/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5822819/)
- __Menthol/Vicks:__ Hope For HS. (2019). “Vicks Vapo-Rub for Hidradenitis Suppurativa.” [hopeforhs.org/vicks-vapo-rub-for-hidradenitis-suppurativa/](https://hopeforhs.org/vicks-vapo-rub-for-hidradenitis-suppurativa/) 
- __Anti-Inflammatory Foods:__ Mayo Clinic. (2019). “How to Use Food to Help Your Body Fight Inflammation.” [mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/how-to-use-food-to-help-your-body-fight-inflammation/art-20457586](http://mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/how-to-use-food-to-help-your-body-fight-inflammation/art-20457586)

Holly Singletary, M.D.

Hidradenitis Suppurativa: Home Remedies for Pain Relief

Wash With Soap

Swipe With Alcohol

Try Warm Compresses

Dab on Aloe Vera

Try Bleach Baths

Smear on Some Honey

Apply Menthol

Eat Anti-Inflammatory Foods

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](https://www.cvs.com/shop/hibiclens-liquid-prodid-102994), 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.

hair follicle diagram

## 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](https://www.webmd.com/beauty/laser-hair-removal) 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](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483576/) 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.



Young woman in white towel shaving armpits with plastic razor after shower

Young woman in white towel shaving armpits with plastic razor after shower-iStock-1126244723

We checked out which hair removal methods are safest (and most effective!) for Hidradenitis Suppurativa. 

HS & Hair Removal

Shaving, waxing, or lasering? Which hair-removal technique is best if you have HS? We've got the answers.

The Best—and Worst—Hair Removal Techniques for Hidradenitis Suppurativa

- __Hidradenitis Suppurativa Info:__ Mayo Clinic. (n.d.) “Hidradenitis suppurativa.” [mayoclinic.org/diseases-conditions/hidradenitis-suppurativa/symptoms-causes/syc-20352306](https://www.mayoclinic.org/diseases-conditions/hidradenitis-suppurativa/symptoms-causes/syc-20352306)
- __HS Causes and Factors:__ Genetic and Rare Diseases Information Center. (2018). “Hidradenitis suppurativa.” [rarediseases.info.nih.gov/diseases/6658/hidradenitis-suppurativa](https://rarediseases.info.nih.gov/diseases/6658/hidradenitis-suppurativa)
- __Laser Treatment for HS Study:__ NEJM Journal Watch. (2010). “Nd:YAG Laser Treatment of Hidradenitis Suppurativa.” [jwatch.org/jd201011190000001/2010/11/19/nd-yag-laser-treatment-hidradenitis-suppurativa](https://www.jwatch.org/jd201011190000001/2010/11/19/nd-yag-laser-treatment-hidradenitis-suppurativa)
- __More Laser Treatments for HS:__ *Macedonian Journal of Medical Sciences*. (2018). “Intralesional Diode Laser 1064 nm for the Treatment of Hidradenitis Suppurativa.” [ncbi.nlm.nih.gov/pmc/articles/PMC5816308/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5816308/)
- __Laser Cooling:__ *Journal of Cutaneous and Aesthetic Surgery*. (2012). “Use of Lasers for the Management of Refractory Cases of Hidradenitis Suppurativa and Pilonidal Sinus.” [ncbi.nlm.nih.gov/pmc/articles/PMC3483576/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483576/)

Hair Removal Techniques for Hidradenitis Suppurativa: Waxing, Laser and Shaving

The Best Hair-Removal Methods for Hidradenitis Suppurativa

Shabnam Shahabadi, M.D.

MeUndies

Ellen Tracy Essentials

Carole Hochman

Torrid

Sloggi

Gap Body

Thinx

Fruit of the Loom

Penningtons

Extra Protection

You know how there never seems to be *quite* enough time to get all of your questions answered during your doctor visits? Well, HealthCentral's "Just One More Question!" video series is here to help! We're asking the top docs in their field to answer all your Qs so you can get a real handle on your condition. 

For this edition on hidradenitis suppurativa (HS), we asked __Christopher Sayed, M.D., an associate professor of dermatology at the UNC School of Medicine at Chapel Hill__, to dig into your most common questions about this painful inflammatory skin condition. He runs a dedicated HS clinic and sees exactly how this disease can impact patients' lives every day. He also knows what it takes to heal. We'll let him take it from here. 

iStock-465480220

Medical desk

Dr. Christopher Sayed, a dermatologist with UNC Chapel Hill, answers patients most common questions about the inflammatory skin condition hidradenitis suppurativa (HS). 

HS Videos

For our "Just One More Question!" video series, Dr. Christopher Sayed sat down with us to answer some of the most common questions he hears from his patients with hidradenitis suppurativa. 

Just One More Question About HS!

Video Series: A Doctor Q/A on Hidradenitis Suppurativa

For our "Just One More Question...!" video series, Dr. Christopher Sayed sat down with us to answer some of the most common questions he hears from his patients with hidradenitis suppurativa. 

*Whether you’ve just been diagnosed with hidradenitis suppurativa (HS) or are concerned you or someone you love might have it, you’re probably confused and scared. Take a deep breath and know this: Everyone featured on HealthCentral with a chronic condition felt like you do now. But we—and they—are here for you. On this page alone, you’ll not only discover the realities and challenges of the condition, but also the latest treatments, helpful lifestyle changes, where to find your hidradenitis suppurativa community, and all the other crucial information you need to help you not merely manage—but thrive. We’re sure you have a lot of questions…and we’ve got the answers you need.*

## What Is Hidradenitis Suppurativa, Anyway?

There is a lot of misinformation surrounding this chronic, inflammatory skin condition that produces painful bumps, called nodules, under the skin. Because the nodules look like acne, boils, or folliculitis (inflamed hair follicles), patients and providers often assume that’s what they are. Hidradentis suppurative (HS for short) is anything but—HS lesions form when bacteria get trapped in hair follicles, trigger an immune reaction, and plug them up. 

Unlike one-and-done pimples, HS nodules keep coming back—sometimes every week, sometimes every few months—in specific places. They can show up where there’s a lot of hair, like your armpits or groin. They also can crop up under the folds of skin on your stomach and breasts. HS happens in stages, and the severity of your symptoms will coincide with whatever stage of the disease you have:
* __Stage 1:__ This is the mildest form of HS. People have solitary bumps, usually in one area. 
* __Stage 2:__ If your HS is moderate, a tunnel, called a sinus tract, forms under your skin connecting a few lesions. 
* __Stage 3:__ If the disease is severe, you have multiple nodules and many tunnels. 

In all cases, when the nodules rupture, they don’t drain like ordinary boils. Instead, the pus and blood spread sideways deep in your skin, which is what helps form more tunnels. 

Whether you have a mild case or a more severe one, the pain can be the same—the lumps feel tender at first, then burn and throb as they swell. If these lumps are in places where your skin rubs together (like your thighs), walking can be agony—and even sitting is painful if you have nodules on your butt. When they drain, the pus-filled fluid often stains your clothes and stinks. No wonder nearly half of all HS patients reported in a recent study that the condition had impacted their life in an extreme way.

Another misconception is that HS is a rare disease. It’s not, really—it affects roughly between 1% to 4% of Americans. You’re more likely to develop it if you’re a woman between the ages of 18 and 50, with people in their 20s and 30s making up the largest number of cases. About a third of HS patients are African-American or biracial. 

It can sometimes take up to 10 years to get a diagnosis, and many patients go from provider to provider with a few stops at the ER and urgent care before a doctor IDs the disease. And because the disease can progress from a few sporadic nodules to many lesions and tunnels (though that’s not always the case), a delay in diagnosis can mean years of unnecessary pain and isolation. Even worse, the skin around these lesions and tunnels can break down, making them even more challenging to treat.

So, yeah, having HS sucks—which is why it’s crucial to arm yourself with knowledge so you can get a diagnosis more quickly, get the treatment you deserve, and take back your life.

Basics

HS INFO stats

HS Infographic Stats

## What Causes HS?

There are no clear answers, though there are theories. One thing for sure, though, is that you’re definitely not to blame—this condition isn’t caused by how often you bathe, change your razor, or clean your house. It’s not caused by unsafe sex or an infection. It’s not contagious. There are factors that play a role, but again, experts aren’t sure exactly how. They include: 

__Genes:__ Research shows that approximately a third of people with HS have a first-degree family member who also has it. But just because you don’t have a family history doesn’t mean you can’t develop HS and vice versa—having a family history doesn’t mean you’ll definitely get it. Researchers think there’s not one single gene, but probably a lot of different ones (and different mutations) that contribute to a person getting the disease.


__A hyperactive immune system:__ People with HS have an overactive immune system, which is triggered by certain things, including genetic mutations and possibly bacteria. Normally, the skin acts as a barrier to the millions of bacteria on it. If certain types of bacteria (say, staph or strep) enter the skin, they destroy the tissue around it, resulting in an infection. But in people with HS, benign bacteria may be causing the immune system to become more hyperactive. The result? Immune cells mistakenly attack these ordinary bacteria, causing inflammation.

__Hair follicles:__ Normally, hair follicles get infected when you irritate them, either by shaving or by rubbing the skin. But while experts think hair follicles play a role in HS, it’s not as simple as the follicle gets blocked up and then bad things happen. One theory is that inflammation may be affecting the oil glands that are attached to hair follicles, changing their structure or the type of oil they produce; that makes it easier for keratin, a type of protein, to build up along the walls of the follicle and plug it up. The blockage traps the normally benign bacteria that live on your skin, and your immune system goes on the attack. As the bacteria proliferate, the inflammation only worsens.

__Hormones:__ Androgens and estrogen, the sex hormones, may play a role in HS, but it’s complicated. It’s true that people typically develop HS as young adults, when these hormones are in high gear and producing changes throughout the body. Another clue: For some female patients, flares become worse during their periods, and doctors have noticed that the rates of HS are lower for women after menopause. But people with HS often have normal hormone levels, though medications like birth control can manage symptoms. Lots more research is needed. 

__Smoking and obesity:__ These things don’t cause HS—not every person with HS smokes or has a high BMI—but they are considered risk factors. Smokers have nearly twice the chance of developing HS than non-smokers. One reason: Nicotine and other chemicals can affect the hair follicles, making them more likely to get plugged up even if you don’t have HS. Being overweight can also aggravate HS—you have more skin folds and friction, two things that can intensify the pain from nodules. 


Causes

## Do I Have the Symptoms of HS?

HS can be unpredictable and symptoms can vary from person to person. Sometimes mild cases progress and become worse, and other times they don’t. You can have breakouts in the exact same spot every time (or in the same general area), or they might occur in multiple places at once. The breakouts on your skin may be small and look more like blackheads, or they might be large and red like boils—until they burst and drain, when they appear more like a wound. Either way, if you’ve noticed these bumps have come back at least twice in the past six months, you may have HS.

Signs of a mild or moderate case of HS can include:

- Having a single nodule that sometimes grows and comes back in the same place again and again, lasting anywhere from 7 to 15 days 
- Having recurrent lumps in your armpits, genitals (yes, even inside), groin area, inner thighs, butt (yes, even in your anus), or under the breasts. Sometimes they appear on the neck or behind the ears. 
- A burning, stinging, or itching sensation. Nodules may also feel warm, tender, and/or very painful.
- Odorous pus and fluid that drains after nodules erupt, leaving a deep, painful wound.
- A rope-like tunnel, called a sinus tract, under the skin that connects several lesions (in stage 2 cases).

In more severe cases:

- You’ll have so many lesions that you get multiple tunnels, or sinus tracts. 
- After breaking open, these lesions may not heal completely and may leak pus more or less continuously.



Symptoms

HS INFO signs

HS Infographic Signs

## When To Call Your Doctor or Dermatologist

If you notice any kind of pus-filled boil or a tender, red lump in your armpits, groin, genitals, or under your breasts, even if you’re not sure you’ve had something there before, see a doctor. Or book an appointment directly with a dermatologist if your insurance allows it: Dermatologists are trained to look at skin conditions, and a savvy one will be able to distinguish HS from boils caused by bacterial infections as well as other skin rashes. 

## How Do Doctors Diagnose HS?

There’s no lab or blood test that will diagnose the disease. Instead, providers take a detailed medical history and do a thorough skin check. Before the physical exam, your doctor will want to know about your symptoms as well as how often these outbreaks happen, how long the lesions last, where they occur, and if anyone in your family has had a similar condition.

Then the provider will examine your skin thoroughly, looking for signs of the disease: boils, blackheads, nodules, tunnels, and scars and where they occur on your body. If these breakouts don’t look like the classic signs of HS or have been there a long time, a provider may do a biopsy to rule out squamous cell cancer, which can occur in some people with severe cases of HS. A biopsy can also rule out rashes produced by other inflammatory diseases, especially IBS and Crohn’s. Patients with these GI disorders sometimes have painful red lumps on their legs and lesions near the anus. 

If your dermatologist suspects you may have another chronic condition along with HS (and many patients do) or you have a high BMI, you’ll get your blood tested to check your cholesterol, triglycerides, and blood sugar. If they’re high, you may have prediabetes, type 2 diabetes, or metabolic syndrome (a cluster of risk factors that include high cholesterol levels as well as high blood pressure), and your doctor may treat that with medications along with the HS.


Diagnosis

## What Are My Treatment Options?

The goal of treatment is simple: to stop or reduce the pain and drainage and prevent the nodules from coming back—or at least lengthen the time between flares. But those goals depend on the severity of the disease. If you have HS in just one area, like the armpits or your breasts, you may be able to go into remission with medications, including topical ones, and laser surgery. If your HS is in multiple parts of your body, then the goal is to manage the pain and drainage and reduce the number of flares. But again, HS is an idiosyncratic disease, and so what works for one person may not work for another, even if both have similar-looking cases. 

### Topicals 

Dermatologists use three ty)pes of topical washes or gels—antibiotics like Cleocin HCl (clindamycin), antiseptics like Brevoxyl (benzoyl peroxide), and keratolytics like DiabetAid Anti-Itch (resorcinol)—to reduce bacteria and decrease inflammation. You might use a benzoyl peroxide wash on a daily basis to prevent flares and control the odor and an antibiotic gel to reduce inflammation on single nodules. These work best for people with mild cases of HS who have nodules in one particular place—and topicals may be all you need to control flares.

### Oral Medications 

These can include a host of drugs, including antibiotics, hormonal therapy like birth control, retinoids, and anti-hyperglycemics (aka diabetes drugs that lower blood sugar like Glucophage, or metoformin). Some of these meds work best on patients who have stage 1 HS or women whose HS flares up when they’re premenstrual. And some are just used to manage outbreaks. Many HS patients have to take several systemic drugs. Options include:

- ### Antibiotics
  While bacteria may not cause HS, they need to be reduced during acute flare-ups. A course of antibiotics, used alone like Sumycin (tetracycline), or in combination such as Cleocin HCl (clindamycin) and Rifadin (rifampin), won’t put you in remission, but it can help stabilize the disease and help manage the drainage and pain. Doxycycline is an oral antibiotic that can be used as well.
 
- ### Hormone Therapy
  Dermatologists will often turn to androgen-blockers to control HS since hormones can make inflammation worse. These drugs work best if your flares get worse before your period or if you have irregular cycles. If you’re a guy who’s balding in the typical way (thinning on the crown along with a receding hairline) you might be a good bet for hormone therapy, too. Birth control pills as well as Aldactone (spironolactone), a blood pressure med, can put women with mild cases in remission. Men usually take Proscar (finasteride), a medication used to shrink an enlarged prostate.

- ### Retinoids
  About 15% of people with HS also have acne, according to the *Journal of the American Academy of Dermatology*. Dermatologists use retinoids in cases that don’t respond to other meds or topicals—these powerful drugs can shrink oil glands and reduce the number bacteria in both the oil glands and on the skin. They can improve HS outbreaks in some people, but are more effective on the acne.

- ### Metformin
  Many patients with HS are obese (though not all), so doctors are likely to screen them to see if they’re prediabetic (or actually have the disease) and recommend an anti-hypoglycemic like Glucophage (metformin) to reduce insulin resistance. But the drug does more than that—it can actually reduce the number of nodules too. The link—high insulin levels can lead to more inflammation.
 
- ### Biologics
  These medications are designed to target different types of proteins that fuel inflammation. People with HS often produce too much TNF-alpha, so biologics called TNF-inhibitors (like Humira) latch onto these cells. That in turn reduces inflammation and the number of flares, and it can prevent the disease from progressing. In severe cases, biologics can reduce drainage, which in turn decreases pain.  

Medication Treatment

HS INFO treatments

HS Infographic Treatments

## Surgery and Laser Treatments

### Lasers

[Getting rid of the hair](https://www.healthcentral.com/article/hair-removal-techniques-for-hidradenitis-suppurativa) under your armpits or your groin can prevent HS from progressing—at least in the earlier stages of the disease. And the best way to do that is via laser. The concentrated beam of light (i.e. the laser) can zap hair follicles to minimizes hair growth. If you do this once a month for about three months, you can reduce nodules and keep outbreaks at bay with topicals.

### Surgery

If your lesions have formed tunnels, you’re probably a candidate for surgery, but what kind depends on the stage of the disease. If you have a single tunnel, then doctors perform something called deroofing, or opening up the tunnel to wipe out the jelly-like material in there called a [biofilm](https://www.healthcentral.com/article/biofilms-and-hs). Then the tunnel heals, becoming a scar and preventing nodules from erupting there.

For multiple, interconnected tunnels in patients who have a severe case that’s not improving with medication, doctors use a laser to remove all the tissue along the tunnels. The wound is either closed or left to heal on its own. This can ease the pain of the lesions. This is a bigger operation, requiring general anesthesia and sometimes a hospital stay. 




Laser Treatment

Think you may have the symptoms of hidradenitis suppurativa? Make sure you are familiar with your treatment options, too. Check out our guide to HS treatment here.


Learn More About HS Treatment Options

## Other Types of Therapy That May Help

### Diet

Eating fewer carbs and more protein can help reduce inflammation for everyone—and it may help you shed pounds, lowering the risk of other diseases associated with HS like heart disease and type 2 diabetes.  So can eating a Mediterranean diet—one that’s rich in vegetables and fruits, lower in red meats and processed carbs—or one that’s mainly plant-based. 

There hasn’t been a lot of research on the role of diet, although there were two small studies that found good effects—symptoms improved, the HS stopped progressing—when people went dairy-free or stopped eating bread and products with yeast. There’s some anecdotal evidence (mainly on social media) that avoiding nightshade plants (tomatoes, eggplants, bell peppers) may help too.

### Supplements

People swear by turmeric, which is an anti-inflammatory, but the evidence that it can help HS flares is purely anecdotal. But taking a zinc supplement every day if you have a mild or moderate HS may help, according to one study. That’s because zinc plays a big role in your immune system’s ability to fight off harmful substances and repair damaged cells; and too little zinc may result in lesions and slow healing.


## Complications and Comorbidities of HS

Many HS patients have other chronic illnesses, leading researchers to think that hidradenitis is a systemic disease affecting the whole body, not just the skin. Another theory: HS shares some sort of defect in the immune system with other autoimmune disorders, like inflammatory bowel disease and certain types of arthritis. In those cases, the autoimmune inflammatory cells occur in the bloodstream, but they're being directed partially to the skin, partially to the gut, partially to the joints. 

If you have a high BMI, you might be at risk for metabolic syndrome, type 2 diabetes, and cardiovascular disease. This may be a result of the inflammation as well as becoming more sedentary if your pain keeps you from walking or doing any kind of physical activity. 

__Comorbidities of HS include:__

__Inflammatory bowel disease (IBD)__—People with HS are two to three times more likely to have this chronic condition that includes Crohn's disease and ulcerative colitis.

__Metabolic syndrome__—Half of all HS patients have metabolic syndrome, which is a group of risk factors including obesity, high blood pressure, high blood sugar and cholesterol that increase your chances of heart attacks, strokes, and type 2 diabetes. 

__Spondyloarthritis (SpA)__—About 5% of people with HS also have this inflammatory joint disease that attacks the spine and produces back pain. Patients who had both conditions developed SpA roughly four years after the first symptoms of HS.

__Polycystic ovary syndrome (PCOS)__—Roughly 9% of HS patients have this hormonal disorder that causes women to produce higher-than-normal__text in bold__ amounts of male sex hormones (testosterone and other androgens).

__Complications of HS include:__

__Squamous cell carcinoma__, the second most common type of skin cancer—4%  percent of HS patients go on to develop this type of skin cancer, maybe because the constant inflammation in lesions and nodules produces changes in your skin at a cellular level.

__Anxiety and depression__—Understandably, about a third of HS patients have anxiety and 35% suffer from depression. 

__Suicide__—Roughly 10% of HS patients have had thoughts of killing themselves or attempted it. And a 2017 study in the *Journal of Investigative Dermatology* found that people with HS were twice as likely to die of suicide.


## Prevention

Well, truthfully, there’s nothing that can prevent hidradenitis because no one knows what causes it in the first place. But these strategies can help you avoid complications, and may improve symptoms and lessen the pain.

__Stop smoking.__ Smokers were twice as likely to have HS—probably because of nicotine, which can affect hair follicles—and the incidence was highest among those who were in their 30s, African-American, female, and obese, according to a study in the *British Journal of Dermatology*. While quitting may not do much to reduce flares, it certainly can’t hurt—it will lower your odds of developing heart disease, which is also high with HS because it is a known comorbidity.  

__Lose weight (or maintain a healthy one).__ If you’re obese, odds are your HS flares may be worse. While that may have something to do with the role body fat plays in inflammation, being overweight means more skin folds, more moisture on the skin, and more places where your skin rubs against itself—all factors that slow down healing and up the pain. There’s some evidence that losing 15% of your weight (so 30 pounds if you weigh 200) could decrease your symptoms by about a third—and significantly reduce the number of places on the body where nodules appear.

__Eat more fruits and vegetables—and less sugar.__ Diet is the best way to lose weight, so to achieve a lower BMI, stay away from empty calories (like soda and sugary snacks), processed foods (like cold cuts, white bread, and chips), and fatty foods. In fact, avoid sugar and high glycemic foods—foods that are white, like pasta, bread, rice, and potatoes—that your body can turn into sugar quickly. That raises insulin, which in turn fuels inflammation.   

__Move.__ You know what an overall health-booster exercise is, but you also know that sweat and the friction caused by clothing or your skin rubbing against itself can make pain and draining nodules worse. That’s why walking and swimming are two great choices (you sweat less, for one) that are gentle on your joints as are yoga and tai chi, which also are good for your mind (and soul). 


Prevention

## What's Life Like for People With HS?

One word: heartbreaking. During outbreaks, your day-to-day life means managing the pain and odor as fluids drain from tunnels and nodules. On top of that, you're figuring out everything from what to wear to what to say about your condition and how you're feeling. And feeling like you have to constantly explain yourself is exhausting. While it may seem overwhelming now, especially if you’ve just been diagnosed, find a doctor who has your back and will work with you to reduce the flares so you can get your life back. It’s possible.

### Emotional Health

It’s hard not to feel depressed or anxious when you have HS—or to get down about the chances of having a “normal” life. The best way to deal?

__Find your tribe.__ No one knows what you’re going through like someone who’s been there before. That’s why talking to someone with HS can help. There are online support groups and those IRL in certain cities (Detroit, New York City, and Atlanta, to name a few) as well as groups, private and public, on Facebook. 

__Talk to others.__ Joining an advocacy group can help you channel difficult feelings into something more positive, like change and awareness. Or simply take the opportunity to open up with family and friends about what your life is like, and let them help you when you can’t manage. 

__Talk to a therapist.__ Finding someone sympathetic who can suggest coping skills and acceptance will help you feel more in control of your emotions—and less depressed and anxious. 

### Sex 

Being intimate with someone is rough when you have oozing, painful boils and tunnels in all the places that are supposed to be erogenous zones—your genitals, breasts, and butt. And some meds might send your libido plummeting, which also doesn’t help. You’re not alone though. Both men and women suffer from sexual distress, though you’re more likely to feel more self-conscious if you’re female (what else is new?) and single. But people with HS do have satisfying sexual relations and partners. What helps:

__Be upfront.__ Explain the condition to any potential partners, and let them ask you as many questions as possible. And don’t assume you know what they’re thinking—ask if you aren’t sure.

__Find satisfaction other ways.__ You may not feel like having sex during a flare, but sex doesn’t necessarily have to include intercourse—there are other things you can do to express your love. Snuggling on the sofa makes intimacy grow, as can having a nice meal together or binge-watching your favorite shows.  

__Change positions.__ If you’re self-conscious about the scars or lesions on your breasts or around your genitals, try spooning from behind or doing it doggie-style.

### Pregnancy

Being pregnant is tough enough without worrying about your skin or having to change up your meds (and routine). But take comfort that your flares aren’t likely to get worse (only 8% of women’s did) and there’s a 1 in 5 chance that your HS may improve, according to a  study in the *Journal of the American Academy of Dermatology*. But it may be more important to discuss your meds with your doctor if you’re planning to become pregnant or as soon as you suspect you are, as biologics, hormones, and retinoids aren’t the safest choices for pregnant moms. 


## Where Can I Find My HS Community? 

We can’t stress this enough—HS can make you feel isolated and alone, so you really need people who really know what you’re dealing with, even if you’re just posting comments online.  Find them here:

### Top HS Instagrammers 

- Selina Ferragamo, [@hidradenitis.selina](https://www.instagram.com/hidradenitis.selina/) __Follow because:__ If ever there was a meme that spoke to your HS-soul, well, you’d find it on Selina’s page. Sprinkled throughout her hilarious and completely relatable feed are small life updates about her own HS, to remind you that there’s a face behind all that hilarity. Now, back to your regularly scheduled meme.  

- Sara Tanner, [@sara.reliving](https://www.instagram.com/sara.reliving/) __Follow because:__ She’s a young mom on a journey to become healthier and more fit, which, in turn, she knows could benefit her HS. She also squashes stigma about HS along the way, reminding everyone not to judge a book by its slightly bumpier cover. 

- Cheyenne Brooke, [@completely_chey](https://www.instagram.com/completely_chey/) __Follow because:__ We really couldn’t say it better than her Instagram profile: night owl, PCOS fighter, mental health advocate, cosmetology student, living with HS, and dog mom. You’ll get a taste of all these things on her feed, including her passion for being brave and “out” about her condition.

### Top HS Support Groups  

- __HS Awareness No More Silence on Instagram.__ Self-proclaimed warriors with battle scars, this is where you’ll find all your fellow HS’ers on Instagram. Hear their stories, reap the benefits of their been-there-tried-that tips, and nod along with their HS-life woes. Share your own story and you could be featured, too! Just be sure to tag them.  

- __Hidradenitis Suppurativa Support Group on Facebook.__ This is a private group on Facebook, and for good reason — it’s a place for you to go where only people with HS will know your name and there’s no chance in someone from your usual feed finding out about your condition or detailed questions. The five admins, all affected by HS, make themselves available by private Facebook message in case you need to talk on an even more private level. 

- __Hidradenitis Suppurativa Warriors on Facebook.__ With nearly 16,000 members and roughly 25 new posts daily, this private Facebook group will have your back with support, a safe place to share news and info, ask questions, and provide the strength you need to tap into your own inner HS warrior.  

### Top HS Non-Profits and Organizations 
 
__[Hidradenitis Suppurativa Foundation](https://www.hs-foundation.org/).__ With a mission to improve the lives of those with HS through education, advocacy, and research, HSF is the place to find clinics and doctors who can help you. Their support goes beyond endless scrolls of treatments, new research, and general education (though, they have that, too), and dives deeper into the effects that HS has on your mental health, and how you can get involved in speaking up about this disease.  

__[HSAwareness.org.](http://hidradenitissuppurativaawareness.org/)__ While there’s yet to be a sole podcast dedicated to HS (hint, hint, nudge, nudge), you can find a sprinkling of podcasts about different aspects of HS curated here, along with videos that tug at your heart strings.  
 
[__Hope for HS.__](https://hopeforhs.org/) Started by people with HS and those who love them, this non-profit is run strictly by volunteers. Here you can find clinical trials and research news in layman’s terms, as well as support groups online and in various cities, including Miami, Richmond, and Detroit. They truly are here to give you hope and show you that you’re not alone.  


Communities

- __HS statistics__: *JAMA Dermatology* (2017). “Sex- and Age-Adjusted Population Analysis of Prevalence Estimates for Hidradenitis Suppurativa in the United States,” [jamanetwork.com](https://jamanetwork.com/journals/jamadermatology/fullarticle/2626146)

- __HS patients’ needs__: *Journal of the American Academy of Dermatology* (2019) “Evaluating Patients' Unmet Needs in Hidradenitis Suppurativa: results from the Global VOICE project,” [ncbi.nlm.nih.gov](https://www.ncbi.nlm.nih.gov/pubmed/31279015)

- __Hormones and HS__: *Acta Dermatovenerologica Croatica* (2016). “The Role of Androgens and Estrogens in Hidradenitis Suppurativa - A Systematic Review,” [ncbi.nlm.nih.gov](https://www.ncbi.nlm.nih.gov/pubmed/28128074)

- __Smoking and HS__: *British Journal of Dermatology* (2017). “Incidence of hidradenitis suppurativa among tobacco smokers: a population‐based retrospective analysis in the U.S.A.,” [onlinelibrary.wiley.com](https://onlinelibrary.wiley.com/doi/full/10.1111/bjd.15939)

- __HS symptoms, diagnosis, and comorbidities__: *Clinical, Cosmetic and Investigational Dermatology* (2017). “Hidradenitis suppurativa: from pathogenesis to diagnosis and treatment,” [ncbi.nlm.nih.gov](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5402905/)

- __Sex and HS__: *International Journal of Women’s Dermatology* (2018). “Quality of life and sexual health in patients with hidradenitis suppurativa,” [sciencedirect.com](https://www.sciencedirect.com/science/article/pii/S2352647517300874)

- __Pregnancy and HC__: *Journal of the American Academy of Dermatology* (2017). “Management of hidradenitis suppurativa in pregnancy,” [ncbi.nlm.nih.gov](https://www.ncbi.nlm.nih.gov/pubmed/28040373) 

- __Biologics and HS__: *Clinical and Experimental Dermatology* (2019). “Clinical response rate and flares of hidradenitis suppurativa in the treatment with adalimumab,” [doi.org](https://doi.org/10.1111/ced.14127)

- __Hormone therapies in HS__: *Dermatology Online Journal* (2017). Hormonal therapies for hidradenitis suppurativa: Review, [escholarship.org](https://escholarship.org/uc/item/6383k0n4)
 
- __Overall Treatment and HS__: *Mayo Clinic Proceedings* (2015). “Hidradenitis Suppurativa,” [mayoclinicproceedings.org](https://www.mayoclinicproceedings.org/article/S0025-6196(15)00711-9/fulltext#sec7.3) 

- __Arthritis and HS__: *The Journal of Rheumatology* (2014). “Hidradenitis Suppurativa Associated with Spondyloarthritis — Results from a Multicenter National Prospective Study,” [jrheum.org](http://www.jrheum.org/content/41/3/490)

- __Suicide and HS__: *Journal of Investigative Dermatology* (2017). “Completed suicide in patients with hidradenitis suppurativa: A population analysis in the United States,” [sciencedirect.com](https://www.sciencedirect.com/science/article/pii/S0022202X17304190)

- __PCOS__: *MD Edge/Dermatology* (2018). “Polycystic Ovary Syndrome Linked with HS,” [mdedge.com](https://www.mdedge.com/dermatology/clinical-edge/summary/mixed-topics/polycystic-ovary-syndrome-linked-hs)

- __IBS and HS__: *JAMA Dermatology* (2019). “Association of Hidradenitis Suppurativa With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis,” [ncbi.nlm.nih.gov](https://www.ncbi.nlm.nih.gov/pubmed/31290938)

- __Heart disease and HS__: *JAMA Dermatology* (2016). “Risk of Major Adverse Cardiovascular Events and All-Cause Mortality in Patients With Hidradenitis Suppurativa,” [jamanetwork.com](https://jamanetwork.com/journals/jamadermatology/fullarticle/2491691) 

- __*British Journal of Dermatology*__ (2015). “Cardiovascular disease risk factors in patients with hidradenitis suppurativa: a systematic review and meta-analysis of observational studies,”
- [ncbi.nlm.nih.gov](https://www.ncbi.nlm.nih.gov/pubmed/26153913)


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