It affects approximately 1–4% of the population worldwide and is more common among females than males.
In this article, learn more about hidradenitis suppurativa, including its stages, causes, symptoms, and treatment options.
What is hidradenitis suppurativa?
Hidradenitis suppurativa is a long term skin condition that is sometimes called acne inversa.
It causes small inflamed nodules that can progress to become very swollen and large. They may sometimes rupture and leak pus.
Hidradenitis suppurativa cysts can resemble the signs of other skin conditions, such as:
- cysts with other causes, such as epidermoid cysts
- furuncles (boils)
However, unlike other common skin sores, hidradenitis suppurativa tends to affect different body regions and cause major scarring. These scars can interfere with movement and a person’s quality of life.
Image credit: Ziyad Alharbi, Jens Kauczok† and Norbert Pallua, 2011.
Image credit: BRI72783, 2012.
Image credit: Samuel Freire da Silva, 2016.
Image credit: Mohammad2018, 2018.
Without early diagnosis and treatment, hidradenitis suppurativa can sometimes progress and result in severe scarring. A doctor will usually send someone with the symptoms of this condition to a dermatologist for a diagnosis.
People who receive a diagnosis of hidradenitis suppurativa have several different treatment options, which focus on:
- resolving breakouts
- removing scars and fistulas
- reducing breakout frequency and severity
Many different medications can help treat minor-to-moderate cases of hidradenitis suppurativa. These medications include:
- Antibiotics: Doctors often prescribe topical or oral antibiotics off-label to kill bacteria, with oral doxycycline being a common choice. Some of these drugs also have anti-inflammatory properties. Usually, a person will need to complete at least a 3 month course of antibiotics to confirm whether the treatment is effective.
- Corticosteroids: These steroids reduce inflammation. A doctor will recommend topical rather than systemic use for hidradenitis suppurativa.
- Diabetes medications: Doctors may prescribe metformin (Glucophage) — a drug for type 2 diabetes — off-label to improve lesions in some people with hidradenitis suppurativa.
- Hormone therapy: Hormone regulators, such as combined birth control pills, may be helpful.
- Potent cleansers: Experts have recommended washes containing chlorhexidine, benzoyl peroxide (10%), and zinc pyrithione for treating hidradenitis suppurativa.
In severe cases, a dermatologist might recommend more aggressive treatments that may be more effective but can come with more side effects.
People should always discuss the potential benefits and risks of different hidradenitis suppurativa treatments with a dermatologist.
Common treatments for severe hidradenitis suppurativa include:
- Biologics: These medications act on the immune system. In 2015, the Food and Drug Administration (FDA) approved the use of the injectable biologic medication adalimumab (Humira) for moderate-to-severe hidradenitis suppurativa. Doctors may prescribe other biologics, such as the popular psoriasis biologic ustekinumab (Stelara), but this use will be off-label.
- Oral retinoids: These drugs, which derive from vitamin A, are only occasionally effective as an off-label option for people with hidradenitis suppurativa.
In severe cases or those that do not respond to other therapies, a dermatologist may need to perform or refer a person for a surgical procedure. These procedures can include:
- Laser surgery: This procedure destroys hair follicles.
- Incision and drainage: In this procedure, the doctor opens up the nodule with a scalpel to allow it to drain, relieving pain. Healthcare professionals do not often recommend it because it creates a draining wound, and the nodule is likely to reoccur.
- Deroofing: Deroofing is best for painful, deep, recurring sores, which it transforms into scars.
- Excision: A doctor can use this procedure to cut out areas prone to severe sores. They will then cover the wound by stretching the surrounding skin over it or using skin from another part of the body. Symptoms usually do not return in the same spot.
Maintaining a healthy body weight may help reduce symptoms of hidradenitis suppurativa.
A few at-home remedies may also help reduce symptoms if a person uses them alongside other treatments. Home remedies include:
- Using antibacterial washes: Washes containing chlorhexidine, benzoyl peroxide (10%), or zinc pyrithione may be effective in treating hidradenitis suppurativa.
- Caring for the wound: Sores require good wound care, such as frequent cleaning with a nonsoap cleanser or antiseptic and the regular application of clean dressings.
- Applying hot compresses: Heat reduces pain and may help draw out the pus from the sores. To create a hot compress, run a clean facecloth under warm water, and place it on the sore for 10 minutes.
- Reaching and maintaining a healthy body weight: Hidradenitis suppurativa is significantly more common in people with obesity, but weight loss can reduce symptoms. Even losing just 10% of body weight can help.
- Stopping smoking: Quitting tobacco products may reduce symptoms.
- Avoiding shaving: Shaving irritates the skin and can allow bacteria to enter broken skin. A dermatologist can offer advice on how to remove hair from around the affected skin.
- Keeping the skin cool: Overheating can lead to symptom flare-ups, so staying cool and dry can help.
- Reducing friction: Rubbing and constriction from clothes can trigger symptoms, so it is best to wear loose fitting clothes and underwear.
People with hidradenitis suppurativa may first develop small pimple-like bumps, sores, or boils on the skin.
- upper thighs
- folds under the stomach
Less commonly, hidradenitis suppurativa sores may also appear on other areas of the body.
Hidradenitis suppurativa may clear up for days, weeks, or months only to reoccur.
For some people, the sores develop in the same place each time, but for others, they appear elsewhere. Hidradenitis suppurativa is a lifelong condition.
The early stages of hidradenitis suppurativa tend to cause vague symptoms that a person can easily mistake for those of another skin condition.
Common early warning signs of hidradenitis suppurativa include:
- one or more breakouts of pea-sized pimples or boils that either disappear, enlarge, or rupture and leak pus after a few hours to days
- breakouts that last for a long time
- breakouts that clear up but then return
In some people, the sores are more severe. Signs and symptoms of severe hidradenitis suppurativa include:
- chronic deep, painful sores that may rupture and leak fluids, such as pus or blood
- rope-like scarring that forms as sores heal
- scarring that thickens over time
- hollow channels very deep under the skin (sinus tracts), which give it a spongy appearance
All hidradenitis suppurativa sores can be painful, tender, and cause scarring. In severe cases, extensive scarring and large or leaking infections can also cause embarrassment and reduce a person’s self-confidence and quality of life.
A dermatologist may determine the severity of hidradenitis suppurativa using the Hurley Stages:
- Hurley Stage I: Single or few sores with no tunneling/sinus tracts.
- Hurley Stage II: More than one sore or affected area but limited tunneling.
- Hurley Stage III: Multiple sores with extensive scarring and tunneling that involves a whole area of the body.
A person who experiences acne may be more at risk of developing hidradenitis suppurativa.
Researchers do not know precisely why hidradenitis suppurativa develops, but the nodules tend to result from blocked hair follicles.
Sex hormones may also play a role in the development of hidradenitis suppurativa. Most people first experience symptoms after puberty.
The immune system could be a factor in the development of hidradenitis suppurativa. One theory is that the immune system overreacts to minor infections in clogged hair follicles.
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About one-third of people with hidradenitis suppurativa also have a relative with the condition, so it may have a genetic component. Research has linked it to changes in the following genes: NCSTN, PSEN1, and PSENEN.
Some other factors and medications may increase the risk of a person developing hidradenitis suppurativa. These include:
- being female
- being overweight or having obesity
- taking lithium
People with hidradenitis suppurativa may also be more likely to have certain other health conditions, including:
- hirsutism, or excessive hair growth
- metabolic syndrome
- polycystic ovary syndrome (PCOS)
- inflammatory bowel disease (IBD)
- heart disease
According to the American Academy of Dermatology Association, poor hygiene is not responsible for hidradenitis suppurativa, and the condition is not contagious.
The outlook for people with hidradenitis suppurativa tends to improve with early diagnosis and effective treatment. However, it is a long term condition that requires constant management.
The symptoms can cause chronic pain, discomfort, depression, low self-esteem, and mobility problems.
A dermatologist can help a person find the best medications, home remedies, and other treatments to manage their symptoms.
People who find their symptoms particularly challenging may benefit from joining a local support group.