Hidradenitis suppurativa is a chronic, relapsing skin condition that causes painful abscesses and scarring.

Hidradenitis suppurativa affects approximately 1–4% of the population worldwide. It is more common among females than males.

In this article, learn more about hidradenitis suppurativa, including its stages, causes, symptoms, and treatment options.

Hidradenitis suppurativa is a chronic skin condition. It is sometimes called acne inversa.

It causes small, inflamed nodules that can become very swollen and large. They may sometimes rupture and leak pus.

Hidradenitis suppurativa cysts can resemble other skin conditions, such as:

However, unlike other common skin sores, hidradenitis suppurativa tends to affect different body regions and cause major scarring. The scars can interfere with movement and a person’s quality of life.

Here are some pictures of hidradenitis suppurativa:

Without early diagnosis and treatment, hidradenitis suppurativa can sometimes progress and cause severe scarring.

If a primary care physician cannot manage a person’s hidradenitis suppurativa with standard treatment, they may refer the person to a board certified dermatologist for more advanced treatment options.

People who receive a diagnosis of hidradenitis suppurativa have several available treatment options, which focus on:

  • resolving breakouts
  • removing scars and fistulas
  • reducing breakout frequency and severity
  • reducing the pain associated with hidradenitis suppurativa lesions

Many medications can help treat minor to moderate cases of hidradenitis suppurativa. These medications include:

  • Antibiotics: Doctors often prescribe oral antibiotics off-label to kill bacteria. Oral doxycycline is a common choice. Some of these drugs also have anti-inflammatory properties. A person may need to complete at least a 3-month course of antibiotics to confirm whether the treatment is effective.
  • Topical antibiotics: Clindamycin solution, a topical antibiotic, is frequently used to manage hidradenitis suppurativa.
  • Corticosteroids: These steroids reduce inflammation. A doctor may use intralesional steroid injections or an oral steroid taper to control hidradenitis suppurativa flare-ups.
  • Diabetes medications: Doctors may prescribe the type 2 diabetes drug metformin (Glucophage) off-label to improve lesions in some people.
  • Hormone therapy: Hormone regulators, such as spironolactone, which is used to reduce swelling from fluid retention, combined with birth control pills, may be helpful.
  • Antimicrobial washes: Experts have recommended washes containing chlorhexidine, benzoyl peroxide (10%), and zinc pyrithione for treating hidradenitis suppurativa.

Read more about off-label drug use here.

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 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 is off-label.

Doctors may also prescribe oral retinoids to treat the condition. These drugs are derived from vitamin A. They are only occasionally effective as an off-label option for some people with hidradenitis suppurativa.

In some severe cases or those that do not respond to other therapies, a dermatologist may perform or refer a person for a surgical procedure. These procedures can include:

  • Incision and drainage: A doctor opens the nodule with a scalpel to allow it to drain, relieving pain. Healthcare professionals do not recommend this procedure often because it creates a draining wound and the nodule is likely to reoccur.
  • Deroofing: Deroofing is best for painful, deep, recurring sores. There are various ways to do this, including curettage and cautery.
  • Excision: A doctor can cut out areas prone to severe sores. They 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.

However, surgery for hidradenitis suppurativa does not guarantee success.

A 2020 study including 75 people with hidradenitis suppurativa and a median age of 31.4 years found a recurrence rate of 35% after excision surgery.

However, two-thirds of the study participants said they were satisfied with their surgery and would recommend it.

People with hidradenitis suppurativa may first develop small pimple-like bumps, sores, or boils on the skin.

Unlike regular pimples, these sores are usually recurrent. They can affect both sides of the body and tend to develop in areas where the skin folds or experiences friction. These areas include the:

  • groin
  • underarms
  • upper thighs
  • breasts
  • buttocks
  • 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, then come back.

For some people, the sores develop in the same place each time. For others, the sores appear elsewhere. Hidradenitis suppurativa is a lifelong condition.

Diet may play a role in the severity of hidradenitis suppurativa.

According to a 2019 study, a dairy-free diet may help reduce the clinical severity of hidradenitis suppurativa. A diet free of dairy and brewer’s yeast may also reduce symptom severity.

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 symptoms 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 affect a person’s quality of life.

A dermatologist may determine the severity of hidradenitis suppurativa using the Hurley stages:

  • Stage 1: Single or few sores, with no sinus tracts or scarring.
  • Stage 2: More than one sore or affected area with localized scarring but limited sinus tracts.
  • Stage 3: Widespread sores with extensive scarring and sinus tracts that involve a whole area of the body.

Researchers do not know exactly why hidradenitis suppurativa develops, but the nodules tend to result from blocked hair follicles.

Sex hormones may 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.

Many people with hidradenitis suppurativa 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.

People do not develop the condition due to poor hygiene. Hidradenitis suppurativa is not contagious.

There is no known cure for hidradenitis suppurativa. It is a chronic condition that needs management. People with hidradenitis suppurativa will not always respond the same to treatment.

A few at-home remedies may help reduce symptoms if a person uses them alongside other treatments. These home remedies include:

  • Using antibacterial washes: Washes containing chlorhexidine, benzoyl peroxide (10%), or zinc pyrithione may be effective.
  • Caring for the wound: Sores require good wound care, such as frequent cleaning with a non-soap cleanser or antiseptic and regularly applying clean dressings.
  • Applying warm compresses: Heat reduces pain and may help draw out the pus from the sores. To create a warm compress, run a clean washcloth under warm water and place it on the sore for 10 minutes.
  • Reaching and maintaining a moderate body weight: Hidradenitis suppurativa is significantly more common in people with obesity, but weight management can reduce symptoms.
  • Stopping smoking: Quitting tobacco products may reduce symptoms.
  • Avoiding shaving: Shaving irritates the skin and can allow bacteria to enter broken skin. A dermatologist may recommend laser hair removal or offer advice on other ways 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. Loose-fitting clothes and underwear can help reduce this.

A person with hidradenitis suppurativa will typically have scars and dyspigmentation. Visible scars may cause psychological distress in some people. The scarring may cause pain and limited mobility.

Several risk factors make hidradenitis suppurativa more likely. Some of these include:

  • smoking
  • obesity
  • family history
  • sex differences

Hidradenitis suppurativa may be present alongside other conditions, such as:

Hidradenitis suppurativa can cause physical and psychological complications, including:

A person with hidradenitis suppurativa may have to change their lifestyle. The complications of hidradenitis suppurativa may make it difficult to work, go to school, and do physical activity.

The social stigma of hidradenitis suppurativa may cause psychological distress. A person with hidradenitis suppurativa may want to find a social support group and a flexible job.

Smoking and obesity are risk factors for the condition. If a person smokes, they may want to consider quitting. If a person has obesity, they may want to consider losing weight with their doctor’s help.

Here are some questions people often ask about hidradenitis suppurativa:

What triggers hidradenitis suppurativa?

Smoking and obesity are the most common triggers of hidradenitis suppurativa. However, what triggers hidradenitis suppurativa for one person may not be the case for another.

Does hidradenitis suppurativa ever go away?

Hidradenitis suppurativa is a lifelong, chronic condition that must be managed. For some people, symptoms may lessen or eventually stop with treatment.

What are the stages of hidradenitis suppurativa?

Hidradenitis suppurativa is classified according to the Hurley staging system. It ranges from stages 1–3. Stage 1 is the mildest form. Stage 3 is the most severe.

Is hidradenitis suppurativa an autoimmune disease?

Some researchers believe that hidradenitis suppurativa may be an autoimmune disease. People with the condition develop antibodies. However, this finding alone does not mean it is definitely an autoimmune disease. More research is needed.

Hidradenitis suppurativa is a long-term skin condition. It can be painful and cause scarring.

The condition requires regular management. A dermatologist can help find the best medications, home remedies, and other treatments to manage hidradenitis suppurativa symptoms.

People who find their symptoms particularly challenging may benefit from joining a local support group.