Painful lumps in the armpits. Recurrent abscesses in the groin. Draining tunnels in the buttocks that never seem to heal. Scars that thicken over years into ropy ridges. For millions of people, this is life with hidradenitis suppurativa, a chronic inflammatory skin disease that has been misdiagnosed and undertreated for decades. New understanding of the underlying biology has transformed what can be offered. Early aggressive treatment preserves skin, reduces suffering, and can dramatically change the course of the disease.
Hidradenitis suppurativa, often shortened to HS, affects about one in a hundred people worldwide, though many estimates are lower because of underdiagnosis. Women are affected more often than men by roughly three to one. Onset is typically in the teens or twenties. Despite being common, the average delay from first symptoms to correct diagnosis exceeds seven years. That delay costs patients dearly.
What Is Actually Happening
HS is not a bacterial infection. It is a chronic inflammatory disease centered on the hair follicle. Blockage of the follicle, driven by a combination of genetic, hormonal, and environmental factors, leads to rupture into surrounding skin. The contents provoke intense inflammation, abscess formation, and tunnel creation as the skin tries and fails to contain the process. Over time, multiple tunnels interconnect beneath the skin, draining through multiple sinuses. Scarring follows, sometimes so extensive that nearby skin becomes fibrotic, painful, and functionally limited.
Bacterial colonization happens secondarily. Treating HS like a simple infection with courses of antibiotics targeted at staph or strep misses the underlying inflammatory driver.
The Three Stages
The Hurley staging system divides disease into three stages. Stage one has isolated abscesses without sinus tracts or scarring. Stage two has recurrent abscesses with limited sinus tracts and scarring. Stage three has diffuse or near-diffuse involvement with multiple interconnected tracts and abscesses across an entire area.
Early stage disease responds best to aggressive topical and systemic medical therapy. Advanced disease often requires surgical intervention in addition to medical control.
Common Locations
HS favors areas with dense hair follicles and apocrine glands where skin rubs against itself. The underarms are the most common site. The groin, inner thighs, buttocks, perianal region, and underneath the breasts are also frequent. The back of the neck, the face, and other sites are less common but occur.
The pattern of involvement varies. Some patients have predominantly axillary disease. Others are most affected in the groin and perineum. Buttock involvement is often the most severe because of the constant pressure and friction and tends to cause the most disability.
Risk Factors and Triggers
Smoking is strongly associated with HS and makes it worse. Quitting does not always cure, but it reduces flare frequency and severity. Obesity compounds the condition through increased skin friction, metabolic inflammation, and hormonal effects. Weight loss, while not curative, often improves disease activity.
Hormonal fluctuations drive flare patterns. Many women report worsening before menstruation, improvement during pregnancy, and variable changes during breastfeeding and with hormonal contraceptives. Metabolic syndrome, insulin resistance, and polycystic ovary syndrome cluster with HS at elevated rates.
Genetics matter. First-degree relatives of patients with HS have a higher risk, and certain gene variants in the gamma-secretase pathway have been identified in familial cases. Most patients, however, do not have a clearly identifiable monogenic driver.
The Diagnostic Hallmarks
Three criteria define HS: typical lesions of deep-seated painful nodules, abscesses, sinus tracts, or scarring; typical locations in intertriginous skin; and a chronic, relapsing course. No laboratory test confirms the diagnosis. Imaging with ultrasound or MRI helps map the extent of disease, particularly before surgery.
Cultures are often obtained during abscess drainage but are rarely useful for guiding treatment because the disease is not infection-driven. Routine broad-spectrum antibiotics are a common early misstep.
Daily Life With HS
Beyond the physical pain, HS exacts a heavy psychological toll. Rates of depression, anxiety, and suicidal ideation are among the highest in dermatology. The smell and drainage from sinus tracts can lead to social withdrawal. Sexual function is affected, particularly when genital and perianal disease is active. Work and school performance suffer. Quality-of-life scores are comparable to or worse than those in many advanced cancers.
Clothing choices become strategic. Loose, breathable fabrics minimize friction. Absorbent dressings manage drainage. Showering, body care, and hair removal require adaptation.
Medical Treatment
Mild disease is often managed with topical and simple systemic measures. Topical clindamycin, chlorhexidine wash, benzoyl peroxide, and resorcinol cream have evidence for mild disease. Intralesional triamcinolone injections directly into individual nodules provide rapid relief.
Tetracycline antibiotics such as doxycycline and minocycline are used not only for their antibacterial properties but also for their anti-inflammatory effects. Oral clindamycin combined with rifampin is a common regimen for moderate disease.
Hormonal therapy helps many women. Combined oral contraceptives with antiandrogenic progestins and spironolactone at moderate doses reduce flare frequency in a meaningful fraction of patients. Metformin, particularly in patients with insulin resistance or PCOS, has evidence.
Adalimumab, a TNF inhibitor, became the first biologic approved for moderate to severe HS. It dramatically improves disease in many patients. Secukinumab, an IL-17 inhibitor, is now also approved and adds a second biologic option. Other biologics and small molecules including JAK inhibitors and IL-1 inhibitors are under investigation. The era of targeted immunomodulation has changed expectations for what treatment can achieve.
Retinoids, cyclosporine, methotrexate, and other immunomodulators have roles in selected cases.
Procedures and Surgery
For localized disease, deroofing is a simple outpatient procedure that unroofs sinus tracts, allowing them to heal by secondary intention. Recurrence at the same site is uncommon.
For extensive, scarred disease, wide local excision of the affected area offers the best chance of durable control. Healing may involve secondary intention, skin grafts, or flaps. Surgery does not cure HS globally but can eliminate disease in a specific region. Combining surgery with ongoing medical therapy produces the best results.
CO2 laser excision is another option for focal disease and offers good cosmetic outcomes in experienced hands.
Lifestyle Levers
Smoking cessation is among the highest-yield interventions. Every patient with HS should be supported in quitting with counseling, medication, and follow-up.
Weight management reduces friction, metabolic inflammation, and symptom burden. Gradual sustained weight loss, rather than extreme dieting, works best. Bariatric surgery in appropriate patients can produce dramatic HS improvement.
Diet modification, particularly reduction of dairy and refined carbohydrates, helps some patients. The evidence is limited but the interventions are low-risk. A Mediterranean-style anti-inflammatory pattern is reasonable.
Friction-reducing strategies including appropriate clothing, careful hair removal, and antiperspirant choices reduce triggers. Shaving can precipitate flares, and laser hair reduction is often preferred once disease is controlled.
Warm compresses, appropriate wound care with absorbent nonstick dressings, and attention to infection surveillance are part of daily management.
Pain Management
HS pain can be severe and is often undertreated. Multimodal pain management includes topical anesthetics, short-course opioids for severe flares, gabapentin for neuropathic components, and non-opioid approaches including acetaminophen and anti-inflammatory dosing of NSAIDs. Interventional pain procedures are sometimes needed.
Depression and anxiety deserve active screening and treatment. Antidepressants, cognitive behavioral therapy, and engagement with patient communities help.
Patient Advocacy
Organizations such as the Hidradenitis Suppurativa Foundation provide education, advocacy, and support. Patient-led communities online offer practical tips, emotional support, and a voice that traditional medicine has sometimes been slow to hear.
HS affects people of all backgrounds but has disproportionately affected those with darker skin tones and those from underrepresented communities in some studies, with diagnostic delay and treatment access disparities that deserve attention.
Setting Expectations
HS is chronic. Complete cure with medical therapy alone is uncommon. The realistic goal is long periods of good control with substantial reduction in flare frequency and severity, reduction of scarring, and improved quality of life. Surgical removal of heavily scarred areas, combined with ongoing medical therapy, can produce durable local remission.
Early aggressive treatment changes the trajectory. A patient diagnosed at Hurley stage one who receives appropriate systemic and topical therapy often avoids the scarring and advanced disease of Hurley stage three.
The Bottom Line
Hidradenitis suppurativa is a chronic inflammatory skin disease, not an infection, and it demands a treatment approach built around inflammation and surgery rather than antibiotics alone. Biologic therapies have transformed options for moderate and severe disease. Lifestyle interventions, including smoking cessation and weight management, meaningfully help. Specialized dermatology or HS clinics offer the best combination of medical and surgical expertise.
If you have recurrent painful abscesses in the armpits, groin, buttocks, or under the breasts, especially if they drain, tunnel, or leave cord-like scarring, you likely have HS. Seek out a clinician experienced with the condition. Starting effective therapy early changes lives.
Sources and Further Reading
Health and Beyond uses reputable medical and scientific sources where possible. These links support or expand on the topics discussed above.
- National Cancer Institute: Skin Cancercancer.gov
- MedlinePlus: Skin Conditionsmedlineplus.gov
