How Hidradenitis Suppurativa Is Treated

Hidradenitis suppurativa (HS) is a chronic skin condition that causes painful and unsightly boils. Without treatment, it can lead to serious complications such as squamous cell carcinoma, cellulitis, and Crohn disease. What's more, because the skin lesions caused by HS are so visible, many people with the disease isolate from other people, leading to loneliness, anxiety, and depression.

For these reasons, treating hidradenitis suppurativa often requires managing both the physical symptoms and the emotional ones. This can be challenging, but there are many effective treatments for HS. This article details each one, including self-care measures, medications for relieving pain and inflammation and preventing infection, and alternative therapies such as nutritional supplements which, although unproven, may be worth trying.

It also explains how doctors make decisions about which treatments to prescribe based on the Hurley staging system, which describes three distinct phases of HS from least severe to most severe and the medical treatments most likely to be effective for each.

Hurley Stage  Definition  Possible Medical Treatments
1 •HS breakouts in one or more isolated areas •No scarring or sinus tracts •Oral or topical antibiotics
•Corticosteroid injection
 2 •HS breakouts in one or more isolated areas •Scars and sinus tracts present •Combination of oral and topical antibiotics
•Surgery (considered if medication fails)
•Large areas of the body •Numerous scars and sinus tracts •Biologic medicine
•Surgery
Woman talking with her doctor in the clinic
Jose Luis Pelaez Inc. / Getty Images

Home Remedies and Lifestyle

An important aspect of living with hidradenitis suppurativa involves protecting skin and treating breakouts. Equally important is adopting habits or making certain changes that lower the risk of flareups.

Skin Care

To protect your skin and help prevent breakouts or keep them from getting worse:

  • Be gentle: Don't scrub affected areas. Use a soft cloth and antibacterial soap daily.
  • Moisturize generously: Slather on a rich body cream or lotion after you shower. Products recommended for atopic dermatitis such as Eucerin and Aveeno or a generic equivalent also are good for HS.
  • Shave carefully: The friction caused by a razor can irritate skin, as can hair as it grows back in. If possible, don't shave during flare-ups.
  • Don't pick or squeeze: Leave lesions, boils, and affected skin alone.

Caring for Wouns

Sometimes boils caused by HS burst, leaving behind open wounds. To help them heal and prevent infection:

  • Gently wash the area daily with an antiseptic cleanser.
  • If the wound is draining, apply an absorbent dressing and change it at least once a day.
  • Ask your doctor if they advise using a topical antibacterial medication.

Bleach Baths

If you develop a chronic bacterial infection, soaking in a highly diluted bleach bath may help to kill the bacteria and prevent future infections.

Before you do, ask your doctor for guidance. Bleach baths can sting or burn your skin. If you have asthma, inhaling bleach may trigger an attack.

Bleach also dries out skin, so it's important to apply a generous layer of moisturizer to your entire body after soaking in it.

The bacteria that most often causes chronic skin infections in people with HS is Staphylococcus aureus—also known as staph.

Dietary Changes

Certain foods have been found to worsen HS symptoms. If any of these are a regular part of your diet, you may want to avoid them for a time to see if your skin clears up:

  • Dairy
  • Sugar
  • Tomatoes
  • Eggplant
  • Potatoes

Brewer's yeast also has been linked to HS. In studies, people with the condition who avoided brewer's yeast for a period of time and then ate foods containing it had immediate flare-ups.

Keep in mind, too, that if you're dealing with HS, what you do eat may be as important as what you don't. For example, there's evidence following the Mediterranean diet, rich in antioxidants, vitamins, and minerals, may reduce inflammation and help prevent flare-ups.

Foods to focus on include fresh fruits, greens, and non-starchy vegetables; whole grains and legumes; nuts and seeds; fatty fish such as salmon and mackerel; and heart-healthy oils, especially olive oil, fish oils, and nut oils.

Don't Smoke

There's a strong link between cigarette smoking and hidradenitis suppurativa. If you smoke, you may have fewer flare-ups and less severe symptoms. Kicking the habit also may help your medications work better.

It can be hard to give up smoking, but there are lots of ways to do it, including quitting cold turkey, nicotine replacement therapy, and prescription medications. Your doctor can help you find the best approach for you.

Maintain a Healthy Weight

Extra pounds can increase the risk of HS and make symptoms worse, especially in skin folds that can trap sweat and cause friction. Being obese or overweight also places extra stress on the body as a whole, which increases the risk of inflammation.

Weight loss can help improve hidradenitis suppurativa in the long term. Research has shown that dropping just 15% of total body weight is enough to improve symptoms.

Besides cutting calories, regular exercise can play an important role in shedding extra pounds. If you have HS, though, chafing and sweat can make it hard to work out. These tips may help:

  • Choose activities that involve as little friction between areas of skin as possible, such as yoga or swimming.
  • Apply an anti-chafe balm to areas between skin folds.
  • Wear full-length sleeves and pants to lessen skin-to-skin contact.
  • Shower or bathe as soon as you finish exercising so sweat doesn't sit on your skin. Pat—don't rub—your body dry with a clean towel.

Recap

Treating hidradenitis suppurativa can be complicated. Symptoms can vary widely and not everyone experiences the disease in the same way. Self-care measures, dietary changes, and quitting smoking are important to managing HS.

Over-the-Counter (OTC) Therapies

You may be able to relieve mild pain and inflammation with over-the-counter (OTC) drugs and skin care products from your local pharmacy.

Pain Relieve Medications

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most common type of OTC pain reliever. NSAIDs that come in pill form include aspirin (which should never be given to children due to a risk of Reye's syndrome), ibuprofen (Advil, Motrin, and others), and Aleve (naproxen).

Tylenol (acetaminophen) is also an effective OTC pain reliever, but does not decrease inflammation and may not be the best choice for long-term treatment. Taking too much Tylenol in one sitting or over time has been linked to hypertension, kidney damage, and liver damage.

Some pain medications can be applied directly to affected areas of skin. They include diclofenac gel, a topical NSAID available under the brands Solaraze and Voltare, and lidocaine which relieves pain by numbing the skin.

Antibacterial Cleansers

Washing with an antibacterial cleanser daily can reduce bacteria on the skin and prevent inflamed lumps and boils from getting worse, help heal wounds, and minimize the odor HS can cause.

Antibacterial washes commonly used to treat HS include those that contain:

  • Chlorhexidine, such a ins Hibiclens
  • Zinc pyrithione, such as in Noble Formula
  • Benzoyl peroxide, such as n Oxy and PanOxyl

Sometimes these products cause skin to become red and dry. If you develop these side effects, ask your doctor to suggest a product that will be less irritating to your skin.

Prescription Medicine

If OTC treatments aren't effective, there are prescription-strength options that may work better to prevent and control HS symptoms.

Antibiotics

Both oral and topical antibiotics may be prescribed to destroy bacteria that can cause infections.

Topical clindamycin is a common first-line treatment for mild to moderate HS. One drawback of this medication is that bacteria is becoming resistant to this drug. For this reason doctors often advise using an antibacterial wash along with topical clindamycin.

Oral antibiotics for treating hydradenitis suppurative include oral tetracyclines, which most often are prescribed for mild to moderate cases. If these don't work or symptoms are severe, oral clindamycin along with another antibioic called rifampin may be effective.

Topical Resorcinol

Resorcinol is a keratolytic medication. As such, it treats hidradenitis suppurativa in a number of ways:

  • Softens keratin, the protein that makes up skin, hair, and nails
  • Helps dead skin cells to shed
  • Kills bacteria on the surface of the skin
  • Relieves itching

Resorcinol cream can be used to keep prevent flare-ups or to treat them. It's most effective for mild HS.

Corticosteroids

Two types of corticosteroids may be used to treat HS. An oral corticosteroid such as prednisone may be prescribed as needed. Corticosteroids also can be injected directly into lesions that are especially severe.

Steroids are never used to treat hydradenitis suppurativa on a long-term, on-going basis. Whether taken by mouth or injected, these medications have a number of serious side effects.

Biologics

Biologics are medications produced from living cells. They work by stopping the immune system from producing inflammation.

Biologics are highly effective for treating moderate to severe HS. Most healthcare providers reserve these drugs for HS cases that are not improving with other treatments.

The first and only biologic drug approved by the Food and Drug Administration (FDA) for treating HS is Humira (adalimumab). Humira is safe to use long-term.

Other biologics, such as Enbrel (etanercept), Stelara (ustekinumab), and Remicade (infliximab), sometimes are prescribed off-label for HS.

Hormonal Therapies

Between 44% and 63% of women with HS have flare-ups just before their periods. Women with polycystic ovary syndrome (PCOS) also are prone to HS.

Hormonal therapies often are effectivel in these cases. They include spironolactone, a medication that blocks the action of groups of hormones and combination oral contraceptives that pair estrogen with progesterone.

For adults of all sexes and children with HS, a hormonal medication called finasteride may help control HS. This drug, which is sold under the brand names Proscar and Propecia, also is used to treat benign prostae growths and male pattern baldness. People who are pregnant should not take finasteride as it has been linked to birth defects.

Oral Retinoids

Oral retinoids, which are derived from vitamin A, sometimes work when other medications for HS don't. They also often are prescribed for people who have severe acne as well as hydradenitis suppurative. They can help reduce inflammation and minimize flares even after the medication is stopped.

The two such drug used for HS are Absorica, Zenatane, and Myorisan (all brand names for isotretinoin) and Soriatane (acitretin).

Warning

Oral retinoids can cause life-threatening birth defects. People who are sexually active must used two forms of birth control while taking them and for up to three years after their last dose. Regular pregnancy checks are also required.

Metformin

Metformin, a medication for type 2 diabetes, sometimes is prescribed off-label to relieve pain, reduce inflammation, and prevent metabolic syndrome in people with HS who are at risk for diabetes.

Most people have no problem tolerating metformin, although the drug can cause diarrhea, nausea, vomiting, and abdominal pain.

Recap

Although mild hidradenitis suppurativa often can be managed with home remedies and OTC treatments, prescription medications may be needed in severe cases. Some options, especially oral retinoids, cause birth defects, so it's important to be frank with your doctor if you're pregnant or plan to be.

Surgeries and Procedures

It sometimes is necessary to remove boils and sinus tracts (tunnels leading from an infection to the surface of the skin) caused by hydradenitis suppuritiva. There are a number of ways this can be done. The goal of each is to preserve as much healthy tissue as possible.

Laser Treatments

A doctor can use any of several laser treatments during an office visit to reduce inflammation from HS, remove hair, and destroy hair follicles to help prevent new boils from forming.

Those procedures are:

  • Carbon dioxide (CO2) laser: Damages thin layers of skin cells in a precise area. It may also be used for deroofing, sinus tract excision, or to repair scars.
  • Nd-YAG laser: Beams infrared light through a crystal to penetrate deep into the skin to destroy hair follicles
  • Intense pulsed light (IPL): Uses heat to destroy hair follicles. It also has an anti-inflammatory effect that may relieve pain from chronic boils and prevent keratin buildup.

It takes an average of three laser treatments before there are noticeable improvements in skin.

Deroofing

Deroofing is a minimally-invasive procedure to remove chronic lesions, sinus tracts, and any tissue affected by hidradenitis suppurativa. A doctor can do it in their office.

They'll begin by using a local anesthetic to numb the affected area and then remove the top portion, or "roof," of the lesion or sinus tract. The area will be allowed to heal. Although the treatment leaves a scar, lesions rarely come back.

Sometimes a biologic drug is prescribed before or after deroofing to suppress the immune system's inflammatory response and help skin recover.

Incision and Drainage

When a boil becomes severely inflamed and painful, it can be drained with an incision and drainage procedure. This is often done when a person goes to the hospital for emergency treatment for pain.

Incision and drainage can provide immediate relief, but won't treat the underlying cause of hidradenitis suppurativa or prevent future flare-ups.

In most cases, HS boils that are drained do come back.

Surgical Excision

For severe cases that aren't responding to treatment, a surgical excision may be done to remove all tissues in the affected area. This procedure is done in the hospital under general anesthesia.

There are two main methods of excision:

  • Wide surgical excision: The affected tissues and healthy tissues bordering them are removed. This way all tissues that could have burst follicles or bacteria are removed.
  • Tissue-saving excision: A laser or a heated wire are used to remove affected tissues while saving as much healthy skin around the border as possible.

After excision, the skin is either left open to heal or closed with stitches. When a large area is removed, healthy skin tissues from another part of your body may be used to cover the wound. This is known as a skin graft.

A benefit of excision is removed boils are unlikely to return. However, the surgery can leave scars and, as with any surgery, wounds can become infected.

According to a global survey in 2020, 80% of people with HS have had some kind of procedure to manage their condition. Of those, 70% of people had incision and drainage, 55% had an excision, 11% had a laser treatment, and 9% had deroofing.

Complementary and Alternative Medicine (CAM)

There's no scientific proof CAM is effective for HS nor are CAM therapies meant to take the place of medicines or treatments.

Nonetheless, because these CAM therapies are generally considered safe and well-tolerated, they may be worth trying with a doctor's guidance.

Zinc

Zinc is a mineral that plays an important role in the health of both skin and the immune system. It also helps wounds to heal.

A 2018 study published in the American Journal of Clinical Dermatology found people with HS are more likely to have lower levels of zinc in their blood than those who don't have the condition.

While there is strong evidence that taking zinc supplements may help relieve inflammation and hidradenitis suppurativa symptoms, more research is needed before zinc can be regarded as an HS treatment.

Because the body can't make zinc on its own, it's important to eat foods that are rich in the mineral, such as oysters, beans, oats, nuts, whole grains, and dairy products.

Vitamin D

Like zinc, vitamin D helps support the immune system. Research has found a possible link between vitamin D deficiency and the onset of and severity of hidradenitis suppurativa.

In one small study of people with HS, those who took vitamin D supplements had a significant improvement in symptoms after six month while those who did not take supplements did not.

Although one study is not enough to prove vitamin D is an effective way to treat hydradenitis suppuritiva, making sure you get enough of this nutrient is important for overall health.

Aside from taking supplements, sun exposure is one measure you can take. Ten to 15 minutes a few times a week without sunscreen is plenty.

Another way to get vitamin D is through diet. Foods rich in vitamin D inclue milk, fortified orange juice, cereal, egg yolks, and fatty fish

Summary

Hidradenitis suppurativa is a chronic skin condition that causes painful and unsightly boils. There's no cure for the condition but there are many effective ways to treat it. These include simple home remedies including gentle skin care, weight loss, avoiding foods that may trigger flare-ups, and, for people who smoke, kicking the habit.

There also is a variety of OTC and prescription medications for easing discomfort and decreasing inflammation, as well as for preventing breakouts and infections that can occur when boils burst, leaving behind open wounds.

In severe cases, a doctor can remove HS lesions using laser therapy or simple surgical procedures.

A Word From Verywell

According to a study by the American Academy of Dermatology, 64% of people with hidradenitis suppurativa visited a healthcare provider at least five times before receiving their diagnosis. Overall, it took an average of 10 years after HS symptoms began for people to get a proper diagnosis and begin treatment.

If you have visited your healthcare provider several times and the recommended treatments aren't working, keep this in mind. Untreated, hidradenitis suppurativa gets worse over time, so it's important to speak up if you feel your doctor isn't taking your symptoms seriously or to get a second opinion.

Frequently Asked Questions

  • What can cause hidradenitis suppurativa to flare up?

    Among the known triggers for flares are:

    • Menstruation
    • Hormone fluctuations
    • Stress
    • Heat
    • Sweat
    • Weight gain
  • Is Vicks VapoRub an effective treatment for hidradenitis suppurativa lesions?

    Although there are no clinical studies looking at Vicks VapoRub as a topical treatment for HS, there's anecdotal reports from patients who claim it has several benefits:

    • Eases pain: The two active ingredients in Vicks VapoRub—menthol and camphor —are both known topical pain relievers.
    • Relieves itching
    • Encourages boils to drain
    • Reduces swelling and inflammation: The nutmeg oil in Vick's has been found to have anti-inflammatory properties.

    It's important to note that Proctor & Gamble, which makes Vick's VapoRub, does not recommend it for treating HS, nor is the product approved for this use by the FDA.

  • Does hidradentitis suppurativa ever go away without treatment?

    No. HS is a chronic condition. That's why being diagnosed as soon as symptoms appear and complying with treatment are important for keeping the disease under control.

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