How Hidradenitis Suppurativa Is Treated

How hidradenitis suppurativa (HS) is treated varies depending on the severity of symptoms. There is no cure for hidradenitis suppurativa, but it can be effectively managed with the correct combination of home care and treatment medications.

Mild symptoms often can be successfully managed with home remedies. When symptoms are more severe, prescription medications such as antibiotics or biologics are needed. It's also possible to receive in-office treatments such as intralesional steroid injections to help individual lesions.

In very severe, long-lasting cases, procedures such as laser treatment or surgical excision of the affected areas may be recommended to get the condition under control.

Woman talking with her doctor in the clinic
Jose Luis Pelaez Inc. / Getty Images

Home Remedies and Lifestyle

Because hidradenitis suppurativa is a chronic condition, it requires long-term management to keep the condition under control. Certain lifestyle changes and good home care can help improve symptoms and minimize flareups.

Daily Skin Care

Whether you're in the midst of a HS flare or not, gentle skin care is important. Any irritation of the hair follicles can trigger a flareup of HS or worsen an existing flare.

  • Cleanse gently: While a daily shower or bath is important to keep affected areas clean, don't scrub at the area. It may be helpful to use antibacterial soap. Use a very soft cloth and a gentle hand when washing.
  • Apply moisturizing cream: Some studies have suggested that applying emollient creams over the affected areas daily, after showering, may help strengthen the skin's barrier function and improve HS. Creams that are recommended for people with atopic dermatitis are also appropriate for hidradenitis suppurativa. These include products such as Eucerin and Aveeno. Ask your doctor for recommendations.
  • Take care while shaving: Shaving can irritate the skin and worsen hidradenitis suppurativa for some people. The friction and drag of the razor can irritate the skin, as can hair as it regrows. If shaving seems to worsen your HS, you may want to avoid shaving for a period of time to see if it improves.
  • Don't squeeze at or pick at hidradenitis suppurativa nodules.

Stop Smoking

There is a strong link between cigarette smoking and hidradenitis suppurativa. 

Although stopping smoking won’t cure the condition, it may help lessen flareups and the severity of breakouts. Quitting smoking may also make hidradenitis suppurativa more responsive to treatment.

Of course, quitting smoking is important for your overall health, too. Talk to your doctor about ways to quit smoking.

Maintain a Healthy Weight

Hidradenitis suppurativa is more common in people who are overweight. Excess friction in affected areas, coupled with trapped sweat, is likely the reason.

Losing weight can be very helpful in improving hidradenitis suppurativa long term. Research has shown that a 15% reduction in weight can significantly improve HS symptoms.

Over-the-Counter (OTC) Therapies

If your hidradenitis suppurativa symptoms are mild, you may be able to treat them with over-the-counter treatments. OTC treatments can also be used, on their own or alongside prescription medications, for long-term management of the condition. Before starting any at-home treatment routine, seek your doctor's advice.

Antibacterial Washes

Topical antibacterial washes or cleansers are often recommended for daily use when you have hidradenitis suppurativa. Antibacterial washes reduce the number of bacteria on the skin that can worsen inflammatory HS nodules.

They typically aren’t effective for treatment alone, except in mild cases, but are good for flareup prevention and to help heal wounds. Antibacterial washes can also help reduce the odor that hidradenitis suppurativa can cause.

Commonly recommended antibacterial washes include chlorhexidine, zinc pyrithione, or benzoyl peroxide. You can find these at your local pharmacy. Hibiclens is the most common brand that contains chlorhexidine, although there are many others. Ask your doctor or pharmacist for recommendations.

Zinc pyrithione is found in medicated bar soaps meant for "problem" skin (acne, eczema, and dermatitis). Noble Formula is one brand, but there are many others that can be found over the counter at the pharmacy. Benzoyl peroxide is found in OTC acne products, like Oxy and PanOxyl.

Your doctor can tell you which antibacterial body wash, if any, is the best product for you and give you instructions on how to use it. Antibacterial washes can cause skin irritation for some people, so watch carefully for excessively dry skin, redness, or irritation, and let your doctor know if they occur.

Bleach Baths

Diluted bleach baths themselves don't treat hidradenitis suppurativa, but they do prevent recurring infection by minimizing bacterial colonies on the skin. Staph is the most common, but other bacteria can cause infection too.

If you have recurring secondary infections of the skin, your doctor may recommend diluted bleach baths. It's important that you don’t use a bleach bath unless your physician tells you to do so, and follow all directions precisely.

Over-the-Counter Pain Relievers

Hidradenitis suppurativa can be very painful. Use over-the-counter anti-inflammatories such as Advil (ibuprofen) or Aleve (naproxen), or topical analgesics containing lidocaine, as needed.

Prescriptions

There is no one “right” hidradenitis suppurativa treatment for everyone. Most people will need a combination of treatments in order to get (and keep) the condition under control. Your doctor will work with you to determine the best treatment options for you.

Know that it can take several tries to find the treatment regimen that works best for you. Keep in touch with your doctor about your treatment plan. If your current treatment isn't working well enough, let your doctor know.

Because hidradenitis suppurativa is a chronic condition, your treatment may change over the years depending on your needs.

Topical Resorcinol is a keratolytic medication, meaning it softens keratin (a protein found in the skin) and causes the skin to exfoliate. Resorcinol creams can be used to treat active flareups as well as maintenance therapy. It may be prescribed by your doctor.

Antibiotics

Antibiotics are used to reduce bacteria and inflammation of the skin. They can also help treat and prevent secondary infections.

Topical clindamycin is a common first-line treatment choice for mild to moderate hidradenitis suppurativa. The drawback is that bacteria are quickly becoming resistant to this drug. Using topical clindamycin along with an antibacterial cleanser may help combat bacterial resistance.

Oral antibiotics are also used in both mild and moderate cases. Oral tetracyclines are commonly prescribed first. In more severe cases, or when tetracyclines aren't effective enough, oral clindamycin along with rifampin is prescribed.

Ideally, antibiotics are used short-term until HS symptoms are improved. But, in many cases, repeated courses or long-term use of antibiotics must be used to keep symptoms in check.

Topical Resorcinol

Resorcinol is a keratolytic medication, meaning it softens keratin (a protein found in the skin) and causes the skin to exfoliate. Resorcinol creams can be used to treat active flareups as well as maintenance therapy.

Corticosteroids

While corticosteroids aren't used as a first-line treatment, they are used to help ease inflammation when needed.

Corticosteroids can be injected into a painful breakout to reduce swelling and pain, and help speed healing. This is called an intralesional corticosteroid injection, or simply a steroid injection. Steroid injections are done on a case-by-case basis.

Oral corticosteroids, such as prednisone, may be prescribed in short courses to reduce widespread inflammation. Again, these are only done on an as-needed basis and not used as a long-term treatment method.

Biologics

Biologics are quite effective at treating moderate to severe hidradenitis suppurativa. Humira (adalimumab) is approved by the U.S. Food and Drug Administration (FDA) for treating HS, and can be used long term to keep the condition under control.

Other biologics, such as Enbrel (etanercept), Stelara (ustekinumab), and Remicade (infliximab), may also be effective. However, they are prescribed off-label for hidradenitis suppurativa.Humira (adalimumab) is the only biologic approved by the Food and Drug Administration for treating hidradenitis suppurativa.

Most physicians reserve these drugs for HS cases that are not improving with other treatments. Talk with your doctor about the risk versus the benefits of using these medications.

Hormonal Treatments

Hormonal therapies can be helpful in certain situations, especially so for adult women who have flares around the time of their periods and those with polycystic ovarian syndrome. Spironolactone and certain oral contraceptives are commonly prescribed in these cases.

For children and adults of both sexes, the medication finasteride is another hormonal treatment that can also be prescribed.

Oral Retinoids

These medications are not used as often to treat hidradenitis suppurativa, but they may be prescribed in severe cases that have not responded well to other treatments, or in people who also have very severe acne as well as HS.

Isotretinoin or acitretin may be prescribed. These medications help reduce the inflammation of severe HS, and can help minimize flares even after the medication is stopped.

These medications can have serious side effects, including causing severe birth defects when taken during pregnancy. The risk to a fetus continues for a long period even after the drug is stopped.

While using these medications you must be monitored carefully by your doctor.

Prescription Pain Medications

Hidradenitis suppurativa can be excruciatingly painful during flareups. If OTC pain medications aren’t enough to relieve your pain, ask your doctor about prescription pain medications. Options vary depending on your needs.

The most important thing to note is that treatment of HS itself is the best thing you can do in terms of pain relief. The pain subsides as the flareups do.

Surgeries and Specialist-Driven Procedures

Especially in more severe cases of hidradenitis suppurativa, when sinus tracts and scarring are present, surgical means may be needed to heal the skin and control symptoms.

Deroofing

Deroofing, also called unroofing, is a minimally-invasive procedure done to instigate healing of chronic abscesses and sinus tracts.

A local anesthetic is used to numb the affected area. The top portion, or "roof," of the abscess or sinus tract, along with other affected tissue, is removed. The skin is then allowed to heal. In the majority of cases, the abscess do not recur.

Incision and Drainage

When an abscess is particularly inflamed and painful, your doctor may recommend making a small incision and draining the contents of the abscess.

Incision and drainage are used as a pain-relieving procedure but don't treat the underlying cause of hidradenitis suppurativa or help prevent future breakouts. In the vast majority of cases, hidradenitis suppurativa abscesses that are drained to come back.

Although this used to be a relatively common treatment for active abscesses, this procedure has fallen out of favor for more effective treatment procedures.

Surgical Excision

For severe, long-lasting cases, surgical excision of the entire affected area may be done. There are two main methods of excision: wide surgical excision, and tissue-saving (laser or electrosurgical) excision.

Surgical excision is done in the hospital under general anesthesia. The entire affected area of skin is removed. With wide surgical excision, a border of healthy skin is also removed to ensure the entirety of affected skin is taken. Laser and electrosurgical excision saves more healthy tissue, but if enough healthy skin border is not removed HS can recur in these areas.

After excision, the skin is either left open to heal or stitches are used to close the wound. Depending on how much tissue was removed, skin graphs may be done.

This procedure is usually done only when medications aren't doing enough to keep the condition under control. Side effects include scarring and possible secondary infection. The benefits are very low recurrence rate, and improvement even in cases that haven't responded to other treatments.

Light and Laser Treatments

Light and laser treatments are not as commonly used as some of the aforementioned, more conventional, treatments but they may be helpful in certain cases.

These treatments are done in-office and are used to reduce inflammation, destroy hair follicles, or as a hair removal treatment. The end result prevents new nodules from forming.

Some of the procedures used for hidradenitis suppurativa treatment include:

  • Carbon dioxide, or CO2 laser
  • Nd-YAG laser
  • Photodynamic therapy

Caring for Wounds

When inflamed nodules burst, the wounds left behind need special treatment. Of course, you should always follow your doctor's advice when it comes to wound care, but you can use these tips:

  • Keep the wound clean by washing daily with an antiseptic cleanser. Remember, be very gentle while cleansing.
  • If the wound is draining, apply an absorbent dressing and change it as needed, but at least once daily. This also can help cut down on odor from the draining wound.
  • Follow your doctor's advice on the application of topical antibacterials.

Call your doctor right away if you notice signs of infection including increased redness, pain, and swelling, or if you develop a fever.

Complementary and Alternative Medicine (CAM)

As of yet, there are no alternative therapies that have been proven to treat hidradenitis suppurativa. But as more research is done, a few therapies are warranting a deeper look.

Remember, though, that these remedies are not meant to take the place of proven treatments. Instead, they may be used in conjunction with your current treatment.

Never change your current treatment plan without first getting advice from your physician.

Zinc Supplementation

Zinc is an important mineral that plays an important role in many of the body's functions. Because your body can't manufacture zinc, you must get adequate amounts through your diet. A 2018 study published in the American Journal of Clinical Dermatology indicates that people with hidradenitis suppurativa are more likely to have low serum zinc levels compared to those without the condition.

Zinc plays a key role in immune function, wound healing, skin health, in addition to a plethora of essential body functions.

Some studies also suggest that zinc supplementation may help decrease symptoms of hidradenitis suppurativa. The caveat here is there is very limited evidence for zinc supplementation as an HS treatment, and much more research is needed.

Foods high in zinc include meat, shellfish, beans, oats, nuts, and seeds. You should talk to your doctor for guidance before starting on zinc supplements.

Vitamin D Supplementation

Vitamin D is an essential vitamin that promotes bone health and supports the immune system. At least one 2015 study, published in the Journal of the European Academy of Dermatology and Venerology, suggests that vitamin D deficiency may play a role in hidradenitis suppurativa development and severity.

In this study, all participants (numbering 22) were found to be deficient in this vitamin. After taking vitamin D supplements for six months, the majority saw an improvement of both the severity and frequency of flareups. It's hypothesized that vitamin D helps stimulate skin immunity.

It's important to remember that this was a very small study, so it alone is far from proof that vitamin D supplementation will do anything for hidradenitis suppurativa. More research is needed to fully suss out this concept.

Spending time in the sunlight can up vitamin D levels. You can also get vitamin D from fortified foods like milk, orange juice, and cereal, as well as egg yolks and fatty fish. Before taking vitamin D supplements, talk to your doctor for advice.

Dietary Modifications

While there is a lack of strong evidence supporting dietary changes in the treatment of hidradenitis suppurativa, a few studies have shown that restricting the intake of certain foods may reduce symptoms in some people.

Brewer's yeast is an ingredient used in the production of beer and hard cider, and found in foods such as miso, dried fruits, breads, and cheese. It's also commonly used as a nutritional supplement.

A 2013 study found that after surgical excision patients that avoided foods containing brewer's yeast saw an improvement of symptoms. What's more, after a period of avoidance, those that ingested foods containing brewer's yeast saw an immediate flareup of symptoms. A study published in 2020 found similar results.

Research is ongoing, because these studies only followed a handful of hidradenitis suppurativa patients, but so far the results are intriguing.

Other foods that have also been implicated in the worsening of hidradenitis suppurativa symptoms are dairy, sugar, and foods in the nightshade family (tomatoes, eggplant, potatoes).

If you think certain foods may be worsening your symptoms, you could try keeping a food journal to track your flareups and regressions. You may also try cutting certain foods from your diet to see if you notice any improvement.

Before making big changes to your diet, you should talk with your doctor to ensure your diet is healthy and will provide all the necessary nutrients.

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