Can you explain hidradenitis suppurativa, its causes, symptoms, and treatment options, as a doctor would to a patient?

Understanding Hidradenitis Suppurativa: A Doctor's Explanation

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that causes painful, deep-seated bumps, abscesses, and draining tunnels in areas where skin rubs together—most commonly your armpits, groin, buttocks, and under the breasts 1, 2.

What Is Happening in Your Body

HS is not a simple infection or hygiene problem. Your immune system becomes overactive in the hair follicles of these areas, causing chronic inflammation that leads to:

• Painful nodules (lumps under the skin)
• Abscesses (pus-filled bumps)
• Draining tunnels that form under the skin
• Scarring and skin damage over time

The disease typically starts in your 20s or 30s, after puberty begins 2. It affects about 1% of people worldwide, with women more commonly affected than men 1, 2.

Why This Happens

The exact cause involves several factors 2:

• Immune system dysfunction: Your body produces too much inflammation through pathways involving IL-1β, TNF, IL-17, and other inflammatory molecules
• Genetic susceptibility: Some people inherit mutations that make them prone to HS
• Contributing factors: Smoking, obesity, and hormonal influences worsen the disease

This is NOT caused by poor hygiene or being "dirty"—that's a harmful myth.

What You'll Experience

The diagnosis requires three key features 1:

1. Typical lesions: Painful bumps, abscesses, blackheads, draining tunnels, and scars
2. Specific locations: Armpits, groin, genitals, buttocks, under breasts
3. Recurrence: The bumps come back repeatedly

Pain is often the most debilitating symptom, and HS significantly impacts quality of life, work, and relationships 1, 2.

Disease Severity Staging

We use the Hurley staging system to guide treatment 1:

• Stage I: Bumps and abscesses with minimal scarring
• Stage II: Scattered areas with tunnels and scarring
• Stage III: Widespread tunnels and extensive scarring across entire regions

Treatment Approach: Matching Therapy to Your Disease Phase

Treatment must address both active inflammation AND structural damage—medicine alone cannot fix tunnels and scars that have already formed 3, 4.

For Mild Disease (Stage I)

Start with 5, 4:

• Topical clindamycin applied to affected areas
• Antiseptic washes (chlorhexidine or zinc pyrithione)
• Oral tetracyclines (doxycycline or tetracycline) for 12 weeks minimum
• Hormonal therapy for women: combined oral contraceptives or spironolactone

For Moderate Disease (Stage II)

Add stronger options 5, 4:

• Combination antibiotics: Clindamycin plus rifampin
• Biologic therapy: Adalimumab (weekly injections)—this is FDA-approved and strongly recommended
• Intralesional steroid injections for individual painful nodules
• Minor surgical procedures: Deroofing of tunnels

For Severe Disease (Stage III)

Requires aggressive treatment 5, 4:

• Biologic therapy is essential: Adalimumab, secukinumab, or bimekizumab (all FDA-approved)
• Wide surgical excision of affected areas—this is the only way to remove established tunnels and scarring
• Combination medical-surgical approach: Use biologics to control inflammation while planning surgery for damaged tissue
• IV ertapenem as rescue therapy for severe flares

Critical Treatment Principles

The most important concept: Early aggressive treatment prevents irreversible scarring and tunnel formation 2, 4. Once tunnels and scars develop, medicine alone cannot reverse them—surgery becomes necessary.

What Works Best

For inflammatory disease, biologics targeting TNF (adalimumab) or IL-17 (secukinumab, bimekizumab) provide the strongest evidence for disease control 2, 6, 4. These are now first-line therapy for moderate-to-severe disease.

For structural damage (tunnels, scars), wide surgical excision has the lowest recurrence rates compared to simple drainage or limited excision 3.

Common Pitfalls to Avoid

• Don't just drain abscesses repeatedly—this doesn't address the underlying disease and leads to more scarring
• Avoid progestogen-only contraceptives—they may worsen HS 5
• Don't delay treatment—waiting allows irreversible damage to accumulate
• Don't rely on antibiotics alone long-term—this risks resistance and doesn't control severe disease

Associated Health Problems

HS is a systemic inflammatory disease. You need screening for 2, 7:

• Metabolic syndrome and diabetes
• Inflammatory bowel disease
• Inflammatory arthritis
• Cardiovascular disease risk
• Depression and anxiety

Pain Management

Pain assessment should be routine at every visit 4. Options include:

• Topical lidocaine for acute pain
• Oral pain medications as needed
• Nerve pain medications (gabapentin, pregabalin) for chronic pain
• Pain control is a treatment goal equal to controlling skin disease

Lifestyle Modifications

These help but are not cures 8, 4:

• Tobacco cessation is essential—smoking worsens disease
• Weight loss if overweight—reduces friction and inflammation
• Loose-fitting clothing—reduces skin trauma
• Zinc supplementation and vitamin D repletion—may provide modest benefit

The Bottom Line

HS requires early, aggressive treatment tailored to your disease stage, combining medical therapy for inflammation with surgery for structural damage when needed 3, 4. The goal is to prevent irreversible scarring while controlling pain and maintaining quality of life. This is a manageable chronic disease with expanding treatment options, but success requires prompt diagnosis and appropriate escalation of therapy before permanent damage occurs.