Is it safe to use sulfur soap from open areas to treat Hidradenitis Suppurativa (HS)?

Safety of Sulfur Soap on Open Areas in Hidradenitis Suppurativa

Sulfur soap should be avoided on open areas in patients with hidradenitis suppurativa (HS) due to potential irritation and discomfort, with chlorhexidine being a safer alternative for antiseptic cleansing of open lesions.

Antiseptic Options for HS Management

When managing open lesions in HS, the choice of cleansing agent is critical for both symptom management and prevention of secondary infection. Current guidelines provide specific recommendations:

Recommended Antiseptic Options:

• Chlorhexidine: The 2025 North American Clinical Practice Guidelines strongly suggest using chlorhexidine for antiseptic cleansing in HS, noting it is "unlikely to be associated with increased risks" based on its mechanism of action 1. This recommendation applies across various patient populations.

• Bleach baths: These are conditionally recommended as an alternative antiseptic wash that is unlikely to cause additional harm 1.

• Zinc pyrithione: This is another conditionally recommended option for antiseptic cleansing in HS 1.

Cautions with Sulfur-Containing Products:

The 2016 American Academy of Dermatology guidelines for acne management (which can be extrapolated to HS due to similar inflammatory pathophysiology) specifically caution about sulfur-containing preparations:

• Sulfur-containing products have "the potential to induce local irritation" and should be used with caution, especially on compromised skin 1.

• This concern is particularly relevant for open areas where the skin barrier is already disrupted, increasing the risk of irritation and discomfort.

Evidence-Based Approach to Cleansing in HS

The British Association of Dermatologists (BAD) guidelines emphasize the importance of appropriate wound care in HS:

1. Provide appropriate dressings for pus-producing lesions 1
2. Use gentle cleansing approaches that don't further irritate compromised skin
3. Manage HS via a multidisciplinary approach, particularly for complex cases 1

Treatment Algorithm for Cleansing Open HS Lesions

For patients with open areas due to HS, follow this evidence-based approach:

1. First-line antiseptic: Use chlorhexidine wash on open areas 1, 2
2. Alternative options: Consider bleach baths or zinc pyrithione if chlorhexidine is not tolerated 1
3. Avoid: Sulfur-containing products and triclosan on open areas 1
4. For intact skin: Antiseptic washes including chlorhexidine can be used as part of the overall management strategy

Important Considerations

• Pain management: Ensure adequate pain control when cleansing open lesions, as this is essential for improving quality of life 2
• Secondary infection: Monitor open areas for signs of secondary infection that may require additional treatment
• Wound care: Provide appropriate dressings for draining lesions 1
• Comorbidity screening: Remember to screen for associated comorbidities including depression, anxiety, and cardiovascular risk factors 1, 2

Pitfalls to Avoid

• Overuse of antiseptics: Prolonged continuous use of antiseptic products without breaks may lead to skin irritation or altered skin microbiome
• Ignoring pain: Inadequate pain management during cleansing can reduce adherence to treatment
• Neglecting comprehensive care: Focusing solely on topical management without addressing other aspects of HS care (systemic treatments, lifestyle modifications, etc.)

By following these evidence-based recommendations, patients with open areas due to HS can safely manage their condition while minimizing additional irritation or discomfort.