Members of myHSteam report struggling with the burden of managing hidradenitis suppurativa (HS), particularly boils (painful enlarged areas that contain pus, sometimes called abscesses) and other lesions (any area of the skin that has suffered damage). These lesions can cause a great deal of pain, may leak fluid, and sometimes have an odor. Members say one of their challenges is figuring out how best to clean and protect different types of HS lesions, in addition to relieving the pain.
One member asked, “Does anyone have any innovative ideas for dressing the HS wounds? These lesions will be in awkward places and nothing seems to stay in place there. My clothes get bloody and messy.” Another wrote, “I have never been told how to cope. Do I leave them alone? How do I clean or deal with them once they've burst? What can I do about the pain and swelling?”
Recently, myHSteam spoke with Dr. Alexa Kimball about how to manage leaking and painful boils and other symptoms of HS at home. Dr. Kimball is a dermatologist, and is CEO and president of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center. She is also a professor of dermatology at Harvard Medical School. Dr. Kimball has researched and written about HS extensively, including authoring a book entitled, "Hidradenitis Suppurativa: Your Questions, Expert Answers."
A really simple, over-the-counter thing you can do — it's not particularly potent, but it might help some with the irritation around it — is to get some topical hydrocortisone, such as Cortaid-10, from the drugstore. And you might even get the ointment, because it helps to actually coat the area in a protective way as well. Hydrocortisone 1 percent ointment can help bring out some of the irritation, especially for the smaller ones. Stronger versions are available by prescription, and I often offer them to my patients for short-term use. Tea tree oil can cause an allergy, so it isn’t typically recommended.
As the boils get a little bit bigger, there are also some over-the-counter pain creams that you can purchase. These include ingredients such as pramoxine, benzocaine, prilocaine, lidocaine, or menthol. Lidocaine 4 percent is one of the strongest and is typically kept in the pharmacist’s area, behind the counter, or you can order it online. You do have to put a thick amount on and cover it. It takes about half an hour to reach numbing capacity. However, you do have to be careful not to put it on too big an area, because you can absorb some of it. If you're just doing a boil or two that's fine.
If the boil is painful but not near bursting, and you want to reduce pain, you can put something cold on it, such as ice or an ice pack. You can also use mild heat, such as a warm compress, but only if the abscess is very inflamed and is close to bursting. Heat is something to think about if you can see a little head [white spot at the center] on top. You may have to learn through trial and error which is the right one to use at the right time, because if you put heat on too early, you could make it more inflamed and [it will] hurt more.
Ibuprofen is probably the best over-the-counter medication for pain as well.
When I give adolescent teenagers advice about acne, I tell them they get one try at a pimple and if it's not easy to pop, then stop, because they're going to make it worse. The same holds true for HS boils. If there is a head on it, you can apply gentle downward pressure around the edges of it and see if you can get it to drain. But if you start squeezing it, you're going to cause more inflammation and pain and actually make it worse. So you get one shot at it, and if it's not easy, then stop.
Occasionally, people say that they drain them with needles and other things. You have to be so careful. I have definitely seen people get rip-roaring infections from trying to drain things themselves with an incision, so I don't recommend doing that.
Dermatologists will sometimes inject steroids into the inflamed boil. Similarly, you can actually get much higher-potency steroid creams like the hydrocortisone I talked about, but at prescription level. Your dermatologist or even your primary care provider could prescribe that for you, and you can use it for just a few days at a time. It won’t likely be as effective, but it is something you can do at home.
The problem with bursting and leaking is that the sac can also refill. Ideally, what you really want to do is apply pressure on the skin with a bandage so it can't reaccumulate [fluid], and so the drainage keeps coming out of it. That’s where you want to use more absorbent bandages and ideally — if you can, depending where it is — create compression to hold the bandages in place and keep the wound from reexpanding. I recognize it's easier said than done, given where some of these are located, but I have seen people do a lot of creative things.
You also have to recognize that the leakage is really irritating to the skin. That's why having absorbent bandages is important because you can get a significant rash around the area just because the drainage is so irritating. Sometimes, the pain from the rash is worse than the pain from the boils.
There are many kinds of bandages out there. Basically, what you need to think through is, do you want something that is really absorbent, or do you want something that is really designed to heal an open wound? Some patients do get these open wounds that take a long time to heal. However, most of the time, the issues have to do with drainage.
Alginate bandages, which are basically [composed of] a seaweed compound that expands with the fluid that drains from the abscess, are helpful. Some of the gel- or foam-type bandages will absorb as well. What you're looking for is something that is highly absorbent.
Colloid or hydrocolloid dressings tend to be used more for extensive wound healing. They actually hold the fluid in place a little bit, and they don't really take the drainage away from the skin. In a really big draining area, you're not going to want to do that.
My favorite hack is to use menstrual pads in some of these areas. The nice thing about menstrual pads is they're so cheap compared to bandages. They are easily accessible and have obviously been designed for sensitive skin areas. They have a sticky backing so you can be creative about how you use them. The Always Infinity brand, for example, is almost a foam, rather than a traditional cotton pad, and can be cut or rolled into different shapes.
Nursing pads are another option for people. They're not very expensive, nicely made, and a decent shape, so that's another thing to look for.
You don't want to scrub — it can irritate the skin and it can be pretty painful too. Use gentle cleansers or Head & Shoulders shampoo. Don’t get at it in an aggressive way, but let water and soap rinse over the area to just get the drainage off. That can be really helpful.
If the wounds are very painful because they're open, you can use saline instead. That can reduce the pain quite a bit. Because the reason the water hurts is that it's just a different salt concentration than saline is. As a hack, you can buy saline in the drugstore and get a turkey baster and squirt it on, or you can buy saline solution for eyes [contact lenses]. You can get one of those containers with a squirt bottle already and use that to clean some of them and you can get a little force from the squeeze bottle as well. Of course, you can make your own saline too, if you need to.
Hibiclens and Puracyn Plus contain potent skin cleansers that reduce bacteria — but those aren’t really necessary once you have a wound. They are likely better at changing the microbiome and preventing new lesions from appearing.
First of all, it's painful to go to the bathroom.
One of the tips I often recommend is Vaseline. It has no allergens. It has no fragrances. I recommend that people actually put it on a tissue and wipe the area before they go to the bathroom. And that's because then you get a little bit of a barrier between the urine (which really can sting) and the skin. It can also be helpful in terms of cleaning the area. If you can put Vaseline back on another tissue when you wipe, it helps to reduce the friction of the rough cloth and it's a pretty good way to clean.
Creative bandaging becomes a kind of an art form. For people with a lot of drainage in the groin area, sometimes adult diapers are worth considering. Also, there are all sorts of new underwear options for women, such as menstrual underwear, that are designed to be much more absorbent. Being creative is completely appropriate.
One strategy is to take a reasonably absorbent bandage material and put it on the affected area, and then seal it with something like Tegaderm, which is a clear plastic adhesive sheet, because then you're essentially sealing it off temporarily. The smell isn't permeating out, but you've got the absorption inside. It helps to change the pads more frequently if you can, recognizing that if you're at work or in certain situations, that's going to be tough.
Odor is caused by a bacteria that is normally present in areas of the body. That's why when you shower, you get rid of the odor, because you're essentially rinsing it off and then it comes back.
There's a difference between antiperspirants and deodorants. Antiperspirants reduce sweat, and deodorants are fragrances that mask odor. Masking the odor may be desirable but won’t affect the HS. Antiperspirants that decrease sweat may have a beneficial effect, however.
Now, there are a lot of myths out there that deodorants are bad for HS, because they clog pores, which is part of the way they work. But what I tell patients is to get the clinical strength antiperspirants. There are some that are creamy, and they're pretty nonirritating. Try it in a small area. You don't have to just limit it to under the armpits. You can use it in the groin, inner thighs, you can use it under the folds, you can use it on your feet — anywhere that is stinky and sweaty. I recommend using a different one for your feet. You could have five different ones for different body areas, and most of them actually work better if you use them at night than during the day to activate. So that will help with the sweat, that'll help with the bacteria, and that'll help with the odor.
Body washes that have an anti-yeast or antibacterial effect can be helpful with odor too.
The older version of antiperspirants contained aluminum chloride, which will sting on normal skin, not to mention HS skin. That's why I like the newer antiperspirants, which are zirconium-based, like Secret Clinical Strength and Dove Clinical [Protection]. They are really much less irritating. Try it in a small area and make sure you don't have a problem with it. Not all of my patients follow through with it, they're still kind of nervous about it, but I've definitely had patients say that it really did the trick for them.
Because HS often occurs in areas where unwanted hair grows (such as the armpits, thighs, or along the bikini line), it’s important to talk about safe ways to remove that hair.
We recommend hair removal with some caveats. The reason that it helps is probably multifold. The hair follicles and the hairs are in a place that bacteria and yeast live, so it keeps things a little bit cleaner and easier to manage. There's also no friction from the hairs getting moved around.
Hair removal works best with a laser, if there is a difference in hair color versus skin color. It works best when there's dark hair and light skin, because in that setting, it's tuned to the darkness of the hair, and it's not confused by the skin color. It does take several treatments typically, but it is a nice way to reduce hair. However, it is expensive.
If you don't do laser hair removal, I don't recommend shaving. Because the hairs retract, you can get ingrown hairs and other issues. So no waxing and no shaving unless you use an electric razor. You can clip or electric shave, but we don't want you to pluck or wax. That actually is pulling the hair out — and it will regrow.
And there are some home hair removal devices as well. Some are better than others. They won't usually permanently remove the hair, but they can reduce it.
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The myHSteam members often ask for advice and share experiences about what works on boils and lesions. How do you manage HS boils? Have you found any tricks that work for you? Share your experience in the comments below or on myHSteam.