Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory skin condition with several treatment options. Severe HS may be treated with injections of medications such as biologics. Mild HS is usually managed with a combination of topical or oral medications and lifestyle changes aimed at preventing flare-ups.
HS is characterized by painful nodules deep in the skin. As the disease progresses, these bumps can link together to form tunnels under the skin (sinus tracts) that create permanent scarring. HS tends to crop up in skin folds that experience a lot of friction, like the armpits and near the genitals. Sometimes HS is triggered by blocked sweat glands or hair follicles. HS is not contagious, and it is not caused by poor hygiene. There currently is no cure for HS, but treating mild HS early may be helpful in slowing the progression of the disease.
Treatments for HS vary depending on the severity of the condition. HS severity is assessed using the Hurley system, which ranges from stage 1 to stage 3. Mild HS falls under Hurley stage 1. A person with Hurley stage 1 HS has inflammatory abscesses or nodules, but no sinus tracts or scarring. Your doctor will use the Hurley system to assess the severity of your HS, which will help them create an appropriate treatment plan.
Minimizing pain, caring for wounds, and managing risk factors are important for all people with HS, including those with mild cases. The goal of generalized HS treatments is to decrease symptoms while improving the quality of life for someone with HS.
People with mild HS may experience pain or discomfort with their lesions. Anti-inflammatory drugs can help manage pain and decrease swelling or inflammation during outbreaks. Warm compresses may also help decrease pain and swelling.
Proper wound care is important for preventing a bacterial infection. Along with other treatments, dermatologists sometimes prescribe antiseptic washes such as chlorhexidine for washing affected areas. Washing with gentle, nonabrasive soaps can prevent skin irritation. Wearing loose clothing that does not trap sweat can also help.
Both smoking and obesity frequently co-occur with HS, but these risk factors have not been proven as causes. Addressing these factors may help relieve symptoms.
Some factors linked with obesity, such as skin friction and changes in insulin production, can increase HS outbreaks. Losing weight through exercise may decrease HS flare-ups, but try to find ways to exercise that don’t irritate your skin. This is especially important if sweating is an HS trigger for you. If you smoke, quitting smoking may also help decrease flares.
Dermatologists may prescribe antibiotics to treat mild HS. For localized flare-ups, topical antibiotics (applied on the skin) may be prescribed. Oral antibiotics (taken by mouth) may be used for more generalized outbreaks. Commonly prescribed antibiotics for mild HS include:
Clindamycin is typically prescribed as a topical antibiotic that’s applied directly to the affected areas. Some people who do not respond to other treatments have found success with a combination of oral clindamycin and rifampin, another antibiotic. However, this treatment is more common in people with advanced HS.
Side effects of antibiotics vary by the type of antibiotic prescribed and the treatment’s duration. Most common side effects include:
Corticosteroids, sometimes just called steroids, are anti-inflammatory treatments that can be administered directly to an inflamed nodule. Corticosteroid injections directly into a nodule work only in mild cases and in nodules that are not infected.
HS usually does not appear until after puberty. This trend has led some doctors to believe that the surge in sex hormones around puberty is part of what causes the skin condition.
Hormonal treatments may reduce HS symptoms. The most common hormonal therapies prescribed to treat mild HS are oral contraceptives and metformin.
Some evidence indicates that hormonal imbalances causing an increase in androgens, such as testosterone, can trigger HS. Oral contraceptives (hormonal birth control) are sometimes prescribed to women with HS to help stabilize hormones and prevent flare-ups associated with menstrual cycles. These medications can also decrease the amount of fluid in chronic HS lesions. Some women may experience side effects from hormonal birth control, including nausea, headaches, and bleeding between periods. These side effects usually occur in the first weeks or months of treatment.
Aldactone (spironolactone) is also sometimes prescribed to women with mild HS when hormonal imbalances associated with testosterone are suspected. This medication works similarly to hormonal birth control. Spironolactone can help decrease inflammation in HS lesions and improve pain.
Finasteride, another androgen inhibitor, may also be prescribed. Finasteride can be used alone or with other hormonal therapies. It can be given to men and women.
In some cases, dermatologists prescribe the diabetes medication metformin. Insulin and hormones similar to insulin are thought to play a role in HS. Conditions associated with insulin, such as metabolic syndrome, often occur alongside HS. This may explain why metformin is an effective treatment.
Metformin can also contribute to weight loss, which can be helpful in controlling HS flare-ups. Metformin can be prescribed to both men and women. The most commonly reported side effects of metformin are gastrointestinal issues.
Resorcinol is a topical treatment sometimes prescribed by dermatologists for mild HS. This treatment is applied directly to acute nodules. Resorcinol has anti-inflammatory properties and can decrease the pain associated with abscesses, as well as how long they last. This treatment causes the top layer of skin to shed — its use should typically be tapered as symptoms begin to improve.
Surgical interventions for HS are generally performed in a doctor’s office. Punch debridement is a type of procedure that is useful for new lesions. It involves:
If lesions have progressed and are painful, lancing (piercing) and draining them may help. Doctors use lancing in special cases to give a person with HS relief, not as a regular treatment. There is also some evidence that laser hair removal can be helpful in newer cases of HS.
Treatments for moderate or severe HS (Hurley stages 2 and 3) can differ from treatments for mild HS. Treatments for advanced stages can include biologic drugs. These drugs aim to change the immune system to stop the immune responses that lead to HS symptoms.
Humira (adalimumab) is the first biologic approved by the U.S. Food and Drug Administration (FDA) to treat HS. Other biologics, such as Remicade (infliximab), are not approved by the FDA for HS but are sometimes prescribed to treat the disease. These off-label treatments are generally only used in severe cases.
Retinoids, such as acitretin or isotretinoin, are used to treat acne. They can also be used to treat severe HS that has not responded to other therapies. Retinoids are not the first course of treatment in HS, so they are not used for mild cases.
In cases of severe disease, surgical excision of large areas of scar tissue and tunnels followed by skin grafting may be considered. This procedure is considered the final treatment option for stage 3 HS. It is not necessary in cases where management and other treatments are effective.
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