Comprehensive Guide to Treating Hidradenitis Suppurativa (HS)
Skin ConditionsHidradenitis Suppurativa
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Hidradenitis Suppurativa Treatment: A Complete Guide

Hidradenitis Suppurativa Treatment: A Complete Guide
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Updated on December 4, 2024
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Hidradenitis suppurativa (HS), also called acne inversa, is a chronic skin condition that causes painful lumps and abscesses under the skin. HS can appear as pimples, cysts, or a boil in the armpit, groin area, or inner thigh, and cause scarring. Treatment for the condition focuses on reducing flare-ups, healing wounds, lessening pain, and relieving symptoms.

 Remedies may include topical creams, oral medications, and sometimes surgery.

 Talk with your healthcare provider first before starting treatment.

Medication

Most medications for hidradenitis suppurativa focus on decreasing inflammation, and they can be applied to the skin, taken by mouth, or by injection (both locally or systemically). It can take weeks, sometimes months, for them to work. Topicals tend to work more slowly.

Topical Creams

Topical creams are used to diminish inflammation, pain, and to fight infection.

Clindamycin (Cleocin T, Clindacin ETZ, Clindacin P) is a prescription antibiotic used to treat mild hidradenitis suppurativa. Applied to the skin, it reduces lumps and swollen areas beneath the skin, and treats infection on the skin’s surface.

 Side effects may include skin dryness, peeling, itching, burning, or redness.

Topical resorcinol is an over-the-counter chemical peeling agent that promotes skin exfoliation, prevents lesions from forming, and boosts wound healing. It can also decrease pain around lumps, but it typically takes three to four months for improvement.

 The cream may cause skin redness or peeling.

Biologics and Biosimilars

Biologics block specific parts of your immune system to decrease inflammation, and prevent and treat skin lesions.

 Three biologics have been approved by the U.S. Food and Drug Administration (FDA) to treat hidradenitis suppurativa:

  • adalimumab (Humira Pen or syringe)
  • secukinumab (Cosentyx)
  • bimekizumab-bkzx (Bimzelx)

Infliximab (Remicade), though not approved, is sometimes used to reduce symptoms and inflammation.

Biologics are typically given through IV infusion or injection, and are currently the most effective medication available for people with moderate to severe hidradenitis suppurativa.

Biosimilar medications, which are similar to biologics, can cost up to 35 percent less than biologics.

 The FDA has approved biosimilars for adalimumab:

  • adalimumab-ryvk (Simlandi)
  • adalimumab-aaty (Yuflyma)
  • adalimumab-aacf (Idacio)
  • adalimumab-aqvh (Yusimry)
  • adalimumab-fkjp (Hulio)
  • adalimumab-afzb (Abrilada)
Because biologics and biosimilars change the way your immune system functions, they can put you at higher risk of infections and may cause side effects such as flu-like symptoms and headache.

Off-Label Oral Medications

Some medications for HS are called “off-label” because the FDA has not approved them specifically for HS. But they have been shown to improve symptoms.

Antibiotics

Your healthcare provider may prescribe oral antibiotics for hidradenitis suppurativa, which can lower inflammation and shrink lesions over a few months.

 Antibiotics can be used for mild, moderate, and sometimes severe symptoms. Some common antibiotics used for HS are:

  • clindamycin (Cleocin HCl, Cleocin Phosphate, Cleocin Phosphate ADD-Vantage)
  • rifampin (Rifadin, Rifadin IV, Rimactane)
  • doxycycline (Vibramycin, Acticlate, Adoxa)
  • minocycline (Minocin, Dynacin, Minocin, Minocin PAC, Minolira)
Side effects for clindamycin and rifampin are generally well-tolerated.

 While uncommon, minocycline can cause ear ringing, drowsiness, and muscle stiffness, and doxycycline can cause diarrhea and vaginal irritation, and sun sensitivity.

Corticosteroids

Corticosteroids can lower inflammation and pain associated with HS. The corticosteroid typically used in hidradenitis suppurativa are medium to high potency topical steroids. (Diprolene AF).

 So is the oral corticosteroid prednisone, typically prescribed in short-term bursts (three months or under) to avoid side effects like fluid buildup, high blood pressure, mood swings, and weight gain.

Hormonal Therapy

Hormones may play a role in hidradenitis suppurativa, with some reporting worsening symptoms just before menstruation and after pregnancy.

 Some hormone therapies are prescribed to treat HS, and have been shown to reduce inflammation, regulate androgen levels, and reduce flare-ups.

 These include:

  • estrogen birth control pills
  • ethinylestradiol/cyproterone acetate (Diane, Diane-35)
  • metformin (Fortamet, Glucophage, Glucophage XR) is not a hormone but does affect hormones

These medications may come with a variety of side effects. If you notice any new symptoms after beginning a medication, let your healthcare provider know right away.

Other Treatment Options

Alternative treatment options for HS may be taken alongside other treatments under the direction of a healthcare provider. Zinc, one alternative treatment, is a nutritional supplement that may act as an anti-inflammatory, and research suggests it may help prevent and shorten HS flares.

 Zinc dosage varies by gender: between 8 and 12 milligrams (mg) per day. Higher dosages carry the risk of side effects like diarrhea, stomach cramps, and vomiting.

Retinoids, another option, affect how your skin cells grow and mature, and some small studies and anecdotal evidence suggests it may help diminish HS symptoms for some people.

 Some commonly prescribed retinoids are:

  • isotretinoin (Absorica, Absorica LD, Accutane)
  • acitretin (Soriatane)
Oral retinoids can cause side effects to the skin like redness, itching, scaling, and dryness, and they should not be taken if you’re pregnant or intend to get pregnant.

Surgery and Procedures

Your healthcare provider may recommend surgery for severe or recurrent cases that don’t respond well to treatment.

Incision and Drainage For bumps that collect a large amount of pus, your provider may make a small incision and drain the abscess for pain relief.

Punch Debridement When a lump under the skin becomes extremely inflamed or painful, a punch debridement may be performed, in which a surgeon removes a single lump with a device that inserts a hollow tube into your skin, withdrawing the lump.

Unroofing Sometimes the bumps under your skin become infected and collect pus, which can form a tunnel under your skin connecting between the bumps. An unroofing procedure opens these tunnels so they can drain and heal.

Injections Steroid injections to the affected areas can lower inflammation, and Botox injections can decrease excessive sweating, both of which alleviate HS symptoms.

Laser Therapy Hidradenitis suppurativa sores can be treated by directing a carbon dioxide laser to the area. And, because hair follicles can play a part in HS symptoms, some people also find laser hair removal helpful in the early stages of HS.

Skin Removal In severe cases of HS, providers may recommend removing the most affected areas of skin. After removal, you may need a skin graft to replace the skin and close the wound.

After any procedure, wound care is vital for recovery. Your provider will give you detailed instructions on how to help yourself heal at home.

Lifestyle Changes

Certain lifestyle changes can help your HS treatment work better, relieve symptoms, and prevent flares.

Skin Care Use mild, unscented soaps, antibacterial wash, and gentle antiperspirant to avoid irritating affected skin.

Diet For some, dairy, red meat, and foods that spike your blood sugar worsen your HS symptoms, so you can ask your provider about cutting some of these out of your diet.

Gentle Cleansing Scrubbing your skin can trigger inflammation and exacerbate symptoms.

 Instead, use a soft cloth to clean up.
Shaving Precautions Experts warn against removing hair with wax, which can irritate the skin, and also recommend taking care when shaving, as both can aggravate HS symptoms. Before you shave, wash the area well with antibacterial soap, apply a gel-to-foam shaving lubricant, and shave slowly and carefully.

Overheating Sweat and overheating can worsen HS symptoms, so try to stay cool and use antiperspirant in warmer weather.

Clothing If tight clothes cause your HS to flare, go for looser options to avoid skin irritation.

Weight Some people with hidradenitis suppurativa find losing weight can reduce flare-ups. A lower weight can also protect against heart disease and diabetes, which may be more prevalent in those with HS.

Smoking Smoking can increase the areas affected by HS, decrease treatment effectiveness, and promote inflammation, worsening symptoms.

 You can get support for quitting from the American Lung Association (ALA).

Pain Management

Pain is common with hidradenitis suppurativa, and pain management is a critical part of treatment. Some medical treatments, like steroid injections and resorcinol cream, help with pain.

 For daily pain with HS, you can also try other interventions for some relief.
Ice and Warmth Alternate cold and warm for painful bumps or sores. You can use a cloth-covered ice pack for cold and a warm (not hot) damp washcloth for heat.

Lidocaine Your provider may offer lidocaine cream, ointment, or patches to numb pain in your affected skin.

Pain Medicine Your provider may recommend over-the-counter pain medications like acetaminophen (Tylenol), ibuprofen (Advil), and naproxen (Aleve). If these don’t improve your pain, your provider may refer you to a pain management team for prescription pain medicines.

Mental Health

Because of the visible and uncomfortable nature of hidradenitis suppurativa, many who have it also experience mental health issues like depression and anxiety, which can cause additional symptoms like self-isolation and feelings of hopelessness, restlessness, and fatigue.

 Your provider can recommend resources that may help, such as an HS support group or a licensed therapist, who can help you adjust to your diagnosis and symptoms.

You can find information and support through these organizations:

The Takeaway

  • Hidradenitis suppurativa (HS), a chronic skin condition that appears after puberty and lasts many years, causes painful bumps under the skin and scarring on the skin’s surface.
  • While there is no cure for HS, the condition can be treated with creams, anti-inflammatory oral medications, and in more severe cases, surgery and certain procedures.
  • Other lifestyle changes like careful skin care, weight management, and keeping your skin dry can help prevent flare-ups.
  • Work closely with your healthcare provider to manage treatment and monitor affected areas of your skin.
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Jacquelyn Dosal

Jacquelyn Dosal, MD

Medical Reviewer
Castle Connolly Top Doctor

Jacquelyn Dosal, MD, is a board-certified dermatologist practicing at The Dermatology House in Park City, Utah. Her areas of expertise include acne, rosacea, integrative treatments of inflammatory skin diseases, as well as laser treatment of the skin and injectables.

Dr. Dosal writes cosmetic questions for the certifying exams for the American Board of Dermatology. She is also the deputy editor for the American Academy of Dermatology's podcast, Dialogues in Dermatology.

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Abby McCoy is an experienced registered nurse who has worked with adults and pediatric patients encompassing trauma, orthopedics, home care, transplant, and case management. She is a married mother of four and loves the circus — that is her home! She has family all over the world, and loves to travel as much as possible.

McCoy has written for publications like Remedy Health Media, Sleepopolis, and Expectful. She is passionate about health education and loves using her experience and knowledge in her writing.

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