How Hidradenitis Suppurativa Is Treated

Treating Hidradenitis suppurativa (HS), a chronic skin condition often requires managing both the physical symptoms and the emotional ones.

Without treatment, it can lead to serious complications such as squamous cell carcinoma (a type of skin cancer), a bacterial skin infection called cellulitis. There is an association between Crohn's disease and HS, but HS does not lead to Crohn's disease.

What's more, because the skin lesions caused by HS are so visible, many people with the disease isolate themselves from other people, leading to loneliness, anxiety, and depression.

This article details treatment options, including self-care measures, medications for relieving pain and inflammation and preventing infection, and alternative therapies which, although unproven, you might find worth trying. It also explains how doctors determine what to prescribe.

Determining Treatment

Treating hidradenitis suppurativa can be complicated. Symptoms can vary widely, and not everyone experiences the disease in the same way.

Doctors make decisions about which treatments to try based on the Hurley staging system.

This system describes three distinct phases of HS—from least to most severe—and the medical treatments most likely to be effective for each, each of which are covered in-depth as you read on.

Hurley Stage	Definition	Possible Medical Treatments
1	•HS breakouts in one or more isolated areas •No scarring or sinus tracts (tunnels leading from an infection to the surface of the skin)	•Oral or topical antibiotics •Corticosteroid injection
2	•HS breakouts in one or more isolated areas •Scars and sinus tracts present	•Combination of oral and topical antibiotics •Surgery (considered if medication fails)
3	•Large areas of the body •Numerous scars and sinus tracts	•Biologic medicine •Surgery

Home Remedies and Lifestyle

An important aspect of living with hidradenitis suppurativa involves protecting skin and treating breakouts. Equally important is adopting habits or making certain changes that lower the risk of flareups.

This applies regardless of the severity of your case.

Skin Care

To protect your skin, help prevent breakouts, and/or keep them from getting worse:

• Be gentle: Don't scrub affected areas when cleansing your skin. Use a soft cloth.
• Moisturize generously: Slather on a rich body cream or lotion after you shower. Products recommended for eczema, such as Eucerin, Aveeno, or a generic equivalent, also are good for HS.
• Shave carefully: The friction caused by a razor can irritate skin, as can hair as it grows back in. If possible, don't shave during flare-ups.
• Don't pick or squeeze lesions, boils, and affected skin.

Bleach Baths

If you develop a chronic bacterial infection as a result of your hidradenitis suppurativa, soaking in a highly diluted bleach bath may help kill the bacteria and prevent future infections. The bacteria that most often causes chronic skin infections in people with HS is Staphylococcus aureus, also known as staph.

Bleach baths can sting or burn your skin. They can also dry it out. It's important to carefully follow instructions for taking a safe bleach bath and to apply a generous layer of moisturizer to your entire body after your soak.

Before you take a bleach bath, however, ask your doctor for guidance. They can guide you on best practices for you. Also note that if you have asthma, you may be told to avoid trying this remedy. Inhaling bleach fumes may trigger an attack.

Dietary Changes

Certain foods have been found to worsen HS symptoms. If any of these are a regular part of your diet, you may want to avoid them for a time to see if your skin clears up:

• Dairy
• Sugar
• Tomatoes
• Eggplant
• Potatoes

Brewer's yeast also has been linked to HS. In studies, people with hidradenitis suppurativa who avoided brewer's yeast for a period of time and then ate foods containing it had immediate flare-ups. Brewer's yeast is found in baked goods such as bread as well as fermented foods and beverages, including vinegar, pickled foods, beer, and wine.

Keep in mind, too, that if you're dealing with HS, what you do eat may be as important as what you don't. For example, there's evidence that following the Mediterranean diet, which is rich in antioxidants, vitamins, and minerals, may reduce inflammation and help prevent HS flare-ups.

Foods to focus on include:

• Fresh fruits, greens, and non-starchy vegetables
• Whole grains
• Legumes, nuts, and seeds
• Fatty fish, such as salmon and mackerel
• Heart-healthy oils, especially olive oil, fish oils, and nut oils
  

Don't Smoke

There's a strong link between cigarette smoking and hidradenitis suppurativa. If you smoke, you may have fewer flare-ups and less severe symptoms. Kicking the habit also may help your medications work better.

It can be hard to give up smoking, but there are lots of ways to do it, including quitting cold turkey, nicotine replacement therapy, and prescription medications.

Your doctor can help you find the best approach for you.

Maintain a Healthy Weight

Extra pounds can increase the risk of hidradenitis suppurativa and make symptoms worse, especially in skin folds that can trap sweat and cause friction.

Being obese or overweight also places extra stress on the body as a whole, which increases the risk of inflammation.

Weight loss can help improve HS in the long term. Research has shown that dropping 15% of your total body weight is enough to improve symptoms.

Besides cutting calories, regular exercise can play an important role in shedding weight. If you have HS, though, chafing and sweat can make it hard to work out.

These tips may help:

• Choose activities that involve as little skin friction as possible, such as yoga or swimming.
• Apply an anti-chafe balm to areas between skin folds right before working out.
• Wear full-length sleeves and pants to lessen skin-to-skin contact.
• Shower or bathe as soon as you finish exercising so sweat doesn't sit on your skin. Pat—don't rub—your body dry with a clean towel.
  

Over-the-Counter Therapies

You may be able to relieve mild pain and inflammation with over-the-counter (OTC) drugs and skincare products from your local pharmacy.

Pain Relievers

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most common type of OTC pain reliever. NSAIDs that come in pill form include aspirin^*, Motrin (ibuprofen), and Aleve (naproxen).

Tylenol (acetaminophen) is also an effective OTC pain reliever, but it does not decrease inflammation and may not be the best choice for long-term treatment. Taking too much Tylenol in one sitting or over time has been linked to hypertension, kidney damage, and liver damage.

Some pain medications can be applied directly to affected areas of skin. They include diclofenac gel, a topical NSAID available under the brand names Solaraze and Voltaren, and lidocaine which relieves pain by numbing the skin.

^{*Aspirin should never be given to children due to a risk of Reye's syndrome.}

Antibacterial Cleansers

Washing with an antibacterial cleanser daily can reduce bacteria on the skin and prevent inflamed lumps and boils from getting worse, help heal wounds, and minimize the odor HS can cause.

Antibacterial washes commonly used to treat HS include those that contain:

• Chlorhexidine, such as in Hibiclens
• Zinc pyrithione, such as in Noble Formula
• Benzoyl peroxide, such as in Oxy and PanOxyl

Sometimes these products cause skin to become red and dry. If you develop these side effects, ask your doctor to suggest a product that will be less irritating to your skin.

Prescription Medicine

If OTC treatments aren't effective, there are prescription-strength options that may work better to prevent and control hidradenitis suppurativa symptoms.

Antibiotics

Both oral and topical antibiotics may be prescribed to destroy bacteria that can cause infections.

Topical clindamycin is a common first-line treatment for mild to moderate HS. One drawback of this medication is that bacteria are becoming resistant to it, meaning it's no longer as effective as it once was. For this reason doctors often advise "doubling up" your efforts by using an antibacterial wash along with topical clindamycin.

Oral antibiotics for treating hidradenitis suppurativa include oral tetracyclines, which most often are prescribed for mild to moderate cases. If these don't work or symptoms are severe, oral clindamycin along with another antibioic called rifampin may be effective.

Topical Resorcinol

Resorcinol is what's known as a keratolytic medication. As such, it treats hidradenitis suppurativa in a number of ways:

• Softens keratin, the protein that makes up skin, hair, and nails
• Helps dead skin cells to shed
• Kills bacteria on the surface of the skin
• Relieves itching

Resorcinol cream can be used to keep prevent or treat HS flare-ups. It's most effective for mild cases.

Corticosteroids

Two types of corticosteroids may be used to treat hidradenitis suppurativa.

• An oral corticosteroid, such as prednisone, may be prescribed as needed.
• Injectable corticosteroids can be delivered directly into lesions that are especially severe.

Steroids are never used to treat hidradenitis suppurativa on a long-term, on-going basis, however. Whether taken by mouth or injected, these medications have a number of serious side effects.

Biologics

Biologics are medications produced from living cells. They work by stopping the immune system from producing inflammation.

Biologics are highly effective for treating moderate to severe HS. Most healthcare providers reserve these drugs for cases that are not improving with other treatments.

The first and only biologic drug approved by the U.S. Food and Drug Administration (FDA) for treating HS is Humira (adalimumab). Humira is safe to use long-term.

Other biologics, such as Enbrel (etanercept), Stelara (ustekinumab), and Remicade (infliximab), are sometimes prescribed off-label for HS.

Hormonal Therapies

Between 44% and 63% of women with HS have flare-ups just before their periods. Women with polycystic ovary syndrome (PCOS) are particularly prone to HS.

Hormonal therapies often are effective in these cases. They include spironolactone, a medication that blocks the action of groups of hormones, and combination oral contraceptives that pair the hormones estrogen and progesterone.

For adults of all sexes and children with hidradenitis suppurativa, a hormonal medication called finasteride may help. This drug, which is sold under the brand names Proscar and Propecia, is also used to treat benign prostate growths and male pattern baldness.

Pregnant women should not take finasteride as it has been linked to birth defects.

Oral Retinoids

Oral retinoids, which are derived from vitamin A, sometimes work when other medications for HS don't. They can help reduce inflammation and minimize flares even after the medication is stopped.

Absorica, Zenatane, and Myorisan (all brand names for isotretinoin) and Soriatane (acitretin) are oral retinoids that may be considered for the treatment of hidradenitis suppurativa.

Metformin

Metformin, a medication for type 2 diabetes, is sometimes prescribed off-label to relieve pain, reduce inflammation, and prevent metabolic syndrome in people with HS who are at risk for diabetes.

Most people have no problem tolerating metformin, although the drug can cause diarrhea, nausea, vomiting, and abdominal pain.

Surgeries and Procedures

It is sometimes necessary to remove boils and sinus tracts caused by hidradenitis suppurativa.

There are a number of ways this can be done. The goal of each is to preserve as much healthy tissue as possible.

Laser Treatments

A doctor can use any of several laser treatments during an office visit to reduce inflammation from HS, remove hair, and destroy hair follicles to help prevent new boils from forming.

Those procedures are:

• Carbon dioxide (CO2) laser: This damages thin layers of skin cells in a precise area. It may also be used for deroofing (see below), sinus tract excision, or to repair scars.
• Nd-YAG laser: Infrared light is beamed through a crystal and penetrates deep into the skin to destroy hair follicles.
• Intense pulsed light (IPL): Heat is used to destroy hair follicles. This treatment also has an anti-inflammatory effect that may relieve pain from chronic boils and prevent keratin buildup.

It takes an average of three laser treatments before there are noticeable improvements in skin.

Deroofing

Deroofing is a minimally-invasive procedure to remove chronic lesions, sinus tracts, and any tissue affected by hidradenitis suppurativa. A doctor can do it in their office.

They'll begin by using a local anesthetic to numb the affected area. Then, they will remove the top portion, or "roof," of the lesion or sinus tract. The area will be allowed to heal.

Although the treatment leaves a scar, lesions rarely come back.

Sometimes a biologic drug is prescribed before or after deroofing to suppress the immune system's inflammatory response and help skin recover.

Incision and Drainage

When a boil becomes severely inflamed and painful, it can be drained with an incision and drainage procedure. This is often done when a person goes to the hospital for emergency treatment for pain.

Incision and drainage can provide immediate relief, but won't treat the underlying cause of hidradenitis suppurativa or prevent future flare-ups.

In most cases, HS boils that are drained do come back.

Surgical Excision

For severe cases that aren't responding to treatment, surgery may be done to remove all tissues in the affected area. This procedure is done in the hospital under general anesthesia.

There are two main methods of excision:

• Wide surgical excision: The affected tissues and healthy tissues bordering them are taken out. This way all tissues that could have burst follicles or bacteria are removed.
• Tissue-saving excision: A laser or a heated wire are used to remove affected tissues while saving as much healthy skin around the border as possible.

After excision, the skin is either left open to heal or closed with stitches. When a large area is removed, healthy skin tissues from another part of your body may be used to cover the wound. This is known as a skin graft.

Removed boils are unlikely to return. However, the surgery can leave scars and, as with any surgery, wounds can become infected.

Complementary and Alternative Medicine (CAM)

There's no scientific proof CAM is effective for HS, nor are CAM therapies meant to take the place of medicines or treatments.

Nonetheless, because these CAM therapies are generally considered safe and well-tolerated, they may be worth trying with a doctor's guidance.

Zinc

Zinc is a mineral that plays an important role in the health of both your skin and immune system. It also helps wounds heal.

A 2018 study published in the American Journal of Clinical Dermatology found people with HS are more likely to have lower levels of zinc in their blood than those who don't have the condition.

While there is strong evidence that taking zinc supplements may help relieve inflammation and hidradenitis suppurativa symptoms, more research is needed before zinc can be regarded as an HS treatment.

Because the body can't make zinc on its own, it's important to eat foods that are rich in the mineral, such as oysters, beans, oats, nuts, whole grains, and dairy products.

Vitamin D

Like zinc, vitamin D helps support the immune system. Research has found a possible link between vitamin D deficiency and the onset of and severity of hidradenitis suppurativa.

In one small study of people with HS, those who took vitamin D supplements had a significant improvement in symptoms after six months; those who didn't take the supplements saw no such benefit. Doses were tailored to each individual based on their blood levels of the vitamin.

Although one study is not enough to prove vitamin D is an effective way to treat hidradenitis suppurativa, making sure you get enough of this nutrient is important for overall health.

Aside from taking supplements, taking in some sun is another step you can take to boost your vitamin D. Just 10 to 15 minutes of exposure a few times a week (without sunscreen) is plenty.

You can also get vitamin D through your diet. Foods rich in vitamin D include milk, fortified orange juice, cereal, egg yolks, and fatty fish.

Summary

Hidradenitis suppurativa is a chronic skin condition that causes painful and unsightly boils. There's no cure for the condition, but there are many effective ways to treat it.

These include gentle skin care, weight loss, avoiding foods that may trigger flare-ups, and, for people who smoke, kicking the habit.

A variety of OTC and prescription medications may also help ease discomfort, decrease inflammation, prevent breakouts, and thwart infections that can occur when boils burst and cause open wounds.

In severe cases, a doctor can remove HS lesions using laser therapy or simple surgical procedures.

A Word From Verywell

According to a study by the American Academy of Dermatology, 64% of people with hidradenitis suppurativa visited a healthcare provider at least five times before receiving their diagnosis. Overall, it took an average of 10 years after HS symptoms began for people to get a proper diagnosis and begin treatment.

If you have visited your healthcare provider several times and the recommended treatments aren't working, keep this in mind. Untreated, hidradenitis suppurativa gets worse over time, so it's important to speak up if you feel your doctor isn't taking your symptoms seriously. You should also consider getting a second opinion.