How to Choose HS Treatments: Get Relief

Hidradenitis Suppurativa (HS) is a chronic, painful, and often misunderstood skin condition that can significantly impact a person’s quality of life. Characterized by recurrent, painful nodules, abscesses, and draining tunnels (sinus tracts) typically found in skin folds like the armpits, groin, buttocks, and under the breasts, HS is more than just “boils.” It’s an inflammatory disease of the hair follicles, and its management requires a multifaceted approach. Navigating the myriad of treatment options can be overwhelming, but with the right knowledge and a collaborative approach with your healthcare team, finding relief and achieving long-term control is absolutely possible. This comprehensive guide will empower you with the insights needed to make informed decisions about your HS treatment journey.

Understanding the Landscape of HS: A Foundation for Treatment

Before diving into specific treatments, it’s crucial to grasp the nature of HS. This isn’t an infection caused by poor hygiene, nor is it contagious. Instead, it’s an autoinflammatory condition, meaning your immune system mistakenly attacks your hair follicles, leading to inflammation and the characteristic lesions. The severity of HS is often categorized using the Hurley staging system:

• Hurley Stage I: Characterized by single or multiple isolated abscesses without sinus tracts or scarring. Flares are typically localized.

• Hurley Stage II: Involves recurrent abscesses with scarring and the formation of single or multiple separated sinus tracts. Lesions might be more widespread but still relatively distinct.

• Hurley Stage III: Represents the most severe form, with diffuse or interconnected abscesses, multiple widespread sinus tracts, and extensive scarring across an entire area.

Your Hurley stage is a primary factor your dermatologist will consider when developing a treatment plan, as different stages often respond best to different interventions.

The Pillars of HS Treatment: A Multi-pronged Approach

Effective HS management rarely relies on a single therapy. Instead, it often involves a combination of medical treatments, procedural interventions, and crucial lifestyle modifications. The goal is not just to clear existing lesions but to prevent new ones, reduce pain, minimize scarring, and ultimately improve your overall quality of life.

1. Medical Therapies: Targeting Inflammation and Symptoms

Medical treatments form the cornerstone of HS management, addressing the underlying inflammation and offering symptomatic relief. They can be topical (applied to the skin), oral (taken by mouth), or injectable.

Topical Treatments: For Mild HS and Adjunctive Care

Topical therapies are often the first line of defense for Hurley Stage I HS or as an adjunct for more severe cases.

• Topical Antibiotics (e.g., Clindamycin): These creams or solutions work by reducing bacterial presence on the skin and, more importantly, exerting an anti-inflammatory effect. A common prescription might be clindamycin applied twice daily to affected areas. While they don’t cure HS, they can significantly reduce the number and severity of active lesions.
  • Concrete Example: If you have small, painful bumps in your armpit, your dermatologist might prescribe topical clindamycin to be applied to the area to help reduce inflammation and prevent them from worsening.
• Topical Resorcinol: This peeling agent can help to reduce inflammation and promote drainage of superficial lesions. It’s often used for localized, painful bumps.
  • Concrete Example: For a new, inflamed nodule that hasn’t formed a deep tunnel, applying topical resorcinol can sometimes help it to resolve more quickly and reduce discomfort.
• Antiseptic Washes (e.g., Chlorhexidine, Benzoyl Peroxide, Zinc Pyrithione): While HS isn’t caused by poor hygiene, using antimicrobial washes can help reduce bacteria on the skin surface, potentially leading to fewer flare-ups. However, aggressive scrubbing should be avoided as it can irritate the skin and worsen HS.
  • Concrete Example: Incorporating a gentle antibacterial wash containing zinc pyrithione into your daily shower routine, focusing on affected areas without scrubbing, can be a simple way to support your overall treatment plan.

Oral Medications: Systemic Relief

Oral medications work throughout your body to address the systemic nature of HS.

• Oral Antibiotics: Unlike topical antibiotics, oral antibiotics are used not just for infection but primarily for their anti-inflammatory properties in HS.
  • Tetracyclines (e.g., Doxycycline, Minocycline): Often prescribed for moderate HS (Hurley Stage I or mild Stage II), these are typically taken for several months. They work by reducing inflammation and suppressing certain immune responses.
    • Concrete Example: Your doctor might prescribe a three-month course of doxycycline if you’re experiencing frequent, widespread flares that aren’t responding to topical treatments.
  • Combination Therapy (e.g., Clindamycin and Rifampin): For more severe or resistant cases, a combination of clindamycin and rifampin is often used. This potent combination targets bacteria and inflammation more broadly and is usually taken for 10-12 weeks.
    • Concrete Example: If your HS has progressed to Hurley Stage II with persistent draining tracts, your dermatologist might recommend a course of oral clindamycin and rifampin to bring down the systemic inflammation.
• Oral Retinoids (e.g., Isotretinoin, Acitretin): These vitamin A derivatives regulate cell growth and can be effective for severe HS, particularly in cases with a strong cystic acne component. However, they come with significant side effects and require careful monitoring.
  • Concrete Example: If your HS is severe and has failed other systemic treatments, your dermatologist might consider isotretinoin, but will thoroughly discuss the potential side effects and necessary blood tests.
• Hormone Therapy: For women, hormonal fluctuations can exacerbate HS. Medications that regulate hormones can be beneficial.
  • Oral Contraceptives: Certain birth control pills can help stabilize hormone levels, leading to fewer and less severe flares.
    • Concrete Example: A woman experiencing worsening HS symptoms around her menstrual cycle might find relief by starting a specific type of oral contraceptive.
  • Spironolactone: This medication has anti-androgen effects, which can be helpful for women whose HS is influenced by male hormones.
    • Concrete Example: If your HS flares seem tied to hormonal shifts and you’re not responding to other treatments, spironolactone could be an option, particularly if you’re a woman of childbearing age.
• Metformin: Typically used for diabetes, metformin has shown promise in some HS patients, particularly those with insulin resistance or polycystic ovarian syndrome (PCOS), as it may influence inflammation pathways.
  • Concrete Example: If you have HS and also have a diagnosis of pre-diabetes or PCOS, your doctor might explore metformin as an additional therapy.
• Corticosteroids: These powerful anti-inflammatory medications can provide rapid relief for severe flares. They can be injected directly into painful lesions or taken orally for widespread inflammation. However, long-term oral corticosteroid use is avoided due to significant side effects.
  • Concrete Example: For an acutely painful, large abscess, a corticosteroid injection directly into the lesion can quickly reduce pain and swelling. For a widespread, severe flare, a short course of oral steroids might be prescribed to gain rapid control before transitioning to other long-term therapies.

Biologic Therapies: Targeted Immunomodulation

Biologics represent a significant advancement in HS treatment, particularly for moderate to severe cases that haven’t responded to conventional therapies. These injectable or intravenous medications work by targeting specific components of the immune system that drive HS inflammation.

• Adalimumab (Humira): Currently the only FDA-approved biologic specifically for HS, adalimumab targets TNF-alpha, a key inflammatory protein. It has demonstrated significant efficacy in reducing flare frequency and severity, as well as improving pain.
  • Concrete Example: If you have Hurley Stage II or III HS with persistent, painful lesions despite trying oral antibiotics, your dermatologist will likely consider adalimumab as a primary systemic treatment. It involves self-injecting typically once a week or every other week.
• Infliximab (Remicade): While not FDA-approved specifically for HS, infliximab (another TNF-alpha inhibitor, given intravenously) is often used off-label for severe, refractory HS, particularly in a hospital or infusion clinic setting.
  • Concrete Example: For very severe, widespread HS that isn’t responding to adalimumab or other treatments, your dermatologist might recommend a course of intravenous infliximab.
• Newer Biologics and Emerging Therapies: Research into HS treatments is ongoing, and several new biologics targeting different inflammatory pathways are in various stages of clinical trials. These include drugs that target IL-17, IL-23, and other immune signaling molecules.
  • Concrete Example: Your dermatologist might discuss participation in a clinical trial for a novel biologic if your HS is particularly challenging to manage with existing therapies, offering access to cutting-edge treatments before they become widely available.

2. Procedural and Surgical Interventions: Addressing Lesions Directly

While medical therapies aim to control the overall disease, procedural and surgical interventions directly address existing lesions, provide pain relief, and can prevent future recurrences in specific areas.

• Incision and Drainage (I&D): This is a quick procedure to drain a painful, swollen abscess, providing immediate pain relief. However, it’s generally considered a temporary solution as the abscess often recurs in the same spot, as it doesn’t remove the underlying diseased tissue.
  • Concrete Example: If you have a large, tense, and extremely painful abscess, an urgent I&D by your doctor can offer significant and immediate relief from discomfort.
• Intralesional Injections (Steroids): As mentioned under medical therapies, injecting corticosteroids directly into a painful nodule can reduce inflammation and promote healing for individual lesions.
  • Concrete Example: For a stubborn, painful lump that’s not ready for drainage but is causing significant discomfort, your dermatologist might inject a small amount of steroid to calm it down.
• Deroofing: This minimally invasive surgical procedure involves removing the “roof” of a sinus tract or abscess, leaving the base open to heal from the inside out. It’s effective for persistent, draining tunnels and significantly reduces recurrence rates compared to simple I&D.
  • Concrete Example: If you have a chronic draining tunnel in your groin, a deroofing procedure can eliminate that specific tract, preventing its continuous recurrence and discharge.
• Punch Debridement/Excision of Individual Lesions: For isolated, inflamed nodules, a surgeon might use a punch biopsy tool or small scalpel to remove the entire lesion, including the surrounding affected tissue.
  • Concrete Example: If you have a single, recurrent painful lump in your armpit that doesn’t form extensive tunnels, its complete removal via excision could be a permanent solution for that specific area.
• Wide Excision: For Hurley Stage III HS or large, interconnected areas of disease, wide excision involves removing all affected skin and underlying tissue. This is a more extensive surgery, often requiring skin grafts or flaps for closure, but it offers the highest chance of long-term remission in the treated area.
  • Concrete Example: If you have widespread, interconnected tunnels and severe scarring across your buttock area, your surgeon might recommend a wide excision to remove all the diseased tissue and reconstruct the area with a skin graft.
• Laser Therapy (Nd:YAG, CO2 Laser): Lasers can be used in several ways for HS.
  • Hair Removal Lasers (Nd:YAG): As HS is a disease of the hair follicle, targeting hair follicles with laser hair removal (especially Nd:YAG for darker hair) can reduce disease activity and prevent new lesions by destroying the hair follicle.
    • Concrete Example: Undergoing a series of Nd:YAG laser hair removal sessions in affected areas like the armpits can reduce the frequency and severity of flares over time.
  • CO2 Laser Ablation: Carbon dioxide (CO2) lasers can be used to vaporize existing abscesses, sinus tracts, and scar tissue, promoting healing and reducing inflammation. It allows for precise removal of diseased tissue.
    • Concrete Example: For multiple, small, superficial lesions that are persistent, CO2 laser ablation can be a precise way to remove them with potentially better cosmetic outcomes than traditional surgical excision.
• Setons: In some cases, particularly for deeper or more complex sinus tracts, a surgical drain called a seton can be inserted. This allows for continuous drainage, reduces inflammation, and can encourage the tract to heal over time.
  • Concrete Example: For a deep, painful sinus tract that is difficult to completely excise, your surgeon might place a seton to keep it open and draining, reducing pain and allowing it to mature or heal gradually.

3. Lifestyle Modifications and Self-Care: Empowering Your Journey

While medical and surgical interventions are crucial, daily self-care and lifestyle adjustments play a vital role in managing HS symptoms, preventing flares, and improving overall well-being. These are not replacements for medical treatment but powerful complements.

• Weight Management: If you are overweight or obese, losing weight can significantly reduce the severity and frequency of HS flares. Excess weight can increase skin friction and inflammation, both of which exacerbate HS.
  • Concrete Example: Committing to a consistent exercise routine and a balanced diet, even losing 5-10% of your body weight, can lead to a noticeable decrease in HS activity, particularly in areas prone to skin-on-skin rubbing.
• Smoking Cessation: Smoking is a well-established trigger and worsening factor for HS. Quitting smoking is one of the most impactful lifestyle changes you can make to improve your condition.
  • Concrete Example: Seeking support from a smoking cessation program can drastically improve your HS prognosis and overall health.
• Dietary Considerations: While no single “HS diet” works for everyone, some individuals find that certain foods trigger their flares. Common culprits include dairy products, red meat, and foods high in refined sugars. An anti-inflammatory diet (like the Mediterranean diet) rich in fruits, vegetables, whole grains, and lean proteins may be beneficial.
  • Concrete Example: Trying an elimination diet under the guidance of a healthcare professional or registered dietitian, where you remove common trigger foods for a few weeks and then reintroduce them one by one, can help identify personal dietary triggers.
• Gentle Skin Care:
  • Avoid Harsh Scrubbing: HS is not due to dirt. Scrubbing can irritate hair follicles and worsen inflammation. Gently wash affected areas with mild, unscented cleansers.
    • Concrete Example: Instead of using a loofah, use your fingertips to gently apply an antibacterial wash in the shower.
  • Moisturize: Keeping the skin hydrated can reduce friction and irritation.

  • Manage Sweating: Excessive sweating can worsen HS. Stay cool, wear breathable fabrics, and consider antiperspirants specifically designed for sensitive skin, or discuss Botox injections for excessive sweating in affected areas.

    • Concrete Example: Opt for loose-fitting cotton clothing, especially in warm weather, and consider using an aluminum-free deodorant or discussing topical prescriptions with your dermatologist if sweat is a significant trigger.
• Pain Management: HS can be incredibly painful.
  • Warm Compresses: Applying warm compresses to painful areas can help reduce swelling and encourage drainage of superficial lesions.
    • Concrete Example: Soaking a clean washcloth in warm water and applying it to a painful nodule for 10-15 minutes several times a day can provide symptomatic relief.
  • Over-the-Counter Pain Relievers: NSAIDs (e.g., ibuprofen, naproxen) can help manage pain and inflammation.

  • Topical Anesthetics (e.g., Lidocaine Cream): Your doctor might prescribe a topical numbing cream for localized pain relief.

    • Concrete Example: Applying a prescribed lidocaine cream to a particularly painful area before changing dressings can make the process more tolerable.
  • Referral to Pain Management: For chronic, severe pain, a referral to a pain management specialist can be invaluable for exploring various strategies.

• Wound Care: Proper wound care is essential for draining lesions to prevent infection and promote healing. Your dermatologist will guide you on appropriate dressings and cleaning techniques. Non-adherent dressings are often preferred to avoid irritation when changing.

  • Concrete Example: If you have a draining lesion, your dermatologist might instruct you to clean it gently with saline solution and cover it with a non-stick gauze pad secured with paper tape, changing it daily.
• Mental Health Support: Living with a chronic, painful, and often stigmatizing condition like HS can take a significant toll on mental health. Seeking support from a therapist, counselor, or support group can be incredibly beneficial.
  • Concrete Example: Joining an online or in-person HS support group can provide a sense of community and shared experience, reducing feelings of isolation and offering practical coping strategies.

Crafting Your Personalized HS Treatment Plan

Choosing the right HS treatment is not a one-size-fits-all endeavor. It’s a dynamic process that requires close collaboration with a dermatologist who has experience treating HS. Here’s how to approach it:

1. Seek a Specialist

The first and most crucial step is to find a dermatologist, preferably one who specializes in chronic inflammatory skin conditions or has a particular interest in HS. Not all doctors are equally familiar with the nuances of HS and its management. A specialist will be better equipped to accurately diagnose your stage, understand the systemic nature of the disease, and tailor a comprehensive treatment plan.

2. Open Communication is Key

Be open and honest with your dermatologist about your symptoms, their impact on your daily life, your treatment goals, and any concerns you have. Share details about:

• Pain Levels: How much pain are you experiencing on a daily basis? Does it interfere with sleep, work, or social activities?

• Flare Frequency and Severity: How often do you experience flares? How long do they last? How large and painful are the lesions?

• Location of Lesions: This helps determine the most appropriate local and systemic treatments.

• Previous Treatments: What have you tried before, and what were the results (good or bad)?

• Impact on Quality of Life: Discuss how HS affects your emotional well-being, relationships, and professional life.

• Lifestyle Factors: Be honest about your smoking habits, diet, and stress levels.

3. Consider Your Hurley Stage

Your dermatologist will use the Hurley staging system to guide initial treatment decisions.

• Hurley Stage I: Often starts with topical treatments, short courses of oral antibiotics, and lifestyle modifications.

• Hurley Stage II: May require longer courses of oral antibiotics, potentially combination antibiotic therapy, hormonal treatments, and sometimes localized surgical procedures like deroofing or excision. Biologics might be considered if these fail.

• Hurley Stage III: Typically necessitates systemic therapies like biologics, often in combination with extensive surgical interventions (e.g., wide excision) and comprehensive wound care.

4. Weigh Benefits and Risks

Every treatment option comes with potential benefits and risks. Your dermatologist should discuss these thoroughly with you. For instance, biologics can be highly effective but carry risks of infection, while surgery offers permanent removal of diseased tissue but involves recovery time and potential scarring.

• Benefits: What kind of relief can you expect? (e.g., reduced pain, fewer flares, faster healing).

• Risks and Side Effects: What are the potential adverse effects, and how will they be managed?

• Duration of Treatment: Is this a short-term solution or a long-term maintenance therapy?

• Cost and Insurance Coverage: These practical considerations are important and should be discussed. Many newer therapies can be expensive, and understanding your insurance coverage or patient assistance programs is crucial.

5. Embrace a Holistic Approach

Remember that HS treatment is rarely just about medication. Integrating lifestyle changes, stress management techniques, and potentially complementary therapies (always discussed with your doctor) can significantly improve your outcomes.

6. Be Patient and Persistent

Finding the optimal treatment regimen for HS can take time and involves trial and error. HS is a chronic condition, and flares can still occur even with effective treatment. Don’t get discouraged if the first treatment doesn’t bring immediate, complete relief. Persistence, consistent follow-up with your dermatologist, and a willingness to adjust your plan are vital for long-term success. Your treatment plan will likely evolve over time as your disease activity changes.

Looking Ahead: The Future of HS Treatment

The landscape of HS treatment is constantly evolving. Ongoing research is deepening our understanding of the disease’s underlying mechanisms, leading to the development of new and more targeted therapies. Clinical trials are exploring novel biologics, small molecule inhibitors, and even gene therapies that could offer more effective and personalized treatment options in the future. Staying informed about these advancements, perhaps through patient advocacy groups or discussions with your dermatologist, can provide hope and access to cutting-edge care.

Choosing the right HS treatment is a journey of collaboration, education, and resilience. By understanding the nature of your condition, exploring the diverse range of available medical, procedural, and lifestyle interventions, and maintaining open communication with a knowledgeable healthcare team, you can gain control over your HS, find lasting relief, and live a fuller, more comfortable life.