Hidradenitis Suppurativa
Hidradenitis suppurativa is a long-term inflammatory condition that causes painful lumps, abscesses and tunnels in the armpits, groin and under the breasts. It is not an infection and it is not caused by poor hygiene, and treating it early is what prevents the scarring.
Key facts
Hidradenitis Suppurativa at a glance.
Typical signs
Painful nodules, drainage and tunnels
Common locations
Underarms, groin, under breasts, buttocks
Expected course
Chronic, recurring flares
Treatment options
Medicines, biologics or targeted procedures
What is it?
Top things to know about Hidradenitis Suppurativa
- It is a chronic inflammatory disease. It causes recurrent painful nodules, draining tunnels and scars, usually in skin folds.
- It is not contagious. It is not caused by poor hygiene.
- Early recognition matters. Prompt diagnosis can reduce treatment delays and limit tissue damage.
- The whole picture guides care. Pain, drainage, activity limits and mood all shape the treatment plan.
What it looks like
What Hidradenitis Suppurativa looks like
Hidradenitis suppurativa is a long-term inflammatory condition that causes painful lumps in areas where skin rubs together, such as the armpits, groin, inner thighs, buttocks and under the breasts. The lumps can grow, break open and drain fluid or pus. Over time, tunnels can form under the skin, and healing leaves rope-like scars. Blackheads that come in pairs are a common sign.
Doctors use Hurley stages to describe how severe hidradenitis suppurativa is.
Hurley stage I
Single lumps, no tunnels or scars.
Hurley stage II
Recurring lumps with tunnels and scars.
Hurley stage III
Widespread tunnels and scarring.
Where it shows up
Common sites include the armpits, groin and buttock folds; under-breast involvement also occurs. Covered areas are outlined.
Armpits
Locations in the underarm folds.
Covered skin folds
The outlined area locates sites beneath the clothing.
On different skin tones
Hidradenitis Suppurativa on different skin tones
Hidradenitis suppurativa is more common in Black people and in women. On lighter skin, lumps look red. On brown and Black skin, they are often dark brown or purple, and the condition leaves significant dark marks and scars. It is often diagnosed late, after years of being mistaken for boils.
What happens in Hidradenitis Suppurativa?
Blocked hair follicles can widen and rupture, releasing contents into nearby tissue and triggering painful inflammation. Repeated episodes may lead to tunnels beneath the skin and scarring.
- A follicle becomes blocked: The opening widens as material builds up.
- Rupture drives inflammation: Released contents trigger painful inflammation.
- Tunnels can develop: Repeated inflammation may leave channels and scars.
Causes and triggers
What causes Hidradenitis Suppurativa
Causes
Why it happens
Hidradenitis suppurativa starts with blocked hair follicles in skin folds. The immune system then overreacts, causing deep, painful lumps.
About 1 in 3 people with it have a relative with it.
Risk factors
Raise the odds
- Obesity
- Smoking
- Female sex
- Family history
Triggers
Bring it on or make it worse
- Smoking (Well established)
- Friction and tight clothing (Strong link)
- Heat and sweat (Strong link)
- Hormone changes (Strong link)
When it usually starts
When it usually starts
Hidradenitis Suppurativa
Usually begins after puberty, often in the teens or younger adult years.
Daily care
Daily care for Hidradenitis Suppurativa
Stopping smoking
The highest-value change available.
Warm compresses
Ease pain and help a lump come to a head.
Loose breathable clothing
Cotton, no waistband over a fold, damp clothes changed promptly.
Weight loss where it applies
Less friction, less background inflammation.
Absorbent dressings
Not treatment, but the right dressing changes daily life.
Topical clindamycin
An antibiotic lotion for mild disease, with benzoyl peroxide.
Clindamycin with rifampicin
Two antibiotics together for moderate disease.
Hormonal treatment
Spironolactone or a combined pill, where flares track the cycle.
Metformin
Added where there is insulin resistance or polycystic ovary syndrome.
Track flares around your menstrual cycle
Many people flare reliably the week before a period.
Discuss sustainable weight goals where relevant; avoid blame or crash dieting
More friction, more affected folds, more background inflammation.
Avoid: Smoking
The clearest avoidable factor, and it acts on the disease itself.
Avoid: Squeezing or lancing at home
Pushes the contents sideways and helps a tunnel form.
Avoid: Friction and tight clothing
Waistbands, seams, tight jeans and underwire set flares off.
Avoid: Shaving and waxing the area
Both irritate the follicle and cause ingrowns.
Avoid: Heat and trapped sweat
Hot weather, and damp gym gear left on.
Avoid: Deodorants and antiperspirants
Fragrance or alcohol on inflamed skin irritates.
Avoid: Stress and poor sleep
Both raise background inflammation.
Avoid: Waiting it out
Every untreated year is more chance of tunnels.
Avoid: Stopping treatment when it works
Control is maintenance. Flares return within weeks to months.
Treatments
Treatments for Hidradenitis Suppurativa
Benzoyl Peroxide wash
An antiseptic wash used two or three times a week on the affected folds, lathered and rinsed rather than left on. It lowers the bacteria on the skin and is often paired with clindamycin lotion to stop resistance building. It will not stop lumps forming on its own, and it bleaches towels and dark clothing.
Ibuprofen and acetaminophen
For flare pain, which is at its worst in the day or two before a lump bursts or is drained. Taken regularly through a flare they work better than taken only at the peak. If they are not touching the pain, that is a reason to be seen rather than to take more, because a steroid injection settles a single lump far faster.
Chlorhexidine wash
An alternative antiseptic wash for the folds if benzoyl peroxide is too drying or bleaches too much. Same use: lather, rinse, a few times a week. It reduces the odor some people find hardest to live with. It does nothing about the inflammation underneath, so it is a support rather than a treatment.
Zinc supplements
Oral zinc is often suggested online for this condition. The studies behind it are small and uncontrolled, and it has not been shown to change flares in any reliable way. High doses upset the stomach and interfere with copper absorption over time. Worth mentioning to your doctor rather than starting alone.
Absorbent dressings
Not a treatment, but the thing that changes daily life most for anyone with a draining lesion. A soft absorbent pad held with tubular netting or a stretchy vest handles the fluid without an adhesive that tears sore skin. A dermatology nurse can advise which dressing suits which site, and many are available on prescription.
Clindamycin
A twice-daily antibiotic lotion for mild disease, the one topical here with real trial evidence behind it. It reduces the number of lumps and abscesses, and in early disease works about as well as tetracycline tablets. It is nearly always paired with a benzoyl peroxide wash, because clindamycin used alone breeds resistant bacteria.
Resorcinol
Resorcinol 15% cream. A peeling cream dabbed on a building lump to help it open and settle faster, made up by a compounding pharmacy. Some people find it shortens a flare noticeably. It stings, it can leave a temporary dark stain on deeper skin tones, and it only goes on the lump itself, not across the whole fold.
Doxycycline
A tetracycline antibiotic taken for two to three months, used here for its anti-inflammatory effect rather than to kill an infection. That is why the course is months rather than a week. It reduces flares for many people with mild to moderate disease, and it generally stops working once it is stopped. Take it with water and stay upright afterwards, and expect to burn more easily in the sun.
Clindamycin with rifampicin
Two antibiotics taken together for a set ten to twelve week course in moderate disease, usually when tetracyclines have not held. The combination works better than either alone. Rifampicin turns urine and tears orange, stains soft contact lenses, and interferes with several medicines including the contraceptive pill, so the doctor needs your full medicine list.
Spironolactone
A hormonal tablet that suits people whose flares track the menstrual cycle. The evidence is from clinics rather than large trials, but the response in the right person can be very good. It takes three to six months to judge, it raises potassium so blood tests are needed, and it must not be used in pregnancy.
Birth Control Pills
A combined pill can reduce flares that cluster before periods, and it is often used alongside spironolactone rather than instead of it. Progesterone-only methods sometimes make the condition worse. Smoking matters here in two ways: it worsens the disease and it also rules out the combined pill for many people over 35.
Metformin
A diabetes tablet sometimes added where there is insulin resistance, polycystic ovary syndrome or metabolic syndrome alongside the skin disease. Small studies show fewer flares in that group. It is an add-on, not a main treatment, and it commonly upsets the stomach for the first few weeks.
Prednisone
A short course of steroid tablets to break a severe flare while a longer-term treatment is being arranged. It works quickly. It is not a way to manage this condition, because flares return as the dose comes down and repeated courses cause weight gain, bone loss and blood sugar problems.
Accutane
Isotretinoin transforms severe acne, so it is a fair question here. It works much less well for this condition, which starts in the follicle but is not driven by oil, and many people are no better on it. Acitretin, a related tablet, has slightly better results. Neither can be used in pregnancy.
Humira
The first biologic licensed for this condition, given as a self-injection under the skin every week or two. It blocks one of the immune signals driving the disease and reduces lumps and abscesses in moderate to severe cases. It does not close existing tunnels. You are screened for tuberculosis and hepatitis first, and infections need reporting while you are on it.
Cosentyx
A newer biologic injection that blocks a different immune signal, licensed for this condition after trials in moderate to severe disease. It is the usual next step when adalimumab has not worked or has stopped working. Like adalimumab, it treats the inflammation rather than the tunnels, so it is often combined with surgery.
Cortisone Injection
A small amount of steroid injected straight into a single painful lump, which usually settles it within a day or two. It is the fastest thing available for one bad flare and it avoids cutting. It treats that one lump only, and repeated injections in the same spot can thin the skin, so it is not a plan on its own.
Deroofing
The roof of a tunnel is removed under local anesthetic and the floor is left to heal open. The tunnel does not come back in that spot. It is small, done in clinic, and leaves a flatter result than cutting a wide block of skin out, which matters more on deeper skin tones. It treats the tunnels you have, not the disease, so medication usually continues.
Excision
Wide excision. A whole affected area is removed surgically, for advanced disease where tunnels run right across an armpit or groin. Disease does not return in the removed area, though it can appear at the edges or in another fold. It is done in an operating theatre, healing takes weeks, and the area may need a skin graft or flap.
Laser Hair Removal
Removing the hair removes the follicle that plugs, and several courses of treatment reduce flares in early disease. It works best on Hurley stage one and two, before tunnels form. On deeper skin tones the device matters: the long-pulsed Nd:YAG is the usual choice, and the wrong laser causes burns and pigment change. Ask which one the clinic will use.
Incision and Drainage
Incision and drainage. Cutting a swollen abscess open relieves severe pressure and pain quickly, which is why it is done in emergency departments. It does not change the course of the condition and the lump usually refills in the same place within weeks. Repeated draining of the same spot encourages a tunnel to form, so it is a rescue measure rather than treatment.
Outlook
What to expect with Hidradenitis Suppurativa
It runs in flares and quiet periods, and follows a longer arc over years. Not everyone progresses. The toll is real — pain, drainage, dressings, clothes chosen around it, embarrassment about the smell — and rates of depression and anxiety are high, worth raising at an appointment.
- 1
First lump · Late teens or twenties
A single painful lump appears in one armpit or the groin. It is drained or given antibiotics, and settles.
- 2
It comes back · Months later
The lump returns in the same place. That repeat is the condition announcing itself, and where it should be named. In practice it takes years and several doctors.
- 3
Flares and quiet periods · The ongoing rhythm
A flare builds over a few days and hurts most just before it bursts or is drained. Frequency varies enormously, and for many they cluster before periods.
- 4
Untreated over years · If it is left alone
More sites get involved, single lumps join into tunnels, and tunnels heal into thick rope-like scars that can restrict how an arm or leg moves. This is why you treat early rather than ride out each flare.
- 5
Later life · Midlife and beyond
Stopping smoking, losing weight where that applies, and proper medical treatment all reduce severity. Tunnels removed surgically do not come back, which makes surgery worth considering rather than a last resort.
Complications
Complications to know about
Scarring and restricted movement
Years of flares in the same fold leave thick, rope-like scars that pull the skin tight. In an armpit that can limit how far the arm lifts; in the groin it can make sitting or walking uncomfortable. Scars cannot be reversed with medication, so the way to avoid them is to get on proper treatment early. Surgery can release or remove a badly scarred area.
Depression and anxiety
Constant pain, drainage, dressings and the smell wear people down, and rates of depression and anxiety in this condition are high. It is a normal response to a hard illness, not a separate weakness. It is also rarely asked about, so it is worth raising yourself at an appointment. Getting the skin under control usually helps a great deal, and support for the mood side can be arranged at the same time.
Squamous Cell Carcinoma
A rare complication of very long-standing disease, usually after decades of tunnels and scarring on the buttocks or groin. A skin cancer can grow in the damaged skin. The warning sign is a lump, ulcer or growth that behaves differently from your usual flares and does not settle. Anything like that should be looked at and biopsied rather than treated as another flare.
When to get help
When to get help
When to seek care
Seek early assessment for recurring painful lumps, drainage or tunnels. Fever, spreading redness or severe pain needs prompt care.
Lookalikes
What else could it be?
Folliculitis
Folliculitis bumps may clear and appear elsewhere. Hidradenitis keeps returning to the same skin folds and can leave tunnels and scars.
Epidermal Inclusion Cyst
A cyst is usually one long-standing lump, sometimes with a dark opening. Hidradenitis causes repeated lumps in the same folds, often with tunnels between them.
Ingrown Hairs
Ingrown hairs are usually shallow, sometimes with a visible trapped hair. Hidradenitis lumps sit deeper and keep returning even when you are not shaving.
Questions
Questions you might be asking.
Is this contagious?
No. It cannot be passed through skin contact, towels, swimming pools or sex. It starts in your own hair follicles and is driven by your own immune system.
Why do antibiotics stop working?
They were never killing an infection. Tetracyclines are given for months here because they calm inflammation, and the effect fades when they stop. If antibiotics are not holding, move up to hormonal treatment or a biologic.
Will I need surgery?
Only if tunnels have formed, and not everyone reaches that stage. Medication treats inflammation but cannot close a tunnel, so once one exists a small procedure called deroofing is often the cleanest answer. It is done under local anesthetic and the tunnel does not return.
Does losing weight fix it?
It helps, and it does not fix it. Losing weight reduces friction, reduces affected folds and lowers background inflammation, and many notice fewer flares. But people of every size get this, and treating it as a weight problem is one reason people are sent away without proper treatment.
Can I still shave or have laser hair removal?
Shaving and waxing tend to provoke flares, so clipping is better day to day. Laser hair removal often reduces flares by removing the follicle and is worth considering, particularly in early disease. On deeper skin tones the device matters — ask which laser will be used.
Will it affect having children?
The condition does not affect fertility, but several treatments are not suitable in pregnancy, including some antibiotics and hormonal treatments. Many find it flares in pregnancy and improves afterwards, or the reverse. Plan ahead with the doctor managing your pregnancy, and never start or stop a medicine on your own.
Sources
Sources and further reading
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