Finding effective hidradenitis suppurativa treatments can be life-changing for the estimated 1-4% of the population affected by this chronic, inflammatory skin condition. Hidradenitis suppurativa (HS) causes painful, recurring nodules, abscesses, and tunneling wounds primarily in the armpits, groin, buttocks, and under the breasts.
While there is no cure, the range of hidradenitis suppurativa treatments has expanded significantly in recent years, with new biologic medications and surgical techniques offering better outcomes than ever before. This guide covers every major treatment option, from first-line medications to advanced surgical interventions, based on guidelines from the NIH, the American Academy of Dermatology (AAD), and peer-reviewed research.
Understanding Hidradenitis Suppurativa Severity Stages
Treatment for HS is guided by the Hurley staging system, which classifies the condition into three stages:
Hurley Stage I (Mild): Single or multiple abscesses without sinus tracts (tunnels) or scarring. Flares come and go with periods of clear skin in between. Treatment typically involves topical and oral medications.
Hurley Stage II (Moderate): Recurrent abscesses with sinus tract formation and scarring in one or more areas. Flares are more frequent and the disease is more persistent. Treatment often combines medications with minor procedures.
Hurley Stage III (Severe): Diffuse or widespread interconnected sinus tracts and abscesses across an entire area. Chronic drainage, significant scarring, and substantial impact on quality of life. Treatment typically requires biologic medications and may include major surgery.
According to the NIH, HS is frequently underdiagnosed and undertreated, with the average patient waiting 7-10 years from symptom onset to correct diagnosis. Early aggressive treatment can prevent disease progression and reduce scarring.
Topical and First-Line Treatments
For mild HS and as adjuncts to other therapies, topical treatments play an important role:
Topical clindamycin 1%: Applied to affected areas twice daily, topical clindamycin is the AAD’s recommended first-line treatment for mild HS. It reduces bacterial colonization in HS lesions and provides modest anti-inflammatory effects. Most patients use it for 8-12 weeks, though long-term use may be needed.
Benzoyl peroxide wash: Used as a daily cleanser for HS-prone areas. It reduces bacterial load and may help prevent new flares. Concentrations of 4-10% are commonly recommended.
Topical resorcinol 15%: A peeling agent that can help reduce nodules and prevent new lesions. Available by prescription in some countries and through compounding pharmacies.
Antiseptic washes: Chlorhexidine or zinc pyrithione washes used in the shower can help reduce bacteria on the skin and decrease the frequency of flares.
Oral Medications
When topical treatments are insufficient, oral medications provide systemic control:
Antibiotics:
- Clindamycin + rifampin combination: A widely used combination for moderate HS. Typically prescribed as clindamycin 300 mg twice daily plus rifampin 600 mg daily for 10-12 weeks. Studies in the NIH database show significant improvement in approximately 60-80% of patients. Note that rifampin has significant drug interactions, particularly with hormonal contraceptives.
- Doxycycline or minocycline: Tetracycline antibiotics with anti-inflammatory properties. Often used as a first-line oral treatment for mild-to-moderate HS. Typically prescribed for 3-6 months.
- Dapsone: Has both antibacterial and anti-inflammatory effects. Used for mild-to-moderate HS when other antibiotics are not tolerated or effective. Requires regular blood monitoring.
Hormonal therapies:
- Spironolactone: An anti-androgen medication that can reduce HS flares in women, particularly those with hormonal patterns. Dosing typically ranges from 50-200 mg daily.
- Combined oral contraceptives: May help some women with HS by modulating hormonal influences on the disease.
- Finasteride: Another anti-androgen option, sometimes used off-label for HS.
Retinoids:
- Acitretin: An oral retinoid that can reduce HS lesions and prevent new ones. Dosing ranges from 25-50 mg daily. Requires monitoring for liver function and lipid levels and is contraindicated in pregnancy.
Immunosuppressants:
- Methotrexate: Occasionally used for HS, though evidence is limited.
- Cyclosporine: May be used short-term for severe flares.
Biologic Medications
Biologic therapies represent the most significant advancement in hidradenitis suppurativa treatments and are the standard of care for moderate-to-severe disease:
Adalimumab (Humira): The first FDA-approved biologic for HS (approved in 2015). Adalimumab is a TNF-alpha inhibitor given as a subcutaneous injection. The standard HS dosing starts with a loading dose followed by weekly injections. Clinical trials showed that approximately 50-60% of patients achieved meaningful improvement. Biosimilar versions are now available at lower cost.
Secukinumab (Cosentyx): An IL-17A inhibitor approved by the FDA for HS in 2023. Given as monthly subcutaneous injections after a loading phase. Clinical trials demonstrated significant improvement in HS lesion counts and pain scores compared to placebo.
Other biologics used off-label:
- Infliximab (Remicade): A TNF-alpha inhibitor given intravenously. Some dermatologists consider it the most effective biologic for severe HS, though it is not FDA-approved for this indication. Studies show response rates of 60-70%.
- Ustekinumab (Stelara): An IL-12/23 inhibitor with some evidence supporting its use in HS.
Pipeline therapies: Several new biologics and small molecule drugs are in clinical trials for HS, including JAK inhibitors and other targeted therapies. The NIH’s clinical trials database (clinicaltrials.gov) lists ongoing studies for patients interested in experimental treatments.
For information on the financial aspects of surgical options, see our guide on hidradenitis suppurativa surgery cost.
Surgical and Procedural Treatments
Procedures range from minor office-based treatments to major surgery depending on disease severity:
Incision and drainage (I&D): Provides temporary relief of acute, painful abscesses. However, I&D alone has a near-100% recurrence rate because it does not address the underlying disease process. It is considered a short-term palliative measure, not a definitive treatment.
Deroofing: A minimally invasive procedure in which the roof of sinus tracts is removed, leaving the wound open to heal from the bottom up. Suitable for isolated, recurring nodules with sinus tracts. Recurrence rates are lower than I&D, approximately 17-27% according to published studies.
Punch debridement: Small sinus tracts are removed using a biopsy punch tool. Useful for limited, well-defined lesions.
Laser therapy:
- Nd:YAG laser: Targets hair follicles in HS-prone areas and reduces the number and severity of flares. Multiple sessions are needed (typically 3-4 monthly sessions).
- CO2 laser excision: Uses a CO2 laser to excise affected tissue. Can be performed under local anesthesia for limited disease.
Wide surgical excision: The most definitive surgical treatment for severe, localized HS. The entire affected area is removed, including all sinus tracts and scarred tissue, with margins extending into healthy tissue. Recurrence rates after wide excision are the lowest of any surgical approach (approximately 13-27%). Wounds may be left to heal by secondary intention, closed primarily, or covered with skin grafts or flaps depending on the size and location.
Lifestyle Changes and Complementary Approaches
Lifestyle modifications can significantly reduce flare frequency and severity:
Weight management: Obesity is a well-established risk factor for HS severity. The NIH reports that weight loss can improve HS symptoms, with some studies showing reduced flare frequency after bariatric surgery. Even modest weight loss of 10-15% can make a noticeable difference.
Smoking cessation: Smoking is strongly associated with HS. The majority of HS patients are current or former smokers, and smoking cessation often leads to disease improvement. The exact mechanism is not fully understood but may involve nicotine’s effects on the immune system and hair follicle inflammation.
Clothing choices: Wear loose-fitting, breathable clothing to reduce friction and heat in affected areas. Avoid tight waistbands, synthetic underwear, and clothing with rough seams.
Wound care: Proper wound care for draining lesions includes using absorbent, non-stick dressings; changing dressings regularly; keeping wounds clean with gentle cleansers; and avoiding adhesive bandages directly on inflamed skin.
Dietary considerations: Some patients report improvement with dairy elimination or anti-inflammatory diets, though research evidence is limited. A trial elimination diet supervised by a healthcare provider may be worth exploring.
Mental health support: HS significantly impacts quality of life, self-esteem, and mental health. The NIH reports higher rates of depression and anxiety among HS patients. Counseling, support groups, and mental health treatment should be considered part of comprehensive HS management.
For broader condition management guidance, visit our conditions guide.
Frequently Asked Questions
Can hidradenitis suppurativa go away on its own?
HS is a chronic condition that does not spontaneously resolve in most cases. Individual flares may come and go, but the underlying disease process continues without treatment. Some patients experience reduced severity after menopause, but this is not guaranteed. Early and consistent treatment is the best approach to managing the disease.
What triggers hidradenitis suppurativa flares?
Common triggers include friction from tight clothing, sweating, stress, hormonal changes (menstrual cycle), heat and humidity, shaving in affected areas, and certain foods (dairy and high-glycemic foods for some patients). Identifying and avoiding personal triggers can help reduce flare frequency.
How effective are biologics for HS?
Biologics provide meaningful improvement for approximately 50-70% of patients with moderate-to-severe HS. Complete remission is less common, but many patients experience significant reductions in pain, drainage, and flare frequency. Response may take 8-12 weeks to become apparent, and long-term maintenance treatment is usually necessary.
Is hidradenitis suppurativa contagious?
No. HS is an inflammatory condition related to the immune system and hair follicle biology. It is not caused by infection and cannot be transmitted from person to person. While bacterial colonization plays a role in some HS lesions, the underlying disease is not infectious.
Should I see a dermatologist or surgeon for HS?
Start with a dermatologist, ideally one experienced in HS. Dermatologists manage the medical treatment plan, including medications and minor procedures. If surgical intervention is needed, your dermatologist can refer you to a surgeon experienced in HS excision. Some academic medical centers have dedicated HS clinics with multidisciplinary teams.
Work With Specialists for the Best Outcomes
Hidradenitis suppurativa treatments have improved dramatically in recent years, offering real hope for symptom control and quality-of-life improvement. Start with a dermatologist experienced in HS, pursue early and aggressive treatment to prevent disease progression, and incorporate lifestyle modifications that reduce flare triggers. Whether you manage your condition with topical treatments, biologics, surgery, or a combination, consistent care and follow-up are key to achieving the best possible outcomes.