Hidradenitis Suppurativa – the Ultimate Guide

Hidradenitis suppurativa, also called acne inversus, is a chronic inflammatory skin condition with lesions including deep-seated nodules, abscesses, draining tracts, and fibrotic scars. These lesions occur more commonly in intertriginous areas and areas that are rich in apocrine glands.

The most common sites of involvement are the axillae (underarm), groin, buttocks, perianal, perineal, mammary, and inframammary areas, with the axillae most commonly affected. The most common sites of involvement in women are the axillary, inframammary, and inguinal areas; in men, perianal hidradenitis suppurativa and involvement of atypical sites such as the retro auricular areas and nuchal scalp occur more frequently. It can also occur anywhere on the body where there are hair follicles. Although hidradenitis suppurativa is three times more common in women than in men, men tend to have more severe diseases.

The causes of hidradenitis suppurativa appear to be genetic, environmental, and behavioral influences.

Genetics plays a huge role in hidradenitis suppurativa and there are previous studies that have estimated that 30% to 40% of those with HS have at least one family member with the skin disorder.

Obesity and smoking are not causes of hidradenitis suppurativa but can be triggers for flares/abscesses.

The influence of hormones can be seen in hidradenitis suppurativa. There is a greater prevalence in females than males, with the age of primary occurrence most commonly between menopause and puberty. In addition, there are fluctuations in acute symptomatic episodes and severity with menstrual cycles and exogenous hormones.

Early diagnosis is very important for hidradenitis suppurativa patients in order to ensure the best possible course of this painful disease and to reduce the number of working days lost through sickness and hidradenitis suppurativa-related healthcare issues. However, hidradenitis suppurativa diagnosis generally occurs after an average 7-year delay because it is mistaken for other conditions.

Clinical diagnosis requires recognition of the morphology (deep, painful nodules, sinus tracts, inflamed, scars), the location (apocrine gland-containing areas and intertriginous areas), and the chronicity of the disease process (prolonged course with periods of activity and remission).

Many individuals will report burning, pruritus, stinging, pain, warmth, or hyperhidrosis in the area 12 to 48 hours before the appearance of a lesion. Triggers can include menstruation, stress, hormonal changes, weight gain, heat, excessive, certain foods, and perspiration.

Characteristic primary lesions are deep-seated nodules, usually 0.5 to 2 cm, that last from days to months. They are often mistaken for boils or furuncles. However, while a furuncle will respond rapidly to drainage or antibiotics, the nodules of hidradenitis suppurativa are deep and can rupture and track subcutaneously. Multiple recurrent nodules in the same area may lead to the formation of intercommunicating sinus tracts that can ulcerate or drain. Drainage may be purulent and malodorous. Other lesions include open comedones (tombstone comedones), often double or multi-headed. In advanced stages, plaques and thick fibrotic scars can develop, leading to architectural distortion of the area.

An abscess becomes an HS when there have been 2 boils in the last 6 months in 2 of the common sites and the abscess heals with scarring.

The axilla is the most common location for hidradenitis suppurativa lesions. Other common areas are the inguinal, inner thighs, perianal and perineal, scrotum, buttocks, pubic area, trunk, vulva, inframammary, and, less commonly, the retro-auricular and scalp areas.

Since hidradenitis suppurativa is a chronic condition, identifying a family history of a similar condition can also be helpful in establishing the proper diagnosis.

Diagnosis does not require a biopsy. However, a biopsy is required to rule out squamous cell carcinoma in the presence of severe hidradenitis suppurativa if the diagnosis is uncertain. Bacterial cultures are not required unless a secondary infection or an alternative diagnosis is suspected. Imaging is not typically helpful; however, ultrasound may be a useful tool to identify the extent of sinus tracts. Lesions may warrant further imaging, including MRI in severe perianal disease.

Once the diagnosis of hidradenitis suppurativa is complete, the Hurley staging system can be used to classify the case.

• Hurley Stage I: Abscess formation without scars or tracts
• Hurley Stage II: Recurrent abscesses with scarring and sinus tracts; there may be single or widely separated lesions
• Hurley Stage III: Diffuse involvement, multiple interconnected sinus tracts, and abscesses across an entire area leaving little to no uninvolved skin

Hidradenitis suppurativa is one component of the follicular occlusion tetrad, including dissecting cellulitis, acne conglobata, and pilonidal sinus. Diagnosis of hidradenitis suppurativa in an individual warrants evaluation for these coexisting diagnoses. Doctors should also keep in mind the association between inflammatory bowel disease, spondyloarthropathy, and metabolic syndrome, and assess for these conditions during the diagnosis.

The characteristic distribution of lesions and postpubertal onset helps distinguish hidradenitis suppurativa from other conditions with similar morphology, such as nodular acne. Microbiology cultures can be used to differentiate hidradenitis suppurativa from infectious entities (mixed or sterile growth vs. growth of single infectious agents) such as carbuncles, abscesses, and furuncles.

Cutaneous manifestations of CD can be difficult to separate from perianal hidradenitis suppurativa lesions. Perianal lesions concomitant with gastrointestinal symptoms favor CD, whereas the involvement of the axillae or other hidradenitis suppurativa-specific areas is suggestive of hidradenitis suppurativa. Furthermore, ulcerative lesions and formation of endoanal fistulas possibly involving the anal sphincter are characteristic of CD and not hidradenitis suppurativa.

Similarly to hidradenitis suppurativa, Hailey-Hailey disease, also known as benign familial pemphigus, involves painful, recurrent lesions in intertriginous areas. However, Hailey-Hailey disease is characterized by erythematous vesicular plaques that can become crusted and develop into painful cracks.

• Acne
• Carbuncles
• Cellulitis
• Erysipelas
• Folliculitis
• Furuncles
• Inflamed epidermal inclusion cyst
• Lymphadenopathy
• Perirectal abscess
• Pilonidal cyst

• Actinomycosis
• Anal fistula
• Cat scratch disease
• Crohn’s disease (particularly with perianal involvement)
• Ischiorectal abscess
• Nocardia infection
• Noduloulcerative syphilis
• Pilonidal disease
• Granuloma inguinale
• Tuberculous abscess
• Actinomycosis
• Lymphogranuloma venereum
• Epidermoid, dermoid, pilonidal, or Bartholin cysts

The main goals include treating existing lesions to minimize pain and drainage, decreasing the frequency of recurrence, and preventing disease progression.

• Topical antibiotics: topical antibiotics are the first-line treatment for hidradenitis suppurativa and can be used only in localized Hurley stage I or mild stage II disease. Topical clindamycin is the only antibiotic that can work for hidradenitis suppurativa. It can help with superficial lesions (folliculitis, papules, and pustules); but was poor with deep lesions (nodules and abscesses).

• Oral antibiotics: treatment for resistant Hurley Stage I and Hurley Stage II involves oral antibiotics. Antibiotics in the tetracycline family like minocycline and doxycycline have been the most effective. If treatment fails, combination therapy with oral clindamycin and rifampin is recommended.

• Clindamycin and rifampicin: in widespread Hurley stage I or mild stage II disease, combining systemic clindamycin and systemic rifampicin (300 mg of clindamycin given in combination with rifampicin [600 mg daily given as either 1 or 2 doses] for 10 weeks) has proved beneficial, with variable results.

• Rifampicin, moxifloxacin, and metronidazole: Rifampicin 10 mg/kg once daily, moxifloxacin 400 mg daily, and metronidazole 500 mg for 6 weeks followed by rifampicin–moxifloxacin therapy has been shown to be effective, with Hurley stage I or II disease achieving complete remission.

• Intralesional corticosteroid injection: (e.g., triamcinolone 3–5 mg) can reduce local inflammation, and partial de-roofing (punch debridement) of individual lesions can facilitate healing but only works for short-term control of acute and recalcitrant hidradenitis suppurativa lesions. Pain is typically reduced fast, and edema, erythema, suppuration, and lesion size are reduced after a few days. However, the long-term effects of this approach remain unclear, and local side effects, most notably skin atrophy, must be carefully monitored.

• Biologics: For Hurley stage III and resistant lower stages, tumor necrosis factor-alpha inhibitors can be used. Adalimumab is the only FDA-approved medication to treat HS. There is also a study where Adalimumab was used peri-surgically in the treatment of HS and was successful.

• Anti-androgenic hormonal therapy: can also be helpful, including oral contraceptives, spironolactone, cyproterone acetate, and finasteride. Oral retinoids have shown mixed responsiveness. While isotretinoin might be effective in acne, acitretin appears more effective in hidradenitis suppurativa. Systemic steroids are effective for some individuals.

• Diets: low-carb diets, low-histamine diets, anti-inflammatory diets, caveman diets, keto diets, carnivore diets, etc can help. Consult a doctor for more information.

• Surgical treatment: Persistent lesions and diffuse scarring in HS are difficult to manage with medical treatment alone and often require surgery. To get the best results, surgery should be carried out during a period of minimum inflammatory activity in the patient’s hidradenitis suppurativa. More about the surgical treatments: 
  • Incision and Drainage: are some of the most frequently performed procedures as we discussed above. However, these procedures have high recurrence rates and shouldn’t be used to manage acutely inflamed abscesses.
  • Excisions: can be used in patients with well-managed hidradenitis suppurativa (to treat individual, persisting lesions).
    • Limited/Local excision: this excision is done locally but has a high risk of recurrence. The selection criteria for local excision include (i) recurrent abscesses in the same location; (ii) Hurley stage I and II lesions where excision could be performed easily, leaving behind healthy tissue around and below the lesion; and (iii) their lesions were smaller than palm size, in order to not exceed the maximum quantity of lidocaine that could be used per procedure.
    • Wide excision: is the opposite of local excision. It is done in a wide area and has lower rates of recurrence. It involves removing the lesions as well as the surrounding disease-free tissue, such as subcutaneous fat or a 1–2 cm lateral margin of intertriginous skin.
    • Radical excision: is another form of excision that removes the entire hair-bearing area in the affected area. However, the removal of entire areas can be extensive and require high surgical expertise (general or plastic surgeon) and reconstructive techniques.
  • Deroofing: is a technique in which the roof of the lesion is removed and the wound is left open for secondary intention healing. It is a simple and low-cost surgery for Hurley stage II and III lesions. It is a procedure that can be achieved by multiple methods, specifically, blunt surgical scissors, carbon dioxide (CO₂) lasers, or electrosurgery probe. Electrosurgery, with a healing time of around 16 days, also proved to be a good alternative for deroofing early HS lesions. Complications with deroofing include post-surgical bleeding, infection, and scarring.

• Postoperative wound healing: Options for postoperative wound healing include various reconstruction techniques such as secondary intention wound healing, primary closure, or closure techniques like sutures, skin flaps, or skin grafting. The type of surgical method and wound healing will depend on various factors, such as the localization, size of the lesions, as well as patient-related factors. As with all surgical procedures, postoperative complications include nerve damage, bleeding, infection, and stricture due to scar tissue. More about postoperative wound healing:
  • Secondary intention healing: is a process in which the wound is left open intentionally rather than approximated and eventually re-epithelializes over time. It is the best option in wound management, but the healing process is prolonged and there is a high risk of scar formation. Moist wound dressings (e.g., silastic foam dressing) can be applied to hasten healing. Secondary intention healing is often used after wide local excision, especially in the more severe Hurley stages II or III, and has been demonstrated to have satisfactory outcomes. It has the lowest recurrence rates and may be the choice of surgery wherever possible.
  • Skin Grafts: Skin grafting may be used when skin flaps or primary closure are not feasible (e.g., in large wounds on the thighs or buttocks), when a shorter time to wound closure is an important concern, or when there is slow wound healing via epithelization. Split-thickness skin grafts (STSG), recycled skin grafts, and full-thickness skin grafts have demonstrated positive outcomes. The healing time in Split-thickness skin grafts (STSG) was faster when compared to healing by secondary intention and is preferred over full-thickness skin grafting due to the ease of harvest and less complicated transfer. Skin grafting after excision is associated with increased pain, prolonged hospitalization, immobilization, and longer healing times compared to skin flaps. The absence of hair follicles and sweat glands in Split-thickness skin grafts (STSG) may be advantageous in HS because they are involved in the pathogenesis of HS.
  • Skin Flaps: Skin flaps are similar to skin grafts, but the flaps maintain an intact blood supply, whereas grafts depend on the growth of new blood vessels. The advantages of skin flaps are that they have shorter healing times and provide thick tissue coverage. However, their use is limited because they frequently require debulking due to their thickness and have poor vascular supply to distant portions of the flap, leading to a high risk of necrosis and ischemia. Skin flaps are recommended when nerves and vascular channels are exposed. Flaps of particular importance are the Limberg flap, musculocutaneous flap, lateral thoracic flap, and fasciocutaneous V-Y flap. Additionally, perforator flaps, such as the thoracodorsal artery perforator (TDAP) flap, have been reported as advantageous in regard to site proximity, range of motion, and skin quality.
  • Primary Closure: is the use of staples or sutures for closure and is most often used to close smaller excisions, especially in lower-grade HS cases. However, if HS lesions are not effectively excised, the disease can recur at the location and result in the wound being open. Primary closure has the highest recurrence rate among all the closure techniques we mentioned.
  • Skin-Tissue-Sparing Excision with Electrosurgical Peeling (STEEP): this is an alternative to wide excision for Hurley stage II or III and is associated with many advantages over other procedures like reduced healing time, low complication rates, and cosmetic outcomes that are better compared to other procedures. The wound should be allowed to heal by secondary intention, and steroids should be used to prevent hyper-granulation.

• Post-surgical care: In procedures, such as STEEP, deroofing, and wide local excision, where the wound is left to heal by secondary intention, more rapid healing is facilitated by moist dressings and daily wound cleansing. Silicone or alginate dressings improve wound healing. In the later weeks, thick absorbent dressings made of gauze soaked in an equal mixture of liquid paraffin and petroleum are placed following irrigation with disinfecting solutions. These dressings are changed every 2 to 3 days. Vacuum-assisted negative pressure dressings can be used in grafts to reduce bacterial growth, increase the local oxygen concentration in the wound, improve healing, and keep the graft intact in curved locations. 

• Lasers: include  CO₂ Laser, Nd: YAG Laser, and Intense Pulsed Light (IPL).

• Pain management: The pain of hidradenitis suppurativa is both inflammatory and non-inflammatory. Sources of pain can include abscesses, scarring, sinus tracts, keloids, open ulcerations, frictional pain, lymphedema, anal fissures, and arthritis. Depending on disease severity and type of pain, topical agents (lidocaine and anti-inflammatories), atypical anticonvulsants, systemic nonsteroidal anti-inflammatories, acetaminophen including pregabalin or gabapentin, and serotonin-norepinephrine reuptake inhibitors may be beneficial. Duloxetine can be helpful if there is comorbid depression.

• Changing lifestyle: Individuals who smoke or are overweight have more severe disease progression, so stopping smoking and losing weight can help with the treatment. Treatment also involves avoidance of skin trauma. Eliminating synthetic or tight clothing, avoiding harsh products or cleaning tools (washcloths, loofahs, brushes), and avoiding adhesive dressings can be beneficial. Soft dressings with clear petroleum jelly or non-occlusive dressings can be used to prevent further irritation to draining lesions. Physiotherapy should be initiated early to prevent wound contractures

• Other treatments: include treating the affected areas with antiseptic washes (triclosan), and keratolytic agents. Prednisone, colchicine, and ciclosporin can also help.

Note: This information does not apply to surgery wounds or large or deep wounds. This is just for normal wounds.

Try not to poke or squeeze the flares, if they pop underneath the skin you can become ill.

• Use ice packs to help with inflammation and pain. Be sure to place a towel between your abscess and the ice pack so you do not burn your skin with the ice pack.

• Covering the flare in Vicks Vapour rub (do not use Vicks on open abscess, too close to your genitals, or on mucous membrane areas) and a dressing should make it open up.

• You can also take Ibuprofen or a drawing salve for the pain and inflammation.

If you have one deep under the skin, the best thing to do is leave it alone.

• Apply continuous hot compresses/moist warm/packs. Your goal is to get the abscess as soft as possible so it starts to drain.

Moist packs can be made out of the following to promote drainage:

• Basil pack
• Apple Cider Vinegar
• Witch hazel
• Turmeric Medi-honey (can be purchased from the store)
• Epsom salt
• Regular honey
• Clove
• Bread and milk packs (bread soaked in milk)

You can make your own moist pack at home using a washcloth, flannel, piece of gauze, or unused tea bag.

Bath Options to Help with Drainage:

If hot baths are causing you problems you may want to follow up with cold running water in your tub and use a cold cloth or ice packs on your wounds after your bath.

Note: keep your bath time as short as possible (20 mins).

These are some bath options for HS:

• Apple cider vinegar bath
• Diluted bleach bath
• Himalayan salt or sea salt bath
• Epsom salt bath
• Epsom salt (food grade 100% pure) detox bath

Drawings Salves to Help Promote Drainage:

• Prid
• Boil Ease
• Vicks
• Ichthammol/pine tar
• Quret Drawing Salve
• Ichthammol ointment

Note: If your abscesses are not ready to drain, stay away from heat as it causes inflammation and pain.

The biggest mistake people make with their abscesses is that they do too much, which keeps the wound open and irritated. Another mistake is not using the proper bandages. Stay away from Band-Aids (trap a lot of moisture and bring in unwanted bacteria) and antibiotic ointments.

Use saltwater and/or saline to wash the wound 1 to 3 times per day. After washing the wound, take a piece of gauze, place it on your wound and secure with tape. If you have a wound that is seeping or draining you can follow the above and also cut a piece of an ABD pad as an extra barrier and place it on top of your gauze before securing with tape.

If the wound sticks to the bandage when removing, you can apply Vaseline on the area to keep it from sticking.

Let your wound air out when you have the opportunity, for example, at bedtime. After a couple of weeks, if you do not see any improvement, you can add colloidal silver gel into the routine one to two times per day.

If your wound is not healing (a few months or a year), speak to your doctor about possible steroid injections in the area to help promote wound healing. Debridement may be necessary, which is a more invasive approach.

We recommend an emollient or hydrogel to be placed in the wound if the opening is large enough and covered with a protective absorbent pad that may be secured with a bordered adhesive dressing or held in place with netting or undergarment/clothing.

For larger or deeper wounds, it may be “lightly filled” to help impart moisture or to wick drainage. Use wet-to-dry dressings (also called saline-moistened gauze) against the wound bed, covered with an absorbent cover dressing, such as an ABD pad. Do change daily or more often to ensure moisture balance; do not allow gauze to dry out.

When needing bandages or dressing, you can actually request them on a prescription. You could also request to see a Tissue Viability Nurse (TVN) to be assessed for the best type of dressing for your skin.

Note: we are recommending these products based on people’s experiences with them.

• Allevyn Gentle Border Dressings: These dressings are foam-based with a silicone adhesive and come in a range of sizes. They are gentle on sensitive skin to avoid trauma to the wound when changing the dressing. They have a bacteria barrier, keeping infections out and maintaining a moist wound environment for better healing. The foam also makes them quite comfortable. If you have sensitive skin, make sure you specifically ask your doctor for the GENTLE border as they come in the normal border as well. They also come in different shapes and sizes that are designed to fit the most awkward areas of the body.

• Mepilex Border Dressings: These dressings are softer on the skin and able to retain more wound exudate than Allevyn, but can be expensive. These dressings are also foam-based with a silicone adhesive, providing all the benefits of Allevyn. However these have higher absorption, they also absorb exudate past a retention layer meaning there won’t be any sticky substance.

• Tegaderm +Pad Film Dressings: all Tegaderm dressings have good versatility however, if using for HS you want the +Pad else you’ll feel some pain at dressing changes. Also, these are not as absorbent as the two previously mentioned dressings but these dressings stay on much longer than other dressings. However we would not recommend these dressings if you have sensitive skin or will need to change them more than twice a week, they stay on well because they’re so adhesive! But for someone who has mild exudate and wants a dressing that will stay in place throughout different activities then this is your dressing. 

• Aquacel AG+ (Extra) Dressings: These dressings have no adhesive so you will want to either use some tape to keep them in place or place them underneath another dressing that is adhesive. Generally, a doctor won’t prescribe these until you’ve already got an infected HS wound. These again come in all sizes and are infused with silver which has antimicrobial properties. These dressings activate once wound exudate gets onto them, at which point they create a seal around the wound and stop bacteria from spreading. They are also incredibly absorbent.

• 3M’s Kerramax Care Super-Absorbent Dressing: This is a dressing that is designed to absorb and retain high levels of exudate or discharge away from the wound bed – including bacteria2* and MMPs3*. It is soft, comfortable, suitable for under compression, and can be left in place for 7 days.

• Cavilon No Sting Barrier Film 1ml Foam Applicator: This is used as a barrier film before placing the dressing on top. This helps to keep the skin dry and comfortable and reduces skin breakdown.

• Inadine Dressings: These look like little pieces of mesh that are covered in Iodine (which has antimicrobial properties) and these little meshes can be put over the top of a wound to help fight off bacteria, reducing the likelihood of infection. They are non-adhesive so will not stick to the wound and they change colour from orange to white (indicating when they need changing).

• Flaminal Hydro/Forte Gel: These two gels are non-toxic and promote natural healing. They help to balance moisture in the wound and dissolve dead tissue and bring it out of the wound. You can use this on deep wounds as you can squeeze the gel directly into the wound hole before covering it with a dressing, but it can be used on any depth of the wound. The gel also has antibacterial properties so it’s good for keeping a wound infection free too. Flaminal Hydro is for mild to moderate exudate, Forte is for moderate to high amounts of exudate.

• Mepitel Wound Contact Layer: This is another product that looks like a little mesh, but this one is just a mesh made of silicone and is non-adhesive. You’ve done your dressing care, you’re finally comfy, and now it’s the next day and you need to remove your dressing. You pull it off and now your wound hurts all over again because even the gentle dressings have irritated your wound to some degree upon removal. Not with this little bit of mesh! It goes over the wound and underneath the dressing, due to the holes in it, it is breathable and wound exudate can pass through it to the other dressing you’ve applied. As it’s silicone it moulds to the shape of your wound without sticking. The idea is that it can stay in place for up to 2 weeks while you change the other dressing, so as not to disturb the healing.

• Hidrawear Dressings: Hidrawear dressings are available on the NHS, you can request a free information pack from them which has instructions to take to your GP. These dressings are for those suffering from HS in their armpits, There is sort of like a little jacket that you wear under your clothes, it does up under the bust and over the chest. There are then absorbent pads that sit in the armpit area but attach to the jacket rather than sticking on the skin. This completely removes the issue of adhesive, they are comfortable and the pads are extremely absorbent (they are the most absorbent out of any listed in this guide). I am not sure of the exact science but they are absorbent enough that they reduce odour and remove any wetness on the skin from wound exudate. The only downside is that sometimes they can stick to the wound, but is easily solved with a light layer of Vaseline.

• Bandages:
  • Equate Sensitive Skin Bandages
  • Nexcare Waterproof Bandages
  • Welly Bravery Bandages
  • Saniderm Bandages
  • 3M Tegaderm Transparent Film Dressing Frame Style
  • Silicone Bandages
  • Hydrocolloid Bandage

• Gauze pads
  • Johnson & Johnson Brand Cushion Care Gauze Pads
  • Equate Nonstick Adhesive Pads

• Tapes:
  • 3M – Medipore Surgical Tape
  • Hypafix Dressing Retention Tape
  • Hypafix Gentle Touch – Soft Silicone Retention Tape
  • Nexcare Sensitive Skin Tape
  • Band-Aid Brand Hurt-Free Paper Tape

• Products for healing and scar prevention:
  • LRP Cicaplast Balm B5
  • Avene – Cicalfate+ Restorative Protective Cream
  • Avene – Cicalfate Post-Procedure Emulsion
  • Avene – Cicalfate+ Scar Gel

When choosing clothes or undergarments for hidradenitis supparativa, go for natural fibers like cotton, linen, wool, or bamboo. Also wearing tighter-fitting clothes or undergarments would be more comfortable than loose clothing. This helps keep everything in place and not cause friction between the skin and prevent flare-ups.

Regarding the colour, black and dark blue would be ideal so the outside won’t stain. If you like other colours, then waterproof clothes are an option.

• You can use the above information for choosing shirts, T-shirts, or pants.

• Waterproof material can be great and won’t cause leakage.

• Make sure there are no underwires in your bra and underwear. 

• Switching from bras to camisoles, wireless sports bras, and wireless posture bras. or tank tops can help to reduce flare-ups and make the skin feel more comfortable. Also, try to go braless as much as possible or use nipple patches instead.   

• Switching from panties to boxer briefs, compression biker shorts, high-waisted underwear, or period underwear can help to reduce flare-ups and make the skin feel more comfortable. This tip was given by a person with HS for inner thigh and panty line: get snug boxer briefs (the sort that goes to just above the knee, or they ride up) and 100% cotton flannel. Hit up a fabric shop for “fat quarters” in flannel. It’s a quarter of a yard. Cut to manageable sizes and wash well, cut off all the strings that result from washing and drying. Tuck the flannel between your flare and the undershorts. The flannel is cushioning and comfortable against angry skin and will absorb any leakage.

• Pads or panty liners can also be used in the affected areas. You can cut them up and place them on the affected areas.

• Duluth Trading Co “Buck Naked” underwear.

• TomboyX underwear, period wear, and boxer briefs. 

• Hidrawear briefs for women. 

• David Archer’s bamboo underwear and boxer briefs on Amazon

• Jockey’s No Panty Line Promise Tactel

• Fruit Of The Loom Women’s Fit for Me Plus Size Women’s Underwear

• Merino boxer briefs

• There is a website called Cottonique and you can find undergarments that can fit

• Lacey underwear is another choice.

• Jessica Simpson brand bras

• The Felina brand makes some really soft and comfy panties and leggings

• Woxers, boxers for women.

• Women’s Boyshort Panties

• Period shorts – Aisle’s Boost Boxer

• Pair of Thieves Super Fit Men’s Boxer Brief

• Culprit Boxers

• Bambody is another brand that makes underwear. They are super soft, not tight, breathable, and wick away all fluids from the skin, helping it to stay dry and comfortable down there during the summertime. They are also made of cotton and bamboo and are easy to clean.

• Best Creams for Hidradenitis Suppurativa

• Best Shampoos for Hidradenitis Suppurativa

Swimming is good exercise and preferable for people with hidradenitis suppurativa because your skin isn’t rubbing on itself much. The water lubricates it. In addition, chlorine in swimming pools can be beneficial for many people with HS by controlling the growth of bacteria on the skin. Make sure to not swim with an open wound.

If you don’t like swimming, yoga may be a great option, since it involves slow movements that cause minimal skin friction. Bicycling can be a good choice, too, but, there is a lot of skin rubbing, so finding the right type of bike shorts is very important.

Simply walking or paced walking is an excellent way to get physical activity, especially if you’re not used to more intense exercise.

When doing normal exercises like weight training, biking, walking, or trekking, you can wear tight-fitting clothes and bandages on the affected areas to avoid friction.

Wearing moisture-wicking fabrics when you exercise can help reduce the effects of sweat, but there are measures you can take to minimize how much you sweat.

• Work out in a well-ventilated area or use an electric fan to create a breeze in your workout area.

• Using powder on the affected areas.

• Use an antiperspirant to prevent sweating.

• Wear moisture-wicking clothes, dressings, and bandages.

• Shower as soon as you can after your workout to wash off the sweat and use a antibacterial body wash to combat the bacteria.

Hidradenitis suppurativa can cause both physical and psychological conditions because of the associated pain, sensitive locations, drainage, odor, and scarring.

Physically, the recurrence of lesions leading to tracts, abscesses, and scarring can cause limb contractures, chronic pain, and impaired mobility. Lymphatic obstruction can lead to peripheral lymphedema. Long-term effects of inflammation can also occur, including hyperproteinemia, anemia, and amyloidosis, as well as peripheral and axial arthropathy. In very rare cases, a superimposed infection can lead to systemic illness of variable severity.

Cancer is a topic everyone gets scared of when looking into HS but is very rare. Also, repeated scarring in one area can cause skin cancers but the chances of that are very rare and would happen more in someone who has had active HS for 30+ years.

Squamous cell carcinoma can occur in the setting of hidradenitis suppurativa, sometimes occurring up to 30 years after diagnosis. There is also an associated increase in buccal and hepatocellular cancer.

Hidradenitis suppurativa can have a psychological impact as well. Combining chronic pain with drainage, odor, and deformity of skin appearance can lead to decreased relationships, sexual dysfunction, depression, social isolation, reduced work productivity, and even suicide in extreme cases.

For mild hidradenitis suppurativa or Hurley stage, I or stage II, topical antibiotics, oral antibiotics, or clindamycin and rifampicin can help.

Rifampicin, moxifloxacin, and metronidazole can also help.

Perianal and perineal hidradenitis suppurativa can be treated by antibiotics and must be chosen to cover both aerobic and anaerobic bacteria. Topical and oral clindamycin with rifampin, in addition to tetracycline, erythromycin, and doxycycline can help to reduce symptoms of hidradenitis suppurativa.

Wide excision is a surgical treatment that can help with perianal and perineal hidradenitis suppurativa and prevent recurrences and reconstruction includes bilateral transposition flap and or using the gracilis musculocutaneous flap for severe lesions.

The anterior Obturator Artery Perforator (aOAP) flap can be a safe option for the reconstruction of perineal defects after wide surgical excision of hidradenitis suppurativa.

Non-surgical treatments include warm baths, hydrotherapy, topical cleansing agents, and systemic antibacterial chemotherapy, which only brings short-term pain relief and alleviation of distressing symptoms.

For treating hidradenitis suppurativa of the groin (with involvement of the labia, buttocks, and mons pubis), topical antibiotics, oral antibiotics, or clindamycin and rifampicin can help. Moxifloxacin, rifampicin, and metronidazole can also help.

Radical surgical excision is the treatment of choice for hidradenitis suppurativa of the groin and a medial thigh lift can be considered for immediate defect closure after radical excision.

Other surgical treatments include pedicled gracilis myocutaneous flap, modified abdominoplasty (as a functional reconstruction for recurrent hidradenitis suppurativa of the groin and lower abdomen), and anterolateral thigh (ALT) flap (for the reconstruction of groin and vulval hidradenitis suppurativa). 

Topical antibiotics, oral antibiotics, or clindamycin and rifampicin are the first-line treatments for hidradenitis suppurativa of the armpit. Metronidazole, rifampicin, and moxifloxacin can help.

Radical excision is the treatment of choice for hidradenitis suppurativa of the armpit and immediate coverage with a flap.

Local fasciocutaneous V-Y advancement flaps were reported for large defects following wide surgical excision of long-standing hidradenitis suppurativa of the armpit. Another option is the double opposing V-Y perforator-based flaps used for reconstruction of the armpit defects following the excision of hidradenitis suppurativa to recreate the axillary contour after wide surgical excision of the hair-bearing skin of the armpit. 

Rotation fasciocutaneous flap and transposition fasciocutaneous flap such as the Limberg flap performed successfully and showed great results. Parascapular fasciocutaneous flap and even thoracodorsal artery perforator (TDAP) flap were selected for moderate to diffuse lesions.

The lateral thoracic fasciocutaneous island flap was used for the treatment of recurrent hidradenitis suppurativa in the armpit and other armpit skin defects.

Wide surgical excision is the treatment of choice for hidradenitis suppurativa of the buttocks.

Reconstruction includes fasciocutaneous (FC) flaps of three different designs (island V-Y advancement flap, a rotation V-Y advancement flap, and, a bilobed flap) and split gluteus maximus musculocutaneous flap (is easy to prepare and does not leave ambulatory insufficiency).

There is some evidence that it can make a big difference because you can put the seton suture through the tunnel and allow it to heal.

Sometimes pyoderma gangrenosum can come on top of hidradenitis suppurativa and should be dealt with cautiously because when you cut it, it expands. You need to get the disease completely quiet before dealing with the HS.

Oral steroids can work for pyoderma gangrenosum.

Ertapenem has been used to calm HS lesions, allowing for bridging to surgery or biologic therapy. There are studies showing the efficacy of ertapenem. Patients reported decreased discharge and pain, as well as increased mobility, leading to improved quality of life.

Pyogenic granulomas are unlikely to respond to surgical removal, they are likely to respond to topical therapies. Topical steroids like dermovate ointment or beta blockers like topical timolol can be used for pyogenic granulomas.

Using dry heat in the form of heating pads is not recommended for hidradenitis suppurativa abscesses. Heat promotes continuous inflammation leading to pain.

Cold or ice reduces inflammation and breaks the inflammation cycle. Always put something down as a barrier such as a cloth or towel when applying heat or cold packs to the wound.

Cold works better for the pain whereas heat helps to soften the abscesses and make it burst.

• People usually go for laser hair removal treatments when dealing with hidradenitis suppurativa which is efficient but very expensive. You can use an at-home IPL device hair removal device if you can’t afford laser hair removal treatments and is cost-efficient.

• Another option is using an electric bikini razor or trimmer to trim the hair and keep it short.

• Waxing and shaving also work but everyone has different experiences.

No, hydrogen peroxide shouldn’t be used to treat hidradenitis suppurativa because it can damage healthy tissue and also prolong healing.

It is not known if hidradenitis suppurativa is the 3rd most painful disease in the world as there are no data or statistics showing it but this disease is known to be extremely painful and searing.

Zinc, copper, vitamin A, vitamin D, vitamin B12, omega 3, fish oil, turmeric, and probiotics are some of the best vitamins for hidradenitis suppurativa.

I am not a doctor and this post is a collaboration of research and HS patient information. It is only for educational purposes and not medical advice.