Hidradenitis suppurativa: Diagnosis and treatment

A dermatologist is often the doctor who diagnoses a patient with hidradenitis suppurativa

Getting an accurate diagnosis and an individualized treatment plan can help prevent this condition from worsening.

How do dermatologists diagnose hidradenitis suppurativa?

Hidradenitis suppurativa can look like other skin conditions, including acne, boils, or herpes. Dermatologists have the training needed to spot the differences between these conditions. This unique training allows them to diagnose hidradenitis suppurativa quickly.

If your dermatologist suspects that you may have hidradenitis suppurativa, here’s what typically happens. Your dermatologist will:

• Ask where you have lumps, drainage, pain, or other signs. Hidradenitis suppurativa tends to occur in certain areas, like the underarms, groin, buttocks, or under the breasts.

• Examine some (or all) the bumps and sores. Hidradenitis suppurativa has certain features, which to the trained eye distinguish it from acne, boils, and other conditions.

• Talk with you about what they see on your skin. During this talk, your dermatologist will ask you about your symptoms, when the bumps and sores appeared, and other specifics. This information helps your dermatologist give you an accurate diagnosis.

If you have a sore that’s leaking fluid, your dermatologist may swab a bit of the fluid so that it can be tested. This test can tell your dermatologist whether you have an infection.

If you have hidradenitis suppurativa, your dermatologist will create a treatment plan tailored to your needs.

How do dermatologists treat hidradenitis suppurativa?

While this condition cannot be cured, your dermatologist will create a treatment plan that can:

• Reduce flare-ups

• Heal wounds

• Relieve pain and itch

• Prevent the condition from worsening

• Allow you to participate comfortably in regular activities, such as walking and exercise

When creating a treatment plan, your dermatologist considers the types of bumps and sores you have, whether you have pain or an infection, and how the condition is affecting your life. This allows your dermatologist to customize a treatment plan for your needs.

Your treatment plan may include one or more of the following:

Skin care

Some soaps and other skin care products may irritate skin with hidradenitis suppurativa. To reduce irritation, your dermatologist can create a skin care plan for you. This plan may include using an antibacterial wash and switching to a gentle antiperspirant.

Medication you apply to your skin

If you have nodules (hard lumps beneath your skin), cysts (lumps that may contain pus, oil, or another substance), or abscesses (infected lumps that contain pus), your dermatologist may prescribe:

A topical (applied to the skin) antibiotic: A topical antibiotic called clindamycin is often prescribed to treat mild hidradenitis suppurativa. This medication can reduce lumps, including lumps that contain pus, and pus-filled swollen areas beneath your skin. It can also help treat an infection.

Apply this medication exactly as prescribed.

• Brand names: Cleocin T, Clindacin ETZ, Clindacin P, Clindacin Pac, Clinda-Derm, Clindagel, ClindaMax, ClindaReach, Clindets, Evoclin, Z-Clinz

Resorcinol cream: This is a peel that can open clogged hair follicles and reduce inflammation.

When used to treat hidradenitis suppurativa, it has been shown to decrease pain, swollen areas that contain pus, and the lumps beneath the skin. It takes about 3 to 4 months to see the effects. For this medication to be effective, you may need to continue using resorcinol for some weeks after you see clearing.

If your skin becomes dry, scaly, itchy, or irritated after using resorcinol, tell your dermatologist.

• Resorcinol is available without a prescription. To reduce the risk of irritating your skin, your dermatologist will tell you which product to get, how to apply it, and how often to use it.

Medication that works throughout the body

When stronger treatment is needed, your dermatologist may prescribe one of the following medications:

Oral (taken by mouth) antibiotic: Antibiotics are frequently prescribed to treat hidradenitis suppurativa. An antibiotic can reduce inflammation and bacteria that cause flare-ups on your skin.

Some patients take one antibiotic pill once or twice a day. Some patients need to take two different kinds of antibiotics.

Be sure to follow your dermatologist’s directions when taking an antibiotic. This may include wearing sun-protective clothing and sunscreen with broad-spectrum protection and an SPF of 30 or higher while outdoors. Some antibiotics can make your skin sensitive to the sun.

Hormonal therapy: For some women, hormonal therapy may be helpful.

Hormonal therapies include birth control pills that contain estrogen, spironolactone, cyproterone acetate, metformin, and finasteride. Your dermatologist may prescribe one or more of these treatments. For example, your dermatologist may prescribe a birth control pill and spironolactone.

Biologics and biosimilars: Biologics differ from other types of medications in that they are made from a living organism, like plant cells or animal cells. Biologics work on part of your immune system. The biologics used to treat hidradenitis suppurativa are designed to reduce inflammation. Studies show that some biologics can effectively treat hidradenitis suppurativa when other treatments fail.

A biosimilar is a type of medication that’s very similar to one specific biologic medication like adalimumab (Brand name: Humira) or secukinumab (Brand name: Cosentyx). However, the cost of a biosimilar may be much less than the cost of a biologic. For more information, go to Biosimilars: 14 questions that patients ask their dermatologist. If a biologic or biosimilar is a treatment option for you, your dermatologist may prescribe one of the following:

• Adalimumab: The U.S. Food and Drug Administration (FDA) has approved adalimumab to treat moderate-to-severe hidradenitis suppurativa.
  
  In studies that led to its approval, the patients who received adalimumab had noticeably fewer abscesses (infected lumps with pus) and nodules (hard lumps beneath the skin) than the patients who did not receive this medication.
  
  Adalimumab is an injectable medication that comes in a prefilled pen or syringe. If your dermatologist prescribes adalimumab, you’ll learn how to give yourself injections so that you can treat yourself at home. Your first injection will be given (or supervised) by your dermatologist or nurse. Always follow your dermatologist’s instructions for taking this medication.
  
  The FDA has approved one brand of adalimumab, Humira, to treat people 12 years of age or older who have moderate or severe hidradenitis. The FDA has approved other brands of adalimumab to treat adults with moderate or severe hidradenitis.
  
  Adalimumab is a strong medication, so it’s not the right treatment for everyone. The most common side effects include an increased risk of developing an infection, rash, redness/discoloration, or swelling where you inject the medication. Headaches are another possible side effect.

  • Brand names: Humira (biologic), Abrilada, Amjevita, Cyltezo, Hadlima, Hulio, Idacio, Simlandi, Yuflyma, Yusimry (biosimilars)

• Secukinumab: This biologic is FDA approved to treat adults who have moderate or severe hidradenitis suppurativa.
  
  In studies that led to its approval, 44% of patients treated with secukinumab saw 50% or more of their nodules (hard lumps beneath their skin), abscesses (infected pus-filled lumps), or skin filled with pus clear in 16 weeks. The patients also had no new fistulas (tunnels that develop beneath the skin). After one year, more than 80% of patients had no increase in the number of draining tunnels. This is important because developing new tunnels is a sign that hidradenitis suppurativa is worsening.
  
  Secukinumab is an injectable medication. Before you use this medication for the first time, your dermatologist or nurse will show you how to inject it.
  
  Like adalimumab, secukinumab is a strong medication, so it’s not the right treatment for everyone. The most common side effects are cold symptoms, diarrhea, and upper respiratory tract infections.

  • Brand name: Cosentyx (biologic)

• Infliximab: This may be prescribed to get moderate or severe hidradenitis suppurativa under control. It’s given as an infusion, so you need to go to an infusion center, clinic, or hospital for treatment.
  
  In studies, the most common side effects are flu-like symptoms and a reaction to the infusion. Symptoms of an infusion reaction include itching, flushing, headache, and shortness of breath. More serious side effects can also occur. If a reaction occurs, it usually begins after you finish getting the infusion, usually within 30 minutes to 2 hours. It can also take 24 hours or up to one week for a reaction to occur.

  • Brand names: Remicade (biologic), Arsola, Infectra, Ixifi, Renflexis (biosimilars)

While you are receiving a biologic or biosimilar, your dermatologist will monitor you closely.

In-office procedures

Some patients can benefit from a treatment plan that uses both medication and an in-office procedure. In-office procedures are especially helpful if tunnels have formed in your skin.

Procedures that dermatologists use to treat hidradenitis suppurativa include:

• Corticosteroid injection: When injected into a nodule, this medication can reduce inflammation. Dermatologists use this procedure to treat early, painful nodules that are not infected. It cannot treat tunnels under your skin.

• Laser hair reduction: Reducing the amount of hair on skin with hidradenitis suppurativa can reduce the number of nodules and pus-filled bumps. Your dermatologist will tell you how many treatments you’ll likely need. Treatment is typically done once every 4 to 6 weeks. It may take months to see improvement.

• Botulinum toxin: While most people think of this medication as a treatment for wrinkles, the FDA has also approved this medication to treat excessive sweating. Your dermatologist may recommend botulinum toxin to reduce sweating, which can help reduce infections.

• In-office surgical procedure: Your dermatologist may recommend this to drain a painful bump. An in-office surgical procedure can also be used to remove an abscess (pus-filled area), tunnel beneath your skin, or lesion that keeps returning after treatment.
  
  Before the procedure, your dermatologist will numb the area, so you don’t feel the surgery. You’ll remain awake during the procedure.
  
  To perform this type of surgery, your dermatologist will use a surgical blade, laser, or other surgical instrument(s) to treat you.
  
  To help prevent an infection and obtain the best results after surgery, you’ll need to care for the surgical wound at home.
  
  Possible side effects of an in-office surgical procedure include an infection and the possibility of the treated lesion returning. Your dermatologist knows how to minimize these risks by carefully selecting patients and following approved surgical methods.

About laser surgery: Strong lasers can vaporize lesions. Before you have laser surgery, your dermatologist will prescribe medication to get hidradenitis suppurativa under control. For laser surgery to be effective, the hidradenitis suppurativa must remain the same for weeks. After laser surgery, it may take up to 6 months for your skin to heal.

Wound care

This plays an important role in treating hidradenitis suppurativa, as this condition can cause slow-healing or non-healing wounds. If you need wound care, you will learn how to do this at home. In the beginning, some patients need to change their dressings several times a day.

What you use to care for your wounds can vary. Your dermatologist will consider where you have wounds, the amount of leakage coming from the wounds, what the skin around each wound looks like, cost, and your preferences.

Along with dressing changes, your dermatologist may recommend the following:

• To decrease the odor: Soak a clean washcloth in diluted white vinegar and apply it before you dress a wound.

• To relieve the pain and discomfort: Use an antiseptic wash.

Treatment for depression or anxiety

If you have developed depression or anxiety, your dermatologist may recommend counseling or joining a hidradenitis suppurativa support group.

Self-care can help you get the best results from treatment

To help their patients get the best outcome from treatment, dermatologists recommend self-care. To see what dermatologists advise, go to Hidradenitis suppurativa: Self-care.

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References
Alikhan A, Sayed C, et al. “North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations Part I: Diagnosis, evaluation, and the use of complementary and procedural management.” J Am Acad Dermatol 2019;81:76-90.

Alikhan A, Sayed C, et al. “North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations Part II: Topical, intralesional, and systemic medical management.” J Am Acad Dermatol 2019;81:91-101.

Brunk D. “FDA approves secukinumab for adults with hidradenitis suppurativa.” Medscape Dermatol. Oct 31, 2023. Last accessed Mar 13, 2024.

Dallo M, Patel K, et al. “Topical antibiotic treatment in dermatology.” Antibiotics (Basel). 2023 Jan 17;12(2):188.

Fernandez-Crehuet P, Haselgruber S, et al. “Short-term effectiveness, safety, and potential predictors of response of secukinumab in patients with severe hidradenitis suppurativa refractory to biologic therapy: A multicenter observational retrospective study. Dermatol Ther (Heidelb). 2023 Apr;13(4):1029-38.

Heymann WR, “Resorcinol’s resourcefulness in hidradenitis suppurativa.” Dermatology World Insights and Inquiries. March 22, 2023;5(12).

Kimball AB, Jemec GBE, et al. “Secukinumab in moderate-to-severe hidradenitis suppurativa (SUNSHINE and SUNRISE): Week 16 and week 52 results of two identical, multicentre, randomised, placebo-controlled, double-blind phase 3 trials.” Lancet. 2023 Mar 4;401(10378):747-61.

Lyons AB, Shabeeb N, et al. “Emerging medical treatments for hidradenitis suppurativa.” J Am Acad Dermatol 2020;83:554-62.

Narla S, Price KN, et al. “Proceeding report of the Fourth Symposium on Hidradenitis Suppurativa Advances 2019. J Am Acad Dermatol. 2021 Jan;84(1):120-9.

Nesbitt E, Clements S, et al. “A concise clinician's guide to therapy for hidradenitis suppurativa.” Int J Womens Dermatol. 2019 Dec 27;6(2):80-4.

van der Zee HH, Prens EP, et al. “Deroofing: A tissue-saving surgical technique for the treatment of mild to moderate hidradenitis suppurativa lesions.” J Am Acad Dermatol. 2010 Sep;63(3):475-80.

Written by:
Paula Ludmann, MS

Reviewed by:
Kesha Buster, MD, FAAD
Laurel Geraghty, MD, FAAD
William Warren Kwan, MD, FAAD
Desmond Shipp, MD, FAAD

Last updated: 7/22/24