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What Causes Hidradenitis Suppurativa

Much like acne, hidradenitis suppurativa is likely caused by genetic or acquired dysfunction of the hair follicle epithelium that makes it “leaky,” allowing increased passage of normal skin bacteria through the skin barrier where they cause an immune reaction. Hormones, diet, smoking, and obesity influence the skin microbiome and may add to this inflammation. Therefore, medical treatments for HS are aimed at reducing the skin’s bacterial load and reducing the overactive immune response to these bacteria by blocking inflammatory proteins, influencing hormone levels, or reducing hair density.  Like acne, HS presents with blackheads, pimples, and boils,and in its early stages we treat it like acne. However, HS can become chronic and create permanent scars and tunnels full of bacteria under the skin surface. When there is scarring or very active inflammation, additional treatments and surgery may be needed.

At the UMass HS Center, we offer the following treatments:  

Topical Antimicrobials

Benzoyl peroxide (OTC) and chlorhexidine are antibacterial washes that are often used for acne and can help prevent HS breakouts. Clindamycin is a topical antibiotic that can applied to affected areas.

Hormonal Therapies

Reduces plugging of the hair follicles by blocking the activity of androgen hormones.

  • For female patients, we may recommend an oral contraceptive pill that contains drospirenone or cyproterone acetate, as these have anti-androgen activity. These pills are not recommended if you experience migraine headaches with aura, if you smoke tobacco products and are over the age of 35, or if you have ever had a blood clot in the leg (deep vein thrombosis/DVT) or in the lungs (pulmonary embolism/PE).
  • Spironolactone is another anti-androgenic oral medication that can be used to treat HS. If you have low blood pressure, this may not be the best treatment for you as spironolactone may slightly lower your blood pressure. This treatment is not recommended if you have severe kidney disease or if you are trying to become pregnant, as it can cause feminization of a male fetus.
  • Metformin: This medication is used to improve insulin sensitivity in people with diabetes. Insulin is a hormone that regulates blood sugar levels. People with type 2 diabetes develop insulin resistance, which is characterized by high insulin levels, as the body is unable to effectively use insulin to regulate blood sugar. Metformin helps the body to use insulin more effectively. Metformin has been used successfully to improve HS, as it can help to reduce the levels of androgens from excess insulin levels.

Oral Antibiotics

HS is not an infectious or a contagious condition, but certain antibiotics have anti- inflammatory effects and can be used to treat HS. Doxycycline and Augmentin are commonly prescribed antibiotics that can be taken for days to months to help control HS.


Adalimumab (HumiraTM) and Secukinuma (CosentyxTM) are the only two biologic medications that are approved by the FDA to treat HS. This treatment is given as an injection and it is an anti-inflammatory medication that blocks production of TNF-α, which contributes to the inflammation in HS lesions. Biologics are reserved for patients with moderate to severe HS who have not seen improvement of their HS with other treatments. Additionally, clinical trials are ongoing for other biologics—please inquire with us about ongoing research trials and visit the ‘clinical trials’ tab on our webpage!

Laser Hair Removal

Laser hair removal selectively targets and destroys hair follicles, which can help prevent new HS lesions from forming in hair-bearing areas of the underarms and pubic area.

Intralesional Corticosteroid Injections

Corticosteroids can be injected directly into HS lesions to reduce pain and inflammation from flare-ups and this can help lesions to resolve more quickly. Ask your dermatologist if their office will allow you to book an urgent, fit-in appointment for these injections.

Botulinum Toxin Injections

Botulinum toxin is used to treat excessive sweating (hyperhidrosis) and although off-label for HS, some studies have found that this can help to reduce the number of HS lesions in treated areas. Some drug insurance plans may cover the cost of this treatment. Also, we have an ongoing clinical trial for Botox in HS where the medication will be provided free of charge– please contact us to learn more and see if you may be eligible to participate!

Surgical deroofing or excision

These are in-office procedures that are performed under local anesthetic to treat lesions which recur in the same spot or sinus tracts underneath the skin. Deroofing surgery can improve your quality of life by eliminating pain and drainage from problem spots and these lesions often do not come back in the same spot! Ask us if you would be a good candidate for deroofing surgery!