DermNet provides Google Translate, a free machine translation service. Note that this may not provide an exact translation in all languages

Hidradenitis suppurativa

Author: Vanessa Ngan, Staff Writer; Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand. 1997. Updated December 2015.

Hidradenitis suppurativa — codes and concepts

What is hidradenitis suppurativa?

Hidradenitis suppurativa is an inflammatory skin disease that affects apocrine gland-bearing skin in the axillae, in the groin, and under the breasts. It is characterised by recurrent boil-like nodules and abscesses that culminate in pus-like discharge, difficult-to-heal open wounds (sinuses) and scarring. Hidradenitis suppurativa also has a significant psychological impact, and many patients suffer from impairment of body image, depression and anxiety. 

The term hidradenitis implies it starts as an inflammatory disorder of sweat glands, which is now known to be incorrect. Hidradenitis suppurativa is also known as acne inversa.

Hidradenitis suppurativa

See more images of hidradenitis suppurativa.

Who gets hidradenitis suppurativa?

Hidradenitis often starts at puberty and is most active between the ages of 20 and 40 years, and in women, can resolve at menopause. It is three times more common in females than in males. Risk factors include:

* PAPA syndrome (pyogenic arthritis, pyoderma gangrenosum and acne), PASH syndrome (pyoderma gangrenosum, acne, suppurative hidradenitis) and PAPASH syndrome (pyogenic arthritis, pyoderma gangrenosum, acne, suppurative hidradenitis).

What causes hidradenitis suppurativa?

Hidradenitis suppurativa is an autoinflammatory disorder. Although the exact cause is not yet understood, contributing factors include:

  • Friction from clothing and body folds
  • Aberrant immune response to commensal bacteria
  • Abnormal cutaneous or follicular microbiome
  • Follicular occlusion
  • Release of proinflammatory cytokines
  • Inflammation causing rupture of the follicular wall and destroying apocrine glands and ducts
  • Secondary bacterial infection
  • Certain drugs.

What are the clinical features of hidradenitis suppurativa?

Hidradenitis can affect single or multiple areas in the armpits, neck, submammary area, and inner thighs. Anogenital involvement most commonly affects the groin, mons pubis, vulva (in females), sides of the scrotum (in males), perineum, buttocks and perianal folds.

Signs include:

Many patients with hidradenitis suppurativa also suffer from other skin disorders, including acne, hirsutism and psoriasis.

The severity and extent of hidradenitis suppurativa are recorded at assessment and when determining the impact of a treatment. The Hurley system describes three distinct clinical stages:

  1. Solitary or multiple, isolated abscess formation without scarring or sinus tracts
  2. Recurrent abscesses, single or multiple widely separated lesions, with sinus tract formation
  3. Diffuse or broad involvement, with multiple interconnected sinus tracts and abscesses.

Read more about the assessment of the severity of hidradenitis suppurativa.

Severe hidradenitis (Hurley Stage 3) has been associated with:

  • Male sex
  • Axillary and perianal involvement
  • Obesity
  • Smoking
  • Higher risk of stroke, coronary artery disease, heart failure, and peripheral artery disease
  • Disease duration.

What is the treatment for hidradenitis suppurativa?

General measures

  • Weight loss; follow an anti-inflammatory, low-sugar, low-grain, low-dairy diet (mainly plants)
  • Smoking cessation: this can lead to improvement within a few months
  • Loose fitting clothing
  • Daily unfragranced antiperspirants
  • If prone to secondary infection, wash with antiseptics or take bleach baths
  • Apply hydrogen peroxide solution or medical grade honey to reduce malodour
  • Use peeling agents such as resorcinol 15% cream to de-roof nodules
  • Apply simple dressings to draining sinuses
  • Analgesics, such as paracetamol (acetaminophen), for pain control
  • Seek help to manage anxiety and depression.

Medical management of hidradenitis suppurativa

Medical management of hidradenitis suppurativa is difficult. Treatment is required long term. Effective options are listed below.



  • Long-term oral contraceptive pill; antiandrogenic progesterones drospirenone or cyproterone acetate may be more effective than standard combined pills. These are more suitable than progesterone-only tablets or devices.
  • Spironolactone and finasteride
  • Response takes six months or longer.

Immunomodulatory treatments for severe disease

Other medical treatments

  • Metformin in patients with insulin resistance
  • Acitretin (unsuitable for females of childbearing potential)
  • Isotretinoin — effective for acne but appears unhelpful for most cases of hidradenitis
  • Colchicine
  • Medical management of anxiety and depression

Surgical management of hidradenitis suppurativa

  • Incision and drainage of acute abscesses
  • Curettage and deroofing of nodules, abscesses and sinuses
  • Laser ablation of nodules, abscesses and sinuses
  • Wide local excision of persistent nodules
  • Radical excisional surgery of entire affected area
  • Nd: YAG laser hair removal

See smartphone apps to check your skin.
[Sponsored content]


Related information



  • van der Zee HH, Boer J, Prens EP, Jemec GB. The effect of combined treatment with oral clindamycin and oral rifampicin in patients with hidradenitis suppurativa. Dermatology 2009; 219: 143–7. DOI: 10.1159/000228337. PubMed
  • Slade DEM, Powell BW, Mortimer PS. Hidradenitis suppurativa: pathogenesis and management. Br J Plast Surg 2003; 56: 451–61. DOI: 10.1016/s0007-1226(03)00177-2. PubMed
  • Rook A, Wilkinson DS, Ebling FJB, Champion RH, Burton JL (eds). Textbook of dermatology, 4th edn. Blackwell Scientific Publications.
  • Buimer MG, Wobbes T, Klinkenbijl THG. Hidradenitis suppurativa. Br J Surg 2009; 96: 350–60. DOI: 10.1002/bjs.6569. PubMed
  • Schrader AM, Deckers IE, van der Zee HH, Boer J, Prens EP. Hidradenitis suppurativa: a retrospective study of 846 Dutch patients to identify factors associated with disease severity. J Am Acad Dermatol 2014; 71: 460–7. DOI: 10.1016/j.jaad.2014.04.001. PubMed 
  • Zouboulis CC, Desai N, Emtestam L, et al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol 2015; 29: 619–44. DOI: 10.1111/jdv.12966. PubMed
  • Faivre C, Villani AP, Aubin F, et al; French Society of Dermatology and Club Rheumatisms and Inflammation. Hidradenitis suppurativa (HS): An unrecognized paradoxical effect of biologic agents (BA) used in chronic inflammatory diseases. J Am Acad Dermatol 2016; 74: 1153–9. DOI: 10.1016/j.jaad.2016.01.018. PubMed
  • Kohorst JJ, Baum CL, Otley CC, et al. Surgical management of hidradenitis suppurativa: Outcomes of 590 consecutive patients. Dermatol Surg 2016; 42: 1030–40. doi: 10.1097/DSS.0000000000000806. PubMed
  • Houriet C, Seyed Jafari SM, Thomi R, Schlapbach C, Borradori L, Yawalkar N, Hunger RE. Canakinumab for severe hidradenitis suppurativa preliminary experience in 2 cases. JAMA Dermatol 2017; 153: 1195–7. DOI: 10.1001/jamadermatol.2017.2392. Journal
  • Ring HC, Thorsen J, Saunte DM, et al. The Follicular Skin Microbiome in Patients With Hidradenitis Suppurativa and Healthy Controls. JAMA Dermatol 2017; 153: 897–905. DOI: 10.1001/jamadermatol.2017.0904. Journal.
  • Acne Inversa Linked to Cardiovascular Disease. Fran Lowry. Medscape. March 5th, 2019. Available at: Accessed 9 March 2019.
  • Ghias MH, Johnston AD, Kutner AJ, Micheletti RG, Hosgood HD, Cohen SR. High-dose, high-frequency infliximab: A novel treatment paradigm for hidradenitis suppurativa. J Am Acad Dermatol. 2020 May;82(5):1094-1101. doi: 10.1016/j.jaad.2019.09.071. Epub 2019 Oct 4. PubMed

On DermNet NZ

Other websites

Books about skin diseases