What it is
Hidradenitis suppurativa, often shortened to HS, begins when hair follicles in areas rich in sweat glands become blocked and inflamed. It most often affects the armpits, groin, buttocks, under the breasts and the inner thighs. Early on it causes tender lumps that come and go. Over time the lumps can become abscesses that drain, and tunnels called sinus tracts can form under the skin, leaving rope like scars.
It is not an infection and it is not caused by poor hygiene. It usually starts after puberty, is more common in women, and is linked with smoking, higher body weight, inflammatory bowel disease and a family history of the condition. The pain, drainage and odour have a serious effect on work, relationships and mental health, and this is taken seriously as part of care.
Staging
Severity is commonly described using the Hurley system, which guides treatment.
- Hurley stage I: single or several separate nodules or abscesses without tunnels or scarring
- Hurley stage II: recurrent abscesses with some tunnels and scarring, separated by normal skin
- Hurley stage III: widespread involvement with many connected tunnels and abscesses across an area
Your dermatologist also records how many lesions are active, how much pain and drainage there is and how often flares occur, so that response to treatment can be measured over time.
Why early referral matters
Tunnels and scarring do not reverse with medicine once they have formed. Treatment started at stage I or early stage II can control inflammation before permanent damage occurs, which is why patients with recurrent boils in the folds should be assessed rather than treated with repeated short courses of antibiotics or drainage alone.
Assessment at DermCare
The first visit includes a full history, examination of all affected areas with staging, and a review of what has been tried. Swabs, blood tests or imaging are arranged where they will change management. We also ask about smoking, weight, joint symptoms and bowel symptoms, and about mood and the effect on daily life.
Treatment options
General measures
Stopping smoking and, where relevant, weight reduction both improve the course of the disease. Loose clothing, gentle antiseptic washes and avoiding shaving of affected areas reduce irritation. Pain management is addressed directly.
Topical and oral antibiotics
Topical antibiotic solutions are used for mild disease. For more active disease, oral antibiotics of the tetracycline class, or a combination course of two antibiotics over several months, are prescribed for their anti-inflammatory effect rather than to treat an infection.
Hormonal and other systemic therapy
In women whose flares follow the menstrual cycle, hormonal therapy including anti-androgen medicines may help. Oral retinoids and other immunomodulating medicines are considered in selected cases. Intralesional corticosteroid injection can settle an individual painful nodule quickly.
Biologic therapy
For moderate to severe disease, injectable biologic therapies that block specific inflammatory signals are approved in Canada for hidradenitis suppurativa and can reduce the number of abscesses and nodules substantially. Treatment is long term and requires baseline screening and periodic monitoring. Details on systemic and biologic therapy.
Procedures and surgery
Incision and drainage relieves pressure in an acute abscess but does not prevent recurrence. Procedures that remove the roof of a tunnel, laser hair removal in affected areas and wider surgical excision of chronically involved skin each have a role, usually alongside medical therapy. Which procedures are performed on site at DermCare, and which are referred onward to surgical colleagues, is being confirmed.
Clinical study now recruiting
DermCare is a site for a Phase 2 study of an investigational treatment for hidradenitis suppurativa in adolescents aged 12 to under 18 (ClinicalTrials.gov NCT07213973, sponsor Incyte). Participation is voluntary, does not affect access to standard care, and is discussed with the young person and their parent or guardian. Referring physicians and families can ask about eligibility at research@dermcare.ca or read about current studies.
For referring physicians
Please describe the sites involved, the duration, how often flares occur, any drainage or tunnels, and treatments tried including antibiotic courses and their length. Note smoking status, body mass index where available and any inflammatory bowel disease. Adolescents with hidradenitis suppurativa may be eligible for the current study and are welcome to be referred for assessment. How to refer.