Hidradenitis suppurativa: the recurring boils that are not your fault
Last updated September 3, 2026.
Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition causing recurring painful boils, abscesses, and tunnels in the armpits, groin, under the breasts, and around the buttocks: the fold areas. It is not an infection, not poor hygiene, and not contagious: it is the hair follicles blocking and rupturing under an overactive immune response. It affects roughly 1 in 100 people, is often misdiagnosed for years as recurrent boils, and has real treatments at every severity.
What does it look and feel like?
Recurrent painful lumps in the same fold areas: deep, tender nodules that come to a head (or fail to), leak pus with an odor, heal slowly, and return. Over time: rope-like scarring, connected tunnels under the skin (sinus tracts), and blackheads in pairs. Flares track stress, sweating, friction, hormones (menstrual flares are classic), and weight gain. The unspoken burden is heavy: pain, odor, stained clothing, and embarrassment shrink social, intimate, and working lives, and depression rates in HS are genuinely elevated.
Why does it happen?
The mechanics: hair follicles in the fold areas block, dilate, and rupture, spilling contents that trigger fierce inflammation; the immune system then sustains it. It is not caused by deodorant, shaving, or cleanliness (though friction and irritation aggravate it). The associations: it runs in families (a third have a relative with it), it is more common in women, onset is typically in the twenties, and smoking and obesity are strongly linked as aggravators (quitting smoking genuinely improves the course). Hormones modulate it: it often eases after menopause and flares with cycles.
What is the treatment ladder?
- Daily-life measures: antiseptic washes, loose clothing, friction reduction, weight management, and stopping smoking: modest effects individually, real effects together.
- Topical and short-course antibiotics: clindamycin lotion for mild disease; oral tetracyclines for months for moderate disease; they work as anti-inflammatories here.
- Flare management: a steroid injection into a hot nodule, a short steroid course, or same-day drainage for a pointing abscess (drainage relieves but does not prevent).
- Hormonal and metabolic options: the pill or anti-androgens for hormonally driven flares; metformin when insulin resistance rides along.
- Severe disease: biologic injections (adalimumab and newer agents) transform many severe cases; retinoids help some; surgery (from deroofing tunnels to wide excision) clears stubborn zones. Dermatology referral is the gateway to all of this.
When is it an emergency?
HS flares are miserable but rarely dangerous. Seek same-day care for: an abscess with fever, spreading redness, or feeling systemically ill (cellulitis on top of HS needs antibiotics); severe uncontrolled pain; and any rapidly changing, bleeding, or fixed lump in scarred long-standing areas (a rare cancer association worth ruling out). The other emergency is quieter: HS with hopelessness, isolation, or thoughts of self-harm deserves the same urgency as any other severe symptom, and your GP can treat both halves. Pymander's escalation routing is built and tested specifically for this class of decision; see the safety architecture working paper.
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Common questions
Is HS caused by poor hygiene or deodorant?
No, and the myth does real harm: HS is an inflammatory disease of hair follicles, driven by immune dysregulation with genetic and hormonal components, and people with HS are often the most fastidious washers in any room. Deodorants and shaving do not cause it (friction and irritation can aggravate flares, which is different). It is not contagious and not an infection: the pus in HS lesions is inflammatory, and antibiotics help because they are anti-inflammatory, not because you are dirty. The hygiene myth delays diagnosis and deepens shame; the correct frame is a chronic inflammatory condition, like psoriasis or eczema, in a specific distribution.
Why did it take years to get diagnosed?
Because the early presentations hide in plain sight: a boil in the armpit or groin is treated as a one-off staph infection (lanced, antibiotics, gone), and only the recurrence pattern across years reveals the disease, often after many separate episodes, different doctors, and growing scarring. Average diagnostic delay in HS studies runs to many years, and it is one of the great missed-pattern diagnoses in primary care. The tell that short-circuits it: boils that recur in the same fold areas, both-sided, with paired blackheads and rope-like scars. Naming the pattern to your GP (or showing photos between flares) is what accelerates the referral.
Does losing weight or quitting smoking actually change the disease?
Genuinely yes for both, unusually for lifestyle advice: smoking is strongly associated with HS (most patients in classic series smoke) and quitting measurably improves flare frequency and treatment response; it is the highest-yield single change. Weight loss reduces friction, sweating, and the hormonal inflammation that feeds flares, and studies of bariatric surgery patients show HS improving or remitting after major weight loss in many. Neither is a cure, and lean non-smokers get HS too, but as disease modifiers they are real, and they compound: the daily-measures package (wash, clothing, weight, smoking) shifts the baseline the medications then work from.
What are biologics, and would I qualify?
Biologics are injections that block specific inflammation signals (adalimumab, the first approved for HS, targets TNF; newer agents targeting IL-17 have joined it), and they transform a substantial share of moderate-to-severe HS: fewer flares, healed tunnels, and restored lives in trial after trial. Qualification generally means moderate-to-severe disease (multiple recurring abscesses and tunnels) that has failed the oral-antibiotic and lifestyle layers, assessed by dermatology. They are long-term treatments with infection-screening beforehand and monitoring during. If your disease is disrupting work, intimacy, or sanity despite tablets, that is the conversation to force with the dermatologist, not to wait out.
Will the scars and tunnels ever go away?
The inflammation can be controlled; established scarring is permanent, which is why early aggressive treatment matters so much: every prevented flare is prevented scar. For existing damage, options exist: deroofing (surgically opening and scraping out tunnels so they heal flat) works well for fixed areas, wider excision clears the worst zones, and laser procedures help scarring and hair-bearing fold skin. The psychological scar load matters too, and it is treatable: HS-specialist dermatology clinics, pain management, and mental-health support together. The trajectory with modern treatment is disease control, not the slow accumulation people experienced a generation ago.
How do people cope with the emotional side of HS?
By treating it as part of the disease, because it is: HS carries one of the highest depression and anxiety burdens of any skin condition (pain, odor fear, intimacy avoidance, work absences, and years of dismissal compound), and naming that to a doctor is a clinical act, not a confession. Practical helps: patient organizations (HS-specific communities share flare kit and clothing strategies and the priceless relief of not being alone), absorbent dressings and dark layers for confidence during flares, honest scripts for partners and employers, and formal mental-health support when the mood load is heavy. The disease attacks quality of life by design; defending that quality is treatment, not indulgence.