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Hidradenitis suppurativa: Treatment

John R Ingram, MD, PhD
Section Editors
Robert P Dellavalle, MD, PhD, MSPH
Mark V Dahl, MD
Deputy Editor
Abena O Ofori, MD


Hidradenitis suppurativa (HS) is a chronic, painful, follicular occlusive disease that affects the folliculopilosebaceous unit, mainly but not exclusively in intertriginous axillary, groin, perianal, perineal, genital, and inframammary skin. The clinical course is highly variable, ranging from relatively mild cases characterized by the recurrent appearance of papules, pustules, and a few inflammatory nodules to severe cases demonstrating deep fluctuant abscesses, draining sinuses, and severe rope-like scars (picture 1A).

The management and prognosis of HS will be reviewed here. Information on the pathogenesis, clinical features, and diagnosis of HS and a detailed discussion of the surgical techniques used in the treatment of HS are provided separately. (See "Hidradenitis suppurativa: Pathogenesis, clinical features, and diagnosis" and "Surgical management of hidradenitis suppurativa".)


The pain, odor, drainage, and disfigurement caused by HS profoundly affects quality of life [1]. Patients often experience feelings of sadness or depression related to the disease, and feelings of shame may contribute to self-imposed social isolation [2-4]. Diagnostic delay, which averages seven years, combined with the significant physical and emotional toll of HS, may lead to patient frustration with medical care [5].

Treatment goals — Untreated, HS can remain active for many years after onset, which is typically in early adulthood. Interventions for HS target one or more of three major goals:

To reduce the frequency of new lesions, minimizing pain and suppuration

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Literature review current through: Nov 2017. | This topic last updated: Oct 30, 2017.
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  1. Wolkenstein P, Loundou A, Barrau K, et al. Quality of life impairment in hidradenitis suppurativa: a study of 61 cases. J Am Acad Dermatol 2007; 56:621.
  2. Matusiak L, Bieniek A, Szepietowski JC. Psychophysical aspects of hidradenitis suppurativa. Acta Derm Venereol 2010; 90:264.
  3. Esmann S, Jemec GB. Psychosocial impact of hidradenitis suppurativa: a qualitative study. Acta Derm Venereol 2011; 91:328.
  4. Kurek A, Peters EM, Chanwangpong A, et al. Profound disturbances of sexual health in patients with acne inversa. J Am Acad Dermatol 2012; 67:422.
  5. Saunte DM, Boer J, Stratigos A, et al. Diagnostic delay in hidradenitis suppurativa is a global problem. Br J Dermatol 2015; 173:1546.
  6. Hurley HJ. Axillary hyperhidrosis, apocrine bromhidrosis, hidradenitis suppurativa, and familial benign pemphigus: surgical approach. In: Dermatologic surgery, Roenigk RK, Roenigk HH (Eds), Dekker, New York 1989. p.729.
  7. Sartorius K, Lapins J, Emtestam L, Jemec GB. Suggestions for uniform outcome variables when reporting treatment effects in hidradenitis suppurativa. Br J Dermatol 2003; 149:211.
  8. Sartorius K, Emtestam L, Jemec GB, Lapins J. Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesity. Br J Dermatol 2009; 161:831.
  9. Sartorius K, Killasli H, Heilborn J, et al. Interobserver variability of clinical scores in hidradenitis suppurativa is low. Br J Dermatol 2010; 162:1261.
  10. Kimball AB, Jemec GB, Yang M, et al. Assessing the validity, responsiveness and meaningfulness of the Hidradenitis Suppurativa Clinical Response (HiSCR) as the clinical endpoint for hidradenitis suppurativa treatment. Br J Dermatol 2014; 171:1434.
  11. Thorlacius L, Ingram JR, Garg A, et al. Protocol for the development of a core domain set for hidradenitis suppurativa trial outcomes. BMJ Open 2017; 7:e014733.
  12. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)--a simple practical measure for routine clinical use. Clin Exp Dermatol 1994; 19:210.
  13. Chren MM, Lasek RJ, Sahay AP, Sands LP. Measurement properties of Skindex-16: a brief quality-of-life measure for patients with skin diseases. J Cutan Med Surg 2001; 5:105.
  14. Onderdijk AJ, van der Zee HH, Esmann S, et al. Depression in patients with hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2013; 27:473.
  15. Jemec GB. Clinical practice. Hidradenitis suppurativa. N Engl J Med 2012; 366:158.
  16. Revuz JE, Canoui-Poitrine F, Wolkenstein P, et al. Prevalence and factors associated with hidradenitis suppurativa: results from two case-control studies. J Am Acad Dermatol 2008; 59:596.
  17. Canoui-Poitrine F, Revuz JE, Wolkenstein P, et al. Clinical characteristics of a series of 302 French patients with hidradenitis suppurativa, with an analysis of factors associated with disease severity. J Am Acad Dermatol 2009; 61:51.
  18. König A, Lehmann C, Rompel R, Happle R. Cigarette smoking as a triggering factor of hidradenitis suppurativa. Dermatology 1999; 198:261.
  19. Simonart T. Hidradenitis suppurativa and smoking. J Am Acad Dermatol 2010; 62:149.
  20. Egeberg A, Gislason GH, Hansen PR. Risk of Major Adverse Cardiovascular Events and All-Cause Mortality in Patients With Hidradenitis Suppurativa. JAMA Dermatol 2016; 152:429.
  21. Arun B, Loffeld A. Long-standing hidradenitis suppurativa treated effectively with metformin. Clin Exp Dermatol 2009; 34:920.
  22. Verdolini R, Clayton N, Smith A, et al. Metformin for the treatment of hidradenitis suppurativa: a little help along the way. J Eur Acad Dermatol Venereol 2013; 27:1101.
  23. Kromann CB, Ibler KS, Kristiansen VB, Jemec GB. The influence of body weight on the prevalence and severity of hidradenitis suppurativa. Acta Derm Venereol 2014; 94:553.
  24. Miller IM, McAndrew RJ, Hamzavi I. Prevalence, Risk Factors, and Comorbidities of Hidradenitis Suppurativa. Dermatol Clin 2016; 34:7.
  25. Shlyankevich J, Chen AJ, Kim GE, Kimball AB. Hidradenitis suppurativa is a systemic disease with substantial comorbidity burden: a chart-verified case-control analysis. J Am Acad Dermatol 2014; 71:1144.
  26. Dauden E, Lazaro P, Aguilar MD, et al. Recommendations for the management of comorbidity in hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2017.
  27. Clemmensen OJ. Topical treatment of hidradenitis suppurativa with clindamycin. Int J Dermatol 1983; 22:325.
  28. Riis PT, Boer J, Prens EP, et al. Intralesional triamcinolone for flares of hidradenitis suppurativa (HS): A case series. J Am Acad Dermatol 2016; 75:1151.
  29. Boer J, Jemec GB. Resorcinol peels as a possible self-treatment of painful nodules in hidradenitis suppurativa. Clin Exp Dermatol 2010; 35:36.
  30. von der Werth JM, Williams HC. The natural history of hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2000; 14:389.
  31. 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.
  32. Nazary M, van der Zee HH, Prens EP, et al. Pathogenesis and pharmacotherapy of Hidradenitis suppurativa. Eur J Pharmacol 2011; 672:1.
  33. Jemec GB, Wendelboe P. Topical clindamycin versus systemic tetracycline in the treatment of hidradenitis suppurativa. J Am Acad Dermatol 1998; 39:971.
  34. Gener G, Canoui-Poitrine F, Revuz JE, et al. Combination therapy with clindamycin and rifampicin for hidradenitis suppurativa: a series of 116 consecutive patients. Dermatology 2009; 219:148.
  35. 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.
  36. Mendonça CO, Griffiths CE. Clindamycin and rifampicin combination therapy for hidradenitis suppurativa. Br J Dermatol 2006; 154:977.
  37. Dessinioti C, Zisimou C, Tzanetakou V, et al. Oral clindamycin and rifampicin combination therapy for hidradenitis suppurativa: a prospective study and 1-year follow-up. Clin Exp Dermatol 2016; 41:852.
  38. Yazdanyar S, Boer J, Ingvarsson G, et al. Dapsone therapy for hidradenitis suppurativa: a series of 24 patients. Dermatology 2011; 222:342.
  39. Kaur MR, Lewis HM. Hidradenitis suppurativa treated with dapsone: A case series of five patients. J Dermatolog Treat 2006; 17:211.
  40. Lorenz M, Wozel G, Schmitt J. Hypersensitivity reactions to dapsone: a systematic review. Acta Derm Venereol 2012; 92:194.
  41. Join-Lambert O, Coignard H, Jais JP, et al. Efficacy of rifampin-moxifloxacin-metronidazole combination therapy in hidradenitis suppurativa. Dermatology 2011; 222:49.
  42. Danby FW, Margesson LJ. Hidradenitis suppurativa. Dermatol Clin 2010; 28:779.
  43. Matusiak L, Bieniek A, Szepietowski JC. Acitretin treatment for hidradenitis suppurativa: a prospective series of 17 patients. Br J Dermatol 2014; 171:170.
  44. Boer J, Nazary M. Long-term results of acitretin therapy for hidradenitis suppurativa. Is acne inversa also a misnomer? Br J Dermatol 2011; 164:170.
  45. Soria A, Canoui-Poitrine F, Wolkenstein P, et al. Absence of efficacy of oral isotretinoin in hidradenitis suppurativa: a retrospective study based on patients' outcome assessment. Dermatology 2009; 218:134.
  46. Boer J, van Gemert MJ. Long-term results of isotretinoin in the treatment of 68 patients with hidradenitis suppurativa. J Am Acad Dermatol 1999; 40:73.
  47. Verdolini R, Simonacci F, Menon S, et al. Alitretinoin: a useful agent in the treatment of hidradenitis suppurativa, especially in women of child-bearing age. G Ital Dermatol Venereol 2015; 150:155.
  48. Danby FW. Night blindness, vitamin A deficiency, and isotretinoin psychotoxicity. Dermatol Online J 2003; 9:30.
  49. Mortimer PS, Dawber RP, Gales MA, Moore RA. A double-blind controlled cross-over trial of cyproterone acetate in females with hidradenitis suppurativa. Br J Dermatol 1986; 115:263.
  50. Kraft JN, Searles GE. Hidradenitis suppurativa in 64 female patients: retrospective study comparing oral antibiotics and antiandrogen therapy. J Cutan Med Surg 2007; 11:125.
  51. Lee A, Fischer G. A case series of 20 women with hidradenitis suppurativa treated with spironolactone. Australas J Dermatol 2015; 56:192.
  52. Joseph MA, Jayaseelan E, Ganapathi B, Stephen J. Hidradenitis suppurativa treated with finasteride. J Dermatolog Treat 2005; 16:75.
  53. Farrell AM, Randall VA, Vafaee T, Dawber RP. Finasteride as a therapy for hidradenitis suppurativa. Br J Dermatol 1999; 141:1138.
  54. Mota F, Machado S, Selores M. Hidradenitis Suppurativa in Children Treated with Finasteride-A Case Series. Pediatr Dermatol 2017; 34:578.
  55. Ellis LZ. Hidradenitis suppurativa: surgical and other management techniques. Dermatol Surg 2012; 38:517.
  56. Shuja F, Chan CS, Rosen T. Biologic drugs for the treatment of hidradenitis suppurativa: an evidence-based review. Dermatol Clin 2010; 28:511.
  57. Rambhatla PV, Lim HW, Hamzavi I. A systematic review of treatments for hidradenitis suppurativa. Arch Dermatol 2012; 148:439.
  58. Blok JL, van Hattem S, Jonkman MF, Horváth B. Systemic therapy with immunosuppressive agents and retinoids in hidradenitis suppurativa: a systematic review. Br J Dermatol 2013; 168:243.
  59. Ingram JR, Woo PN, Chua SL, et al. Interventions for hidradenitis suppurativa. Cochrane Database Syst Rev 2015; :CD010081.
  60. Kimball AB, Okun MM, Williams DA, et al. Two Phase 3 Trials of Adalimumab for Hidradenitis Suppurativa. N Engl J Med 2016; 375:422.
  61. Kimball AB, Kerdel F, Adams D, et al. Adalimumab for the treatment of moderate to severe Hidradenitis suppurativa: a parallel randomized trial. Ann Intern Med 2012; 157:846.
  62. Grant A, Gonzalez T, Montgomery MO, et al. Infliximab therapy for patients with moderate to severe hidradenitis suppurativa: a randomized, double-blind, placebo-controlled crossover trial. J Am Acad Dermatol 2010; 62:205.
  63. Mekkes JR, Bos JD. Long-term efficacy of a single course of infliximab in hidradenitis suppurativa. Br J Dermatol 2008; 158:370.
  64. Blanco R, Martínez-Taboada VM, Villa I, et al. Long-term successful adalimumab therapy in severe hidradenitis suppurativa. Arch Dermatol 2009; 145:580.
  65. Miller I, Lynggaard CD, Lophaven S, et al. A double-blind placebo-controlled randomized trial of adalimumab in the treatment of hidradenitis suppurativa. Br J Dermatol 2011; 165:391.
  66. Jacob SE, Kerdel SA. Biologics for hidradenitis suppurativa (Verneuil's disease in the Era of biologics). In: Hidradenitis suppurativa, 1st ed, Jemec GBE, Revuz J, Leyden J (Eds), Springer, Berlin 2006. p.145.
  67. Harvin G, Kasarala G. Two Cases of Paradoxical Hidradenitis Suppurativa while on Adalimumab. Case Rep Gastroenterol 2016; 10:88.
  68. Faivre C, Villani AP, Aubin F, et al. Hidradenitis suppurativa (HS): An unrecognized paradoxical effect of biologic agents (BA) used in chronic inflammatory diseases. J Am Acad Dermatol 2016; 74:1153.
  69. Anderson MD, Zauli S, Bettoli V, et al. Cyclosporine treatment of severe Hidradenitis suppurativa--A case series. J Dermatolog Treat 2016; 27:247.
  70. Gupta AK, Ellis CN, Nickoloff BJ, et al. Oral cyclosporine in the treatment of inflammatory and noninflammatory dermatoses. A clinical and immunopathologic analysis. Arch Dermatol 1990; 126:339.
  71. Buckley DA, Rogers S. Cyclosporin-responsive hidradenitis suppurativa. J R Soc Med 1995; 88:289P.
  72. Rose RF, Goodfield MJ, Clark SM. Treatment of recalcitrant hidradenitis suppurativa with oral ciclosporin. Clin Exp Dermatol 2006; 31:154.
  73. Sharon VR, Garcia MS, Bagheri S, et al. Management of recalcitrant hidradenitis suppurativa with ustekinumab. Acta Derm Venereol 2012; 92:320.
  74. Gulliver WP, Jemec GB, Baker KA. Experience with ustekinumab for the treatment of moderate to severe hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2012; 26:911.
  75. Blok JL, Li K, Brodmerkel C, et al. Ustekinumab in hidradenitis suppurativa: clinical results and a search for potential biomarkers in serum. Br J Dermatol 2016; 174:839.
  76. Tzanetakou V, Kanni T, Giatrakou S, et al. Safety and Efficacy of Anakinra in Severe Hidradenitis Suppurativa: A Randomized Clinical Trial. JAMA Dermatol 2016; 152:52.
  77. Zarchi K, Dufour DN, Jemec GB. Successful treatment of severe hidradenitis suppurativa with anakinra. JAMA Dermatol 2013; 149:1192.
  78. Leslie KS, Tripathi SV, Nguyen TV, et al. An open-label study of anakinra for the treatment of moderate to severe hidradenitis suppurativa. J Am Acad Dermatol 2014; 70:243.
  79. van der Zee HH, Prens EP. Failure of anti-interleukin-1 therapy in severe hidradenitis suppurativa: a case report. Dermatology 2013; 226:97.
  80. Menis D, Maroñas-Jiménez L, Delgado-Marquez AM, et al. Two cases of severe hidradenitis suppurativa with failure of anakinra therapy. Br J Dermatol 2015; 172:810.
  81. Russo V, Alikhan A. Failure of Anakinra in a Case of Severe Hidradenitis Suppurativa. J Drugs Dermatol 2016; 15:772.
  82. Houriet C, Seyed Jafari SM, Thomi R, et al. Canakinumab for Severe Hidradenitis Suppurativa: Preliminary Experience in 2 Cases. JAMA Dermatol 2017; 153:1195.
  83. Ducroux E, Ocampo MA, Kanitakis J, et al. Hidradenitis suppurativa after renal transplantation: complete remission after switching from oral cyclosporine to oral tacrolimus. J Am Acad Dermatol 2014; 71:e210.
  84. Brocard A, Knol AC, Khammari A, Dréno B. Hidradenitis suppurativa and zinc: a new therapeutic approach. A pilot study. Dermatology 2007; 214:325.
  85. Dréno B, Khammari A, Brocard A, et al. Hidradenitis suppurativa: the role of deficient cutaneous innate immunity. Arch Dermatol 2012; 148:182.
  86. Tierney E, Mahmoud BH, Hexsel C, et al. Randomized control trial for the treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet laser. Dermatol Surg 2009; 35:1188.
  87. Xu LY, Wright DR, Mahmoud BH, et al. Histopathologic study of hidradenitis suppurativa following long-pulsed 1064-nm Nd:YAG laser treatment. Arch Dermatol 2011; 147:21.
  88. Highton L, Chan WY, Khwaja N, Laitung JK. Treatment of hidradenitis suppurativa with intense pulsed light: a prospective study. Plast Reconstr Surg 2011; 128:459.
  89. Gold M, Bridges TM, Bradshaw VL, Boring M. ALA-PDT and blue light therapy for hidradenitis suppurativa. J Drugs Dermatol 2004; 3:S32.
  90. Strauss RM, Pollock B, Stables GI, et al. Photodynamic therapy using aminolaevulinic acid does not lead to clinical improvement in hidradenitis suppurativa. Br J Dermatol 2005; 152:803.
  91. Guglielmetti A, Bedoya J, Acuna M, et al. Successful aminolevulinic acid photodynamic therapy for recalcitrant severe hidradenitis suppurativa. Photodermatol Photoimmunol Photomed 2010; 26:110.
  92. Schweiger ES, Riddle CC, Aires DJ. Treatment of hidradenitis suppurativa by photodynamic therapy with aminolevulinic acid: preliminary results. J Drugs Dermatol 2011; 10:381.
  93. Fadel MA, Tawfik AA. New topical photodynamic therapy for treatment of hidradenitis suppurativa using methylene blue niosomal gel: a single-blind, randomized, comparative study. Clin Exp Dermatol 2015; 40:116.
  94. Rodríguez-Prieto MÁ, Valladares-Narganes LM, González-Sixto B, Noguerol-Cal M. Efficacy of intralesional photodynamic therapy for the treatment of hidradenitis suppurativa. J Am Acad Dermatol 2013; 68:873.
  95. Agut-Busquet E, Romaní J, Gilaberte Y, et al. Photodynamic therapy with intralesional methylene blue and a 635 nm light-emitting diode lamp in hidradenitis suppurativa: a retrospective follow-up study in 7 patients and a review of the literature. Photochem Photobiol Sci 2016; 15:1020.
  96. Fröhlich D, Baaske D, Glatzel M. [Radiotherapy of hidradenitis suppurativa--still valid today?]. Strahlenther Onkol 2000; 176:286.
  97. Trombetta M, Werts ED, Parda D. The role of radiotherapy in the treatment of hidradenitis suppurativa: case report and review of the literature. Dermatol Online J 2010; 16:16.
  98. Deckers IE, van der Zee HH, Balak DM, Prens EP. Fumarates, a new treatment option for therapy-resistant hidradenitis suppurativa: a prospective open-label pilot study. Br J Dermatol 2015; 172:828.
  99. Guillet A, Brocard A, Bach Ngohou K, et al. Verneuil's disease, innate immunity and vitamin D: a pilot study. J Eur Acad Dermatol Venereol 2015; 29:1347.
  100. Feito-Rodríguez M, Sendagorta-Cudós E, Herranz-Pinto P, de Lucas-Laguna R. Prepubertal hidradenitis suppurativa successfully treated with botulinum toxin A. Dermatol Surg 2009; 35:1300.
  101. O'Reilly DJ, Pleat JM, Richards AM. Treatment of hidradenitis suppurativa with botulinum toxin A. Plast Reconstr Surg 2005; 116:1575.
  102. Pagliarello C, Fabrizi G, Feliciani C, Di Nuzzo S. Cryoinsufflation for Hurley stage II hidradenitis suppurativa: a useful treatment option when systemic therapies should be avoided. JAMA Dermatol 2014; 150:765.
  103. Jennings L, Nestor L, Molloy O, et al. The treatment of hidradenitis suppurativa with the glucagon-like peptide-1 agonist liraglutide. Br J Dermatol 2017; 177:858.
  104. Harrison BJ, Mudge M, Hughes LE. Recurrence after surgical treatment of hidradenitis suppurativa. Br Med J (Clin Res Ed) 1987; 294:487.
  105. Williams ST, Busby RC, DeMuth RJ, Nelson H. Perineal hidradenitis suppurativa: presentation of two unusual complications and a review. Ann Plast Surg 1991; 26:456.
  106. Grewal NS, Wan DC, Roostaeian J, Rubayi SR. Marjolin ulcer in hidradenitis suppurativa: case reports. Ann Plast Surg 2010; 64:315.
  107. Lavogiez C, Delaporte E, Darras-Vercambre S, et al. Clinicopathological study of 13 cases of squamous cell carcinoma complicating hidradenitis suppurativa. Dermatology 2010; 220:147.
  108. Makris GM, Poulakaki N, Papanota AM, et al. Vulvar, Perianal and Perineal Cancer After Hidradenitis Suppurativa: A Systematic Review and Pooled Analysis. Dermatol Surg 2017; 43:107.