Hidradenitis suppurativa (HS) can’t be permanently cured, but a combination of medical treatments, lifestyle changes, and procedures can significantly reduce flares and prevent the disease from progressing. The right approach depends on your current stage, ranging from mild abscesses to deep, interconnected tunnels under the skin. Most people benefit from layering several strategies together rather than relying on any single treatment.
What’s Actually Happening Under Your Skin
HS starts when hair follicles become clogged, similar to acne but deeper. The clogged follicle swells, eventually ruptures beneath the skin surface, and spills its contents (keratin, bacteria, debris) into the surrounding tissue. Your immune system responds aggressively, sending waves of inflammatory cells to the area. This creates the painful, swollen lumps you feel. Over time, repeated cycles of rupture and inflammation carve out sinus tracts, which are tunnel-like passages under the skin that connect lesions and drain fluid.
Understanding this cycle matters because effective treatment targets different points along it: preventing the initial clog, calming the immune overreaction, reducing bacterial load, or surgically removing damaged tissue that keeps the cycle going.
How Severity Shapes Your Treatment Options
Doctors classify HS into three Hurley stages, and your stage largely determines which treatments make sense:
- Stage I: Single or multiple abscesses without sinus tracts or scarring. This is the most treatable stage.
- Stage II: Recurrent abscesses with sinus tracts and scarring, either as a single area or multiple separated lesions.
- Stage III: Widespread involvement with multiple interconnected sinus tracts and abscesses across an entire area, such as both armpits or the full groin.
The earlier you intervene, the better. Stage I responds well to antibiotics, lifestyle changes, and topical care. Stage III often requires biologics or surgery. If your current approach isn’t working, pushing for escalation sooner rather than later can prevent irreversible scarring.
Antibiotics for Active Flares and Prevention
Oral antibiotics are typically the first medical treatment for HS, and they work both by reducing bacteria and by calming inflammation directly. Doxycycline, taken twice daily for three to six months, is a common starting point. Doctors generally wait at least three months before deciding whether it’s working.
If doxycycline doesn’t help enough, a combination of clindamycin and rifampin taken together for 12 weeks is a second-line option. This pairing can be more effective for moderate disease, though rifampin interacts with many other medications (including birth control pills), so you’ll need to discuss that with your prescriber.
Biologic Medications for Moderate to Severe HS
Three biologic medications are now FDA-approved specifically for HS. Adalimumab was approved in 2015 and remained the only option for nearly a decade. Secukinumab followed in 2023, and bimekizumab was approved about a year later. All three are injectable medications that work by blocking specific immune signals driving the chronic inflammation in HS.
Before adalimumab’s approval, people with HS essentially had only antibiotics and surgery. Biologics represented a major shift because they target the underlying immune dysfunction rather than just managing symptoms. They don’t work for everyone, and response can take several months, but for moderate to severe disease they offer the best chance of sustained improvement without surgery. Your body weight can influence how well biologics work. Research from the PIONEER trials found that even a modest difference in BMI (roughly a 4% change in body weight) fell within the range considered clinically significant for treatment response.
Dietary Changes That Reduce Flares
Diet isn’t a cure for HS, but certain foods have a measurable connection to flares. In a survey of over 700 HS patients, the most commonly reported trigger foods were sweets (68%), bread and pasta (51%), dairy products (51%), and high-fat foods (42%).
The proposed mechanism involves insulin and a growth factor called IGF-1. Simple carbohydrates and dairy breakdown products (casein and whey) increase insulin production, which downstream promotes the kind of skin cell overgrowth that clogs hair follicles in the first place.
Brewer’s yeast deserves special attention. In one study, 70% of HS patients following a yeast-free diet reported improvement in symptoms, and 87% of those who resumed eating yeast products saw lesions return within a week. Brewer’s yeast is found in beer, some breads, and certain nutritional supplements. This connection appears strongest in people who have a specific immune sensitivity to yeast, but given how striking the results are, a trial elimination may be worth trying.
Weight Loss and Its Limits
Obesity is one of the strongest modifiable risk factors for HS severity. Excess weight increases skin-on-skin friction in the areas most prone to HS (groin, armpits, under the breasts), traps heat and moisture, and amplifies systemic inflammation. Research suggests that weight loss produces the best results for people with Stage I or II disease. By Stage III, the structural damage to the skin is often too advanced for weight loss alone to reverse, though it can still improve comfort and reduce new flare frequency.
There’s no specific number of pounds that guarantees improvement. The evidence points to even small reductions being meaningful. A 4% drop in body weight (about 8 pounds for someone weighing 200) is considered clinically significant in terms of treatment response.
Daily Skin Care to Lower Bacterial Load
HS-prone skin carries a heavier bacterial burden than unaffected skin, and keeping that load down can reduce the frequency and intensity of flares. Washing affected areas in the morning with a body wash containing chlorhexidine (the active ingredient in Hibiclens) or benzoyl peroxide helps disinfect the skin without being harsh enough to cause irritation. These products work as a preventive measure, not a treatment for active abscesses.
Avoid scrubbing affected areas aggressively, shaving over active lesions, or using heavily fragranced products in the folds where HS tends to appear. Loose, breathable clothing reduces friction. Some people find that applying a thin layer of zinc oxide or an anti-chafing balm to high-friction areas between flares helps prevent new lesions from forming.
Laser Treatment for Long-Term Reduction
Laser therapy using a 1064 nm Nd:YAG laser has shown strong results for HS, particularly in Stages I and II. The laser works by destroying hair follicles and inflammatory tissue through targeted heat, reducing the number of follicles available to become clogged in the first place.
Most treatment protocols involve four sessions spaced two to four weeks apart. In one controlled study, patients who completed four monthly sessions saw an average 73% improvement in disease severity on treated areas, compared to 23% on untreated control areas. Another study reported a 65% overall reduction in severity after three months of treatment. Results aren’t guaranteed for everyone: some patients experience complete resolution while others show only partial improvement. The treatment is generally well tolerated, and unlike surgery, it preserves the surrounding healthy tissue.
Surgical Options When Other Treatments Fail
Surgery becomes necessary when sinus tracts, scarring, or tunneling has developed to the point where medications can’t reach or resolve the damage. The two most common approaches are deroofing and wide excision, and they differ significantly in scope, recovery, and recurrence.
Deroofing
Deroofing is a minimally invasive procedure where the roof of a sinus tract is removed, exposing the base and allowing it to heal from the bottom up. It’s best suited for Stage I or II disease with isolated sinus tracts. Average healing time is about 14 days for a typical 3 cm lesion. In one study of 88 deroofed lesions, 83% showed no recurrence after a median follow-up of nearly three years. The overall recurrence rate across studies is around 27%. It provides immediate pain relief but doesn’t remove the deeper diseased tissue.
Wide Excision
Wide excision removes the lesion plus a margin of surrounding tissue, including subcutaneous fat and a 1 to 2 cm border of skin that appears unaffected. It’s the most aggressive option and is typically reserved for Stage II or III disease. Recurrence rates are the lowest of any surgical approach, around 13%. The trade-off is a much longer recovery: 6 to 12 weeks when the wound is left open to heal on its own, or about 3 weeks with primary closure (stitching the wound shut). Full recovery of range of motion takes 4 to 10 weeks depending on the location and size of the excision. Complications can include wound reopening, secondary infections, and contractures that limit movement.
Hormonal Therapy for Women
Spironolactone, a medication that blocks androgen hormones, is sometimes used off-label for HS in women. Androgens contribute to the follicular clogging that initiates HS, so blocking them can theoretically reduce flares. The typical dose is 50 to 100 mg daily.
The evidence, however, is modest. In a retrospective study of 157 women, only 20% improved on spironolactone. Response was better for those with Stage I disease. Patients with Stage III were 85% less likely to improve compared to those with milder disease. Spironolactone may be worth trying as an add-on therapy for women with early-stage HS, but it shouldn’t be relied on as a primary treatment.
Building a Layered Treatment Plan
The most effective approach to HS almost always combines multiple strategies. A realistic plan might look like daily antiseptic washes, dietary modifications to reduce known triggers, an oral antibiotic course during active flares, and a biologic medication for ongoing suppression in moderate to severe cases. Laser therapy can be layered in to reduce the follicle count in problem areas. Surgery addresses the structural damage that medications can’t undo.
HS tends to progress if left undertreated, so the goal isn’t just managing today’s flare but preventing the tunneling and scarring that make future flares harder to control. If your current regimen isn’t keeping flares at bay, escalating to the next tier of treatment early, before permanent tissue damage sets in, consistently produces better long-term outcomes.