Beneath the Surface of Hidradenitis Suppurativa

Some things are immediately recognized for what they are, like Mozart’s musical genius. Other things take a bit longer to properly identify: counterfeit money, spies, or even which remote control turns on the TV.

The skin condition hidradenitis suppurativa (HS) also falls into the latter category. As Dr. Michael Bernhardt states on the MedEvidence! Podcast, “The average person with hidradenitis starts with lesions, typically in their teens, and it'll go for eight to 10 years before that person's diagnosed.”^[1]

Hidradenitis comes from the Ancient Greek root words “hidros” meaning “sweat,” “aden” meaning “gland,” and “-itis,” indicating an inflammatory disease. Suppurativa is a medical Latin word meaning “producing pus.” Hidradenitis suppurativa is a chronic, inflammatory skin condition in which the sweat glands (and other parts of the hair unit) become inflamed and release pus, eventually resulting in social problems, pain, wounds, and scarring.^[1,2,3]

Hidradenitis suppurativa usually starts after puberty, peaking in the 20s and falling off by the 50s.^[4] Though HS is fairly rare, in the U.S. the condition disproportionately affects women and African Americans.^[1,4,5] Those with a family history of HS, those who smoke, and those who are overweight or obese are at higher risk.^[4] Symptoms of HS include fluid-filled, painful wounds that drain pus, emit an odor, and lead to scarring.^[2] Symptoms also tend to flare up for a little over a week with increased pain and pus drainage.^[4] Wounds tend to localize around creased areas of the skin including the armpits, under the breasts, and around the groin and anus.^[2,4]

The symptoms of hidradenitis suppurativa are as hard to miss as the genius behind Mozart’s most famous piece, Requiem in D minor. Unfortunately, HS isn’t the only condition that can create skin wounds, leading to common misdiagnosis.^[1,2,4] Clues that HS is the culprit include wounds in the skin’s creases that recur in the same areas for long periods of time and lead to tracks and scarring.^[1] Contrary to popular belief, HS is not caused by poor hygiene, infections, or the use of deodorant.^[3]

Hidradenitis suppurativa originates in the pilosebaceous unit located in the folds of our skin.^[3,4] This unit is where hair grows and contains a hair follicle and an oily sebaceous gland. With HS, inflammatory particles flow into the pilosebaceous unit, causing the sebaceous gland to atrophy and form a keratin plug, which blocks hair or oil from escaping.^[4] The trapped oil and other particles build up and eventually rupture, causing pus-filled nodules to form. These nodules trigger an inflammatory feedback loop, causing further inflammation on top of the initial inflammation, which spreads the problem to nearby units.^[4] Wounds can also spread under the skin, forming tracks; scars form as the body tries to limit damage.^[4]

Lifestyle modifications are the first line of defense against hidradenitis suppurativa. Wearing loose clothing and keeping skin clean can lessen pain, while smoking cessation and weight loss can lower the incidence of HS.^[2,3] Therapies include surgical removal, laser therapy, skin grafting, and topical creams.^[3,2,4] Traditional systemic treatments for HS have had a difficult time controlling the disease in the past. Antibiotics have been prescribed to attack bacteria that enter open wounds, but the wounds themselves are caused by inflammation, not bacteria.^[4] 

During hidradenitis suppurativa, the immune system struggles to differentiate between danger from healthy tissue. The inflammation pathway includes cells, cytokine signaling molecules, interleukin immune molecules, and other molecules in a complex composition.^{[1, 3,4]} It has taken scientists decades to identify and classify the key molecules at play in HS, and researchers have only recently been able to create disease-altering medications targeting the inflammation itself. New classes of medications, some of which are currently in clinical trials, target the underlying inflammation to stop the problem at the source.^[1,5,4] Identifying the molecules responsible for HS has been challenging, but it’s easy to recognize that solutions need to be found.

Creative Director Benton Lowey-Ball, BS, BFA
 

References:

^[1] Schramm, E. & Bernhardt, M. (11 June, 2025). Modern Medicine is Transforming Hidradenitis Suppurativa Treatment. On MedEvidence! Truth Behind the Data. [Podcast]. https://medevidence.com/modern-medicine-is-transforming-hidradenitis-suppurativa-treatment

^[2] Ballard, K., & Shuman, V. (2024). Hidradenitis suppurativa. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK534867/

^[3] Saunte, D. M. L., & Jemec, G. B. E. (2017). Hidradenitis suppurativa: advances in diagnosis and treatment. Jama, 318(20), 2019-2032. https://jamanetwork.com/journals/jama/article-abstract/2664466

^[4] Jemec, G. B. (2012). Hidradenitis suppurativa. New England Journal of Medicine, 366(2), 158-164. https://www.nejm.org/doi/full/10.1056/NEJMcp1014163