Hidradenitis Suppurativa: A Patient-Friendly Guide to Causes, Treatment & What Really Helps
By Dr. Hetav K Pandya
Almost every week, someone walks into my clinic with a story that goes like this: "Doctor, I keep getting these painful boils in my armpits and groin. I've been to three doctors, taken antibiotics five times, cut them open twice, and they still come back in the same place." By the time they reach me, they are exhausted, embarrassed, and often convinced it must be something they are doing wrong.
Let me say this first, clearly — you are not doing anything wrong. What you have is almost certainly not "recurrent boils". It is a condition called hidradenitis suppurativa (HS), and it is very different from a normal skin infection. Once you understand what is really going on, the whole picture changes.
So what is hidradenitis suppurativa, actually?
HS is a long-term inflammatory condition of the skin. It has nothing to do with hygiene, nothing to do with any infection you may have caught, and nothing to do with something you ate. The problem starts deep inside the hair follicles and the sweat gland area — the follicle gets blocked, bursts under the skin, and the immune system reacts far more aggressively than it should. That is what causes the pain, the pus, and the lumps.
It shows up in very specific places — the armpits, the groin, the inner thighs, under the breasts, sometimes the buttocks. Anywhere skin rubs against skin. Over years, if it keeps flaring, the body starts forming tunnels under the skin (we call them sinus tracts) and thick rope-like scars.
Two things I want you to remember: HS is not contagious. You cannot give it to your partner, your children, or anyone else. And HS is not caused by poor hygiene — I have seen it in people who bathe twice a day with the best soaps in the market.
How do I know if this is what I have?
The most common story I hear is: a painful, tender lump comes up in the armpit or groin. It grows over a few days, sometimes bursts and drains, and then heals. A few weeks or months later, it comes back — often in the exact same spot, or right next to it. Blackheads in pairs are another classic clue, especially in the armpit.
We grade HS in three stages — mild (occasional lumps, no scarring), moderate (recurrent lumps with some tunnelling and scars in one or two areas), and severe (widespread tunnels and continuously draining lesions across large areas). But honestly, the stage does not always match how much a patient is suffering. Even mild HS can be miserable if the flares are painful and the location is embarrassing.
Why me? Why did this happen?
This is the question every patient asks, and the honest answer is — we don't fully know. But we do know a few things play a role together:
Your hair follicles get blocked. Your immune system, for reasons that are partly genetic, overreacts to that blockage. Hormones matter — that's why HS often begins after puberty and flares around periods or pregnancy. Friction, heat and sweat in skin folds keep the fire going. Smoking and excess weight don't cause HS, but they absolutely make it worse and slow down every treatment I try. Family history is common — if you have HS, there is a fair chance a parent or sibling had "recurrent boils" too, just never diagnosed.
Roughly one in a hundred people has HS. It's more common in women, and it usually starts somewhere between the late teens and forties.
What actually helps
There is no single "cure" tablet for HS. Anyone who promises one is not being honest with you. But with the right combination, I can almost always bring the disease under control, reduce your flares dramatically, and stop new scarring. Here is how I usually approach it.
The lifestyle side first, because it does half the work. If you smoke, please stop — I know this is hard, but smoking is one of the strongest predictors of severe HS. If your weight is on the higher side, even losing 5–10% makes a visible difference in friction and inflammation. Switch to loose, breathable cotton clothing; avoid tight synthetic gym wear over affected areas. A short-contact wash with chlorhexidine or benzoyl peroxide a few times a week helps keep skin bacteria down. Warm compresses on a fresh painful lump often bring relief before you even reach the clinic. And keep a small diary of your flares — many women, for example, notice a clear pattern around their cycles.
On the medical side, depending on how bad your disease is, I use antibiotics — not because it's an infection, but because certain antibiotics like doxycycline or a rifampicin-clindamycin combination have strong anti-inflammatory action in HS. In women with hormone-sensitive flares, spironolactone or the right combined oral contraceptive can be a game changer. A quick steroid injection into a fresh painful lump can settle it in a day or two — very satisfying for both of us. Retinoids like acitretin help selected patients. If a lump becomes a large painful abscess, we drain it properly in the clinic instead of you cutting it open at home.
Laser hair removal is one of my favourite tools for long-term HS control. By reducing the hair in the affected folds, we reduce the number of follicles that can get blocked in the first place. Fewer follicles, fewer flares. It works particularly well in the armpits and groin. It is not a one-time thing — it needs a proper series of sessions — but combined with medical treatment, it genuinely changes the trajectory of the disease for many of my patients.
A word on Ozempic and Mounjaro, since patients keep asking. These are medicines originally made for diabetes and now widely used for weight loss (semaglutide and tirzepatide). They are not a treatment for HS. But if your weight is contributing to your HS — and in a lot of my patients it is — then losing weight in a controlled, medically supervised way often reduces friction and background inflammation, and I do see flares becoming less frequent. If it fits your case, I discuss it as part of the bigger plan, not as a shortcut.
For severe, localised disease with tunnels that will not settle, sometimes surgery — deroofing the tunnels or a wider excision — is the right answer, and it can be curative for that specific area.
Please stop doing these things
I have to be blunt here, because these mistakes are what keep making the disease worse:
Do not squeeze or pop a lump. It feels satisfying for a second and pushes the inflammation deeper for months. Do not shave over active areas — you are cutting the top of already-inflamed follicles. Do not scrub with harsh antiseptics thinking "cleaner is better". Do not keep buying leftover antibiotics from the medical store every time a lump appears — you are only building resistance, not treating the disease. And please, please do not keep waiting for it to "just settle on its own". Every flare you ignore is more scar tissue you are building.
Food, mind, and the rest of your life
Food does not cause HS. But some patients — not all — notice their flares reduce when they cut back on dairy (especially skim milk), sugary drinks and refined carbohydrates. A short, sensible trial is worth trying under guidance. Don't put yourself on strange elimination diets on your own.
And on the emotional side — I see how much this disease can affect people. It is painful, it is in intimate areas, it drains, it stains clothes, it disrupts sleep and intimacy. If you are feeling low or anxious about it, please tell me. That is a real part of the illness, not a weakness, and it deserves to be addressed like any other symptom.
When you should come and see me
Come in if you keep getting painful lumps in the same skin folds, if they are draining pus or blood, if you can feel rope-like cords or tunnels under the skin, or if you are simply exhausted from treating "boils" over and over. The earlier we start proper treatment, the more scarring we can prevent — and scarring, once formed, is much harder to fix than the inflammation itself.
The short version
HS is a chronic inflammatory disease, not an infection. It is not your fault. It responds beautifully to a proper plan — lifestyle changes, the right medicines, hair removal, procedures where needed, and honest follow-up. Stop the home surgery, stop the leftover antibiotics, stop hiding it. Come in early, and let us build a plan that fits your life.
This article is for education. It does not replace an in-person consultation. If any of this sounds like your story, please book an appointment — we will look at your skin properly and design a treatment plan that actually works for you.