Hidradenitis Suppurativa (HS) is a long-term inflammatory skin condition that causes painful, recurring lumps and abscesses, typically in areas where skin rubs together, such as the armpits and groin. The intense, deep inflammation frequently results in significant scarring, even when active flare-ups are managed. These scars are a common consequence of the disease, often leading to restricted movement and emotional distress. Treating these marks is complex and usually requires a comprehensive, multi-modal approach.
Unique Characteristics of HS Scarring
HS scarring differs structurally and visually from typical acne or injury-related scars because inflammation occurs deep within the skin. The constant cycle of rupture and healing causes the formation of several distinct scar types simultaneously. These include atrophic scars, which appear as depressed or pitted areas where tissue has been lost.
Individuals often develop hypertrophic scars, which are thick and raised, or keloidal scars, which grow beyond the original wound boundaries. Chronic inflammation also leads to the formation of dermal tunnels, known as sinus tracts, which are interconnected channels of scar tissue beneath the skin’s surface. This rope-like scarring pulls the skin downward, creating ridges and making the area feel firm and inflexible.
Topical and Injection Therapies
The least invasive treatments for HS scars focus on reducing inflammation and altering scar tissue composition. Silicone-based sheets or gels are a common non-prescription choice, working by hydrating the scar and applying gentle pressure to flatten raised, hypertrophic marks. Gentle massage of mature scars with emollients can help soften the fibrous bands of tissue and improve flexibility.
Prescription-strength topical agents are often utilized, including retinoids, which help normalize cell turnover and prevent the follicular occlusion that initiates HS lesions. Vitamin D analogues may also inhibit the excess collagen production that contributes to scar formation. For color correction, topical creams containing ingredients like hydroquinone, kojic acid, or vitamin C can help fade the hyperpigmentation that often remains after a lesion heals.
Intralesional injections offer a more direct approach to treating raised scars. A corticosteroid, most commonly triamcinolone acetonide, is injected directly into the hypertrophic or keloid scar tissue. This works by suppressing inflammation and breaking down collagen, leading to a visible flattening of the scar over several treatment sessions. Sometimes, the corticosteroid is combined with an anti-metabolite like 5-fluorouracil (5-FU) to inhibit abnormal cell growth and reduce the risk of recurrence.
Advanced Non-Surgical Procedures
Procedural treatments performed in a dermatologist’s office can significantly improve the texture and appearance of HS scars. Laser resurfacing, particularly using fractional carbon dioxide (CO2) lasers, creates controlled microscopic injuries in the scarred skin. This process stimulates the skin’s natural healing response, promoting new collagen production and improving the texture and depth of atrophic or pitted scars.
For scars that are red or purple, a pulsed dye laser (PDL) targets the underlying blood vessels, reducing visible redness and improving the color match with the surrounding skin. Microneedling is another textural treatment, using fine needles to puncture the skin and induce collagen remodeling. This is sometimes enhanced by combining it with radiofrequency energy for deeper heat penetration.
For depressed scars tethered to deeper tissue, a technique called subcision is employed, which involves using a specialized needle to mechanically break the fibrous bands beneath the scar. This release allows the skin surface to elevate and become less indented. Dermal fillers, typically hyaluronic acid-based products, can be injected immediately after subcision or as a standalone treatment to physically lift the depressed scar tissue, providing an immediate smoothing effect.
Surgical Correction of Severe Scars and Tunnels
For the most severe and complex HS scars, especially those involving deep, chronic sinus tracts, surgical intervention is often necessary. These tunnels represent permanent channels of inflammation and scar tissue that are unlikely to resolve with non-surgical methods. The primary goal of surgery is to remove the diseased tissue to prevent recurrence and improve the contour of the skin.
One common surgical approach is deroofing, or unroofing, where the top layer of skin covering the tunnel is removed, exposing the underlying tract. The tract lining is then cleaned out, and the resulting wound is left open to heal from the base upward, minimizing the chance of recurrence. This technique is less invasive than full excision and typically results in a flatter, more manageable scar.
For extensive scarring or deep tracts, wide local excision may be required. This involves surgically removing the entire affected area, including active lesions, sinus tracts, and surrounding scar tissue down to the healthy fat layer. While this procedure can lead to a larger surgical scar, it offers the highest chance of long-term disease clearance and can significantly restore flexibility and mobility.