Hidradenitis Suppurativa (HS) is a chronic inflammatory skin condition characterized by recurring, painful nodules and abscesses, often developing where skin rubs together (e.g., armpits and groin). The repeated cycle of inflammation and healing leaves behind scars, affecting both skin texture and color. While physical changes like indentations or raised tissue can be permanent, the discoloration or “dark spots” known as hyperpigmentation can often be significantly lightened. Improving the appearance and color of HS scars involves a combination of topical strategies and professional interventions.
Identifying Types of HS Scarring
HS lesions resolve into several distinct types of scars. The most common type related to scar lightening is post-inflammatory hyperpigmentation (PIH), which appears as flat patches of brown or black discoloration. This darkening occurs because intense inflammation stimulates melanocytes, causing an overproduction and irregular deposition of the skin pigment melanin.
Other scar types present physical texture changes that must be addressed alongside color. Atrophic scars are characterized by a loss of tissue and appear as depressed or pitted areas, resulting from a lack of collagen production. Conversely, hypertrophic scars and keloids are raised, thickened scars that result from an excessive accumulation of collagen. While lightening efforts primarily target PIH, overall scar revision often requires addressing these textural issues.
At-Home and Topical Lightening Strategies
Topical treatments focus on interrupting the melanin production pathway or accelerating the skin’s natural exfoliation to shed pigmented cells. Over-the-counter agents such as Vitamin C work as an antioxidant, brightening the skin by inhibiting the enzyme tyrosinase necessary for melanin synthesis. Niacinamide (Vitamin B3) interferes with the transfer of melanin from melanocytes to surrounding skin cells, preventing surface discoloration.
Alpha Hydroxy Acids (AHAs), such as glycolic or lactic acid, chemically exfoliate the top layer of the skin, promoting cell turnover to shed hyperpigmented skin quickly. Azelaic acid offers a dual benefit: mild exfoliating properties and the ability to directly inhibit tyrosinase activity. These non-prescription ingredients are gentler and require consistent use over several months to show results in fading PIH.
For more pronounced pigmentation, a dermatologist may prescribe stronger topical agents like retinoids or hydroquinone. Retinoids, which are Vitamin A derivatives, accelerate cell renewal deep within the epidermis, pushing pigmented cells to the surface faster. Hydroquinone is a powerful depigmenting agent that works by decreasing the number of active melanocytes and inhibiting melanin production, making it highly effective for stubborn PIH. Due to its potency, hydroquinone use is typically limited to short cycles under medical supervision to mitigate the risk of side effects.
Professional Procedures for Scar Revision
For deeper scarring and significant texture changes, professional in-office procedures are often necessary. Procedures aimed at surface pigmentation include medium-depth chemical peels, which use higher concentrations of acids (e.g., trichloroacetic acid or TCA) to remove the entire epidermis and part of the dermis. This controlled injury stimulates the formation of new, less-pigmented skin. Specific laser treatments, such as Q-switched and picosecond (Pico) lasers, target melanin directly by emitting rapid bursts of energy. These lasers break up the excess pigment into smaller fragments, allowing the body’s immune system to clear the discoloration.
Treatments designed to improve scar texture rely on stimulating collagen production. Microneedling uses fine needles to create micro-injuries, triggering a healing response that includes new collagen and elastin formation to fill in atrophic scars. This can be enhanced with radiofrequency energy (RF microneedling), where heat is delivered deeper into the skin to tighten tissue and further remodel collagen.
Fractional ablative lasers, like the CO2 laser, create microscopic columns of thermal damage, leaving surrounding tissue intact to aid healing. As the skin repairs itself, it produces new collagen, which smooths the texture of atrophic scars, though this treatment carries a risk of post-inflammatory hyperpigmentation in darker skin types. For raised scars, intralesional corticosteroid injections deliver anti-inflammatory medication directly into hypertrophic or keloid tissue. The steroid works to reduce inflammation and slow the production of collagen, helping to flatten and soften the raised scar tissue.
Maintaining Results and Preventing Further Hyperpigmentation
Once lightening is achieved, a maintenance routine is necessary to preserve results and prevent scars from darkening. The most significant factor in preventing a recurrence of PIH is meticulous sun protection. Ultraviolet (UV) radiation triggers an inflammatory response in the skin that stimulates melanocyte activity, causing scars to darken and making them more persistent.
Applying a broad-spectrum sunscreen with an SPF of 30 or higher daily is necessary, even on cloudy days or when indoors near windows. Physical protection, such as wearing sun-protective clothing or covering treated areas, offers a reliable barrier against UV exposure. Managing the underlying HS activity is paramount, as new inflammatory flares will inevitably lead to new scars and fresh hyperpigmentation. Adherence to a dermatologist-prescribed treatment plan for HS helps limit the frequency and severity of new lesions, preventing future scar formation.