Hidradenitis suppurativa (HS) is treatable, though the right approach depends on how severe your symptoms are. Mild cases often respond to topical treatments alone, while moderate to severe HS typically requires oral medications, biologics, or surgery. Most dermatologists match treatment to your disease stage, starting with the least aggressive option and escalating if needed.
HS is staged using a three-tier system. Stage I means you have one or more abscesses but no tunnels under the skin and no scarring. Stage II involves recurring abscesses with tunnels (called sinus tracts) and some scarring. Stage III means widespread, interconnected tunnels and abscesses across a large area. Knowing your stage helps you and your doctor choose the most effective path forward.
Topical Treatments for Mild HS
If your HS is at Stage I or early Stage II, topical treatments are the usual starting point. A 1% clindamycin gel applied twice daily is one of the most commonly prescribed options. It works by reducing bacteria on the skin and calming inflammation around the hair follicles. A typical course lasts about 12 weeks.
Another topical option is 15% resorcinol cream, applied once daily directly to inflamed nodules and abscesses. Resorcinol is a peeling agent that helps open clogged follicles and reduce the size of lesions. In a head-to-head comparison, both clindamycin and resorcinol showed meaningful improvement in mild to moderate cases over 12 weeks. Resorcinol has the advantage of not contributing to antibiotic resistance, which matters if you need long-term treatment.
Oral Antibiotics for Moderate Disease
When topical treatments aren’t enough, oral antibiotics are the next step. The most well-studied combination pairs clindamycin (300 mg twice daily) with rifampicin (600 mg daily) for 10 weeks. In a study of 116 patients with severe HS, this combination cut disease severity scores roughly in half. About 7% of patients stopped treatment early due to side effects, mostly gastrointestinal issues.
This combination works not just by killing bacteria but by reducing the underlying inflammation that drives HS flares. It’s not a permanent fix for most people. Symptoms can return after the course ends, which is why many dermatologists use antibiotics as a bridge while starting longer-term therapies.
Biologic Medications for Moderate to Severe HS
Two biologic medications are currently FDA-approved specifically for HS. Adalimumab, approved in 2015, blocks a key inflammatory protein called TNF-alpha. Secukinumab, approved in 2023, targets a different inflammatory pathway by blocking IL-17A. Both are self-injected at home on a regular schedule.
To qualify for either biologic, you generally need a combined count of at least 3 to 5 active abscesses and inflammatory nodules. These medications don’t cure HS, but they can significantly reduce the number and severity of flares. Many patients notice improvement within the first few months, though it can take longer to see full results. If one biologic doesn’t work well enough, switching to the other is a reasonable next step since they target different parts of the immune system.
Hormonal Treatments
Because HS is influenced by hormones, particularly androgens, hormonal therapies can help some patients. Spironolactone, a medication that blocks androgen activity, showed improvement in about 50.5% of patients across pooled studies. Metformin, more commonly known as a diabetes drug, helped about 46% of patients, likely by improving insulin resistance and lowering androgen levels.
These options are most often used in women and can be combined with other HS treatments. Response rates aren’t as high as with biologics, but hormonal therapies are oral medications with well-understood safety profiles, making them a practical addition for people whose HS worsens around their menstrual cycle or who have signs of hormonal imbalance.
Surgical Options
Surgery becomes important when you have persistent tunnels, scarring, or areas that don’t respond to medication. The two main approaches are deroofing (also called unroofing) and wide excision.
Deroofing is a tissue-sparing procedure where the roof of a tunnel is removed, leaving the base to heal from the bottom up. It’s less invasive and preserves more healthy skin. Wide excision removes the entire affected area, including all tunnels and surrounding tissue. It’s more aggressive but has a lower recurrence rate, averaging around 10%. In one study of 206 procedures (mostly wide excisions), the overall recurrence rate was 18.5%, and the average time to complete wound healing was about 46 days. Most wounds healed by secondary intention, meaning they were left open to close naturally rather than being stitched shut.
When recurrence did happen, it took an average of 5 to 9 months to appear. Surgery doesn’t prevent new HS from developing in other areas, so many patients continue medical therapy afterward to reduce the chance of new flares.
Laser Therapy
Laser treatment using a long-pulsed Nd:YAG laser (1064 nm wavelength) targets the hair follicles and reduces inflammation in affected areas. Protocols typically involve four sessions spaced two to four weeks apart. Results are encouraging: one study found a 65.3% reduction in HS severity after three months, while another showed 72.7% improvement on the laser-treated side compared to 22.9% on the untreated control side.
Laser therapy works best for Stage II and III disease and is particularly useful for patients who want to reduce flares in a specific area without surgery. It can be combined with medical treatments for a more comprehensive approach.
Managing HS Pain
Pain is one of the most disruptive parts of living with HS, and it often gets under-treated. There are several practical options depending on whether your pain is constant or tied to specific flares.
For localized pain, numbing creams containing lidocaine (4-5%) can be applied directly to painful areas up to six times daily. Anti-inflammatory gels or patches containing diclofenac are another option for targeted relief. Menthol cream (4%) provides a cooling sensation that some people find helpful. For acute, intensely painful nodules, a steroid injection directly into the lesion can bring rapid relief within a day or two.
For broader or ongoing pain, over-the-counter anti-inflammatory medications like ibuprofen or naproxen are a reasonable first line. When inflammation-driven pain becomes chronic, your doctor may suggest medications originally developed for nerve pain, such as gabapentin or pregabalin, or antidepressants like duloxetine that also dampen pain signals. These aren’t prescribed because HS pain is “in your head.” They work because chronic pain changes how your nervous system processes signals, and these medications help reset that.
Cognitive behavioral therapy has shown real benefit for chronic pain conditions, including HS. It focuses on practical strategies like pacing activity, restructuring thoughts about pain, and relaxation techniques. This isn’t a replacement for medication but works well alongside it.
Zinc and Dietary Supplements
Zinc gluconate at 90 mg per day (providing about 15 mg of elemental zinc per capsule, taken as six capsules daily) showed promising results in a pilot study of 22 patients. Eight achieved complete remission and 14 had partial improvement. Once remission was reached, the dose was tapered to an average maintenance level. About 4 in 22 patients had gastrointestinal side effects.
Other supplements with some preliminary evidence include alpha-lipoic acid (300-600 mg daily) and curcumin (1000-1500 mg daily), both of which have anti-inflammatory properties. These are not strong enough to replace standard treatments on their own, but some patients use them as add-on therapies. If you try zinc, take it with food to reduce stomach upset.
Building a Long-Term Treatment Plan
HS is a chronic condition, and the most effective approach usually combines multiple treatments. A common pattern is using a biologic or oral therapy as the backbone, adding topical treatments for mild flares, managing pain proactively, and turning to surgery or laser therapy for areas that don’t respond to medication alone. Hormonal therapy or zinc supplementation can layer on top for additional benefit.
Weight loss, if applicable, has been shown to reduce flare frequency, likely because skin folds create friction and trap moisture. Loose-fitting clothing, gentle cleansers, and avoiding shaving in affected areas also help reduce irritation. Smoking cessation is one of the most impactful lifestyle changes, as tobacco use is strongly linked to HS severity. None of these lifestyle measures replace medical treatment, but they can meaningfully improve how well your other treatments work.