HS can present in different ways depending on severity and duration. Early disease may resemble recurring “boils” or tender bumps, while more advanced disease may involve chronic drainage and scar tissue. Common symptoms include:

• Painful, deep nodules beneath the skin
• Abscesses that enlarge, become inflamed, and may rupture
• Recurrent flares in the same locations
• Drainage that can be persistent or intermittent
• Sinus tracts (tunnels) under the skin in more advanced cases
• Scarring and thickened, rope-like tissue over time

Symptoms often worsen with friction, heat, sweating, and prolonged inflammation. HS can also affect daily activities, sleep, work, and emotional well-being due to pain, odor, drainage, or visible scarring.

HS is not contagious and is not caused by poor hygiene. It is widely understood as a follicular and immune-mediated inflammatory condition involving hair follicles and surrounding tissue. The precise cause can vary, but several factors may contribute:

• Genetic predisposition, as HS can occur in families
• Inflammatory immune activity that drives recurrent lesions
• Mechanical friction and occlusion in skin folds
• Hormonal influences, which may contribute to flares in some patients
• Smoking and obesity, which are commonly associated with increased severity and may be addressed as part of a comprehensive plan

HS is a chronic condition, but treatment can reduce the frequency and intensity of flares and help prevent progressive scarring.

HS is typically diagnosed through a clinical dermatology evaluation. Diagnosis relies on three key features:

1. Typical lesions (painful nodules, abscesses, tunnels, and scarring)
2. Typical locations (intertriginous or friction-prone areas)
3. Chronicity and recurrence (repeated episodes over time)

Dr. Thomas Knackstedt and the team at Peak Skin Center evaluate lesion pattern, flare history, scarring, and drainage to determine severity and guide treatment selection. Some practices use staging systems to categorize HS, which can help align therapy with disease extent. Testing is not always required, but a review of overall health, medications, and contributing factors may be included to support a complete care plan.

HS treatment is individualized and often benefits from a stepwise approach. The goal is to reduce active inflammation, limit new lesion formation, address pain and drainage, and prevent long-term scarring. Treatment may include a combination of medical therapy, procedures, and surgical management when indicated.

Medical treatment options

Medical therapy is often used to control inflammation and reduce flare frequency:

• Topical therapies (such as topical antibiotics) may be used for mild disease or localized areas.
• Oral antibiotics may be selected for their anti-inflammatory effects and to address secondary infection when present.
• Intralesional corticosteroid injections may be considered for individual painful lesions to reduce inflammation more rapidly.
• Hormonal or anti-androgen strategies may be appropriate in selected patients when clinical features suggest a hormonal component.
• Biologic medications may be considered for moderate to severe HS or disease that does not respond to standard therapies. These advanced treatments are designed to target inflammatory pathways and can reduce flare frequency and severity in appropriate candidates.

Supportive measures may include pain control strategies, wound-care guidance, and recommendations that reduce friction and irritation. Long-term success often depends on consistent follow-up and adjustments based on response.

Surgical and procedural treatment options

Procedures and surgery can play an important role, particularly when tunnels, recurrent localized disease, or significant scarring are present:

• Deroofing: A tissue-sparing procedure that opens sinus tracts and removes the overlying “roof,” allowing the area to heal from the inside out. This approach is often used for persistent tunnels in limited areas.
• Local excision: Removal of a defined area of chronically affected tissue.
• Wide excision: Removal of more extensive disease in advanced HS, sometimes required when scarring and tunnels are widespread. Healing may involve secondary intention or reconstructive planning depending on the site and extent.
• Laser-based procedures: In select cases, laser approaches may be used to reduce disease activity or address hair follicles associated with HS activity.

Incision and drainage can provide short-term relief for an acutely painful abscess, but it is generally not considered a durable strategy for long-term HS control. A comprehensive plan typically combines medical therapy with targeted procedural or surgical management when indicated.