- 3 minutes ago
Are you struggling to tell the difference between an ingrown hair and hidradenitis suppurativa (HS)? Wondering how to safely manage painful flares, odor, or scarring? Board-certified dermatologist Dr. Zoe Indigo answers 17 of the most common questions about hidradenitis suppurativa (HS). From breaking down the root causes and progression stages to sharing practical skincare routines, pain-management tips, and treatment options, this comprehensive guide offers expert insight to help you navigate living with HS.
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00:00Hi, come on in. Make yourself comfortable. I'm Dr. Zoe Indigo, a board-certified dermatologist.
00:06Today, we're clearing up the confusion and answering the most important questions about
00:11hydrogenitis suprativa. Do I have an ingrown hair, or is it possibly hydrogenitis suprativa?
00:18It might actually be easier for me to show you the difference between an ingrown hair and HS.
00:23Let's take a look. This is an example of an ingrown hair. You see it's a single lesion, a single
00:31hair follicle.
00:32There's a tuft of hair underneath the skin. Sometimes even, this might not even be hair,
00:38sometimes it's dead skin cells and like keratin, like a little black head under the skin.
00:43Some people call them ingrown hairs. Compare that to something like HS. HS is a chronic condition,
00:49so there will definitely be scarring. And HS is not just one lesion. It's typically what we call
00:56double comedones. So that's where you see almost like two ingrown hairs in one. There's scarring,
01:03there's painful cysts under the skin, there's often drainage, and it can move around from your armpits
01:09to your skin folds to your groin to your buttocks. A lot of involvement in these really hormone-sensitive
01:16areas. But you can see the scarring. When you have chronic scarring, multiple sites of involvement
01:23creating these tunnels and sinus tracts under the skin, that's HS. HS is an inflammatory process,
01:31so it causes swelling around the hair follicle. So it can easily be mistaken for an ingrown hair.
01:37They're very different though. An ingrown hair may happen once in a blue moon. HS is cyclical
01:42and can happen monthly or even several times in a month. Is this not the same as cystic acne?
01:50Not exactly. So cystic acne can definitely look like HS, that boil, that inflame, that red under the
01:59skin. But it's very different. The root cause of cystic acne is actually the sebaceous unit,
02:05what we call the oil gland. Whereas the root cause of HS is the hair follicle. So autoimmune means
02:13that your body is reacting to itself. Instead of attacking bacteria, for example, you're attacking
02:18your own hair follicles. And it creates that same sort of reaction, that inflammation around the hair
02:25follicle that can look like cystic acne, but it's very different. So these boils actually connect
02:31and can rupture or burst under the skin. Sometimes they burst on their own, and sometimes they need
02:39help. Acne, on the other hand, usually doesn't burst or drain. That's one way that you can tell
02:45the difference. Why are HS flare-ups so excruciatingly painful? Is there anything I can do right now
02:52to relieve the pain? I had a patient. She told me her story. Young college woman. Her HS impacted
03:00every part of her daily routine. From waking up in the morning, changing her bandages, going to class,
03:07walking to class, painful boils between her legs, coming back from class to change her bandages between
03:13classes. It's really frustrating. And this is why I'm so passionate about it. Because it impacts the
03:21quality of life. All of your everyday activities become chores and painful burdens. So for my
03:28patients, I recommend a number of different things to help with the pain. One is creating a barrier
03:34with bandages. There are topical and prescription medications that can absolutely help calm down that
03:40inflammation. That, and sometimes we need to do an injection to help calm down the skin and create
03:47a calm environment. At home, patients can reach for ibuprofen or even warm compresses to help bring
03:54those boils to a head faster and relieve that tension and pressure under the skin. In my office,
04:00we have an HS rescue cream that's compounded with an ingredient called resorcinol that's like a fire
04:07extinguisher for HS flares. Is it contagious? HS is not contagious, but it is genetic, which means it can
04:15run in families. Why does it smell? Technically, HS doesn't smell. It's the bacteria. Bacteria lives on our
04:24body normally, even in non-HS affected skin. And that is what gives off that stench. In HS, there's more
04:34of an
04:34inflammatory situation. You have this more zone. The immune system is recruiting all different types
04:43of cells, including neutrophils. And they create this what we call granulomatous reaction. And that
04:50attracts even more cells. That's why you have this increasing growing boil. And all of those cells
04:57mixing together creates inflammation that smells. And it gives an environment for bacteria to really
05:03thrive. One product that my patients love to clear bacteria is called Hibiclens. Hibiclens is a name
05:11brand also known as chlorhexidine. It kills away bacteria, including the normal bacteria on our body,
05:18but especially all the extra bacteria that comes to the HS party. Hibiclens can actually be used as a daily
05:25wash in my HS patients. Simply wipe down the areas involved, let it percolate for a few minutes,
05:33and then rinse. It can be a little bit drying, but for my patients who have active drainage,
05:39they appreciate that. What type of bandages actually stick to the skin folds without tearing
05:46off the skin when removed? There's a unique brand called Hydrawear that was specifically designed for
05:52HS patients. It works with bandages specifically designed to absorb so much fluid and drainage.
06:00And honestly, a lot of my patients use maxi pads, literally sanitary napkins, to absorb the fluid.
06:08Does diagnosis require a blood test? No, you don't need a blood test to diagnose HS. It's actually a
06:15clinical diagnosis. So I use visual clues to diagnose HS, as well as a history. But it's important to
06:22remember the three Rs. Recurrence, meaning that it happens frequently and cyclically around the same
06:32times of the month. Regen, we talked about under the arms, on the buttocks and the groin, in those
06:39skin folds. And rupture and resurfacing, meaning these boils sort of come to a head, they form these
06:46sinus tracks. They drain and they scar. Is there a cure? HS is something we treat, not something we cure.
06:56So like brushing your teeth every day, it's something you have to give attention to every day. But it is
07:01something that we can quiet. With the proper medication, I've had patients who had flares once
07:07a week, flaring maybe once a month, some not flaring at all. So it really depends on your unique
07:15circumstance, your unique genetic makeup, what medications you're willing to try and take.
07:20But I would definitely say HS is something that we can treat. While it's not a cure,
07:25surgery can be a definitive treatment. That's when the tissue and all of that war zone is cut out
07:31completely. That being said, surgery doesn't prevent more flares from coming in new places.
07:37What causes HS? We actually don't know what causes HS, but we have some clues. First off is genetics.
07:45It often runs in families. Secondly, it's predominant in women. So we know that there's a hormonal
07:51component, generally driven by changes in hormones, which is why you see it around your period. Thirdly,
07:58is the hair follicle. I've seen cases where we've removed the hair follicle and the HS has stopped. So we
08:06know that there's this combination of factors. What I can tell you is it has nothing to do with hygiene.
08:12It's not about cleanliness. It's not about infection. It is an autoimmune condition.
08:19HS disproportionately affects women of color. And women of color often treat it much later because
08:25they don't have access to care. Sometimes HS can be stopped early before the scarring process sets in.
08:31But oftentimes we're seeing the more aggressive cases, the more severe cases later in women of color.
08:39How can I tell if I have a more aggressive case?
08:42It's important to remember that HS is a progressive condition and can come in stages. Stage 1 starts with
08:50the cyst or bump under the skin. These recurrent boils, so to speak. By the time you get to stage
08:572,
08:57there are sinuses. So multiple boils connected and communicating with each other, forming these
09:04sinus tracks. And in stage 3, there's hardly any normal skin left. All you're seeing are multiple
09:11boils and tunnels under the skin. Massive draining, permanent scarring. Starting treatment early is
09:19important because if we can catch it at stage 1, we can prevent it progressing to stage 3 and prevent
09:25scarring.
09:27What are my treatment options? There are a ladder of treatment options available for HS.
09:35Treating HS is personal. Some people want to start with topicals. Some people want orals. Some
09:41people aren't afraid of a needle. Let's talk about the ladder. First, topical and oral antibiotics.
09:48It is our bread and butter for treating HS and calming down that inflammation and reducing that bacteria.
09:54Topical and injectable steroids. Steroids are like a fire extinguisher for any inflammatory process. So it
10:02really helps locally shut down that inflammation. Hormonal therapy. There are oral options like birth
10:09control or even testosterone blocking pills that can help reduce the hormonal component of the flare.
10:17Biologics. Biologics are a category of medicine, typically an injectable form that overall change your
10:27immune response. We talked about how HS is an autoimmune condition. Biologics modulate the immune
10:34system. So they don't turn your immune system off, but they do dampen the response. So they help your
10:41immune system calm down and stop attacking the hair follicles so much. Surgery. Surgery is a common
10:47option for HS. The goal is to cut out those sinus tracts and create scar tissue. So when that scar
10:56tissue
10:56is laid down, almost like concrete in the skin, the flares can't happen. The cells literally can't get to
11:03the area. And while it does leave a scar, it does calm down the inflammation in its place. A holistic
11:10approach is so important. I've rarely am reaching for just one treatment for HS. Holistically, we want
11:17to think about our habits, our smoking habits, our diet, and other things that cause inflammation in
11:22the skin. So we can talk about which options best for you. I'm really worried about the potential
11:27medical costs. Are there affordable options for me? There are affordable options. In fact, a lot of the
11:35treatments are inexpensive even without insurance, especially when it comes to the oral antibiotics
11:41or the topical steroids. The biologic medicines can be expensive. Without insurance, I'm talking
11:48several thousand dollars per month. That being said, a lot of pharmaceutical companies have these
11:54bridge programs that allow patients to start the medicine while they're waiting for their insurance
12:01to kick in. And there's a lot of resources to help you get medical insurance. Clinical trials
12:07are another way to get access to great care because many of them are free. Some of them even pay
12:13you to
12:13participate. In my office, we offer patients clinical trials with new and innovative medicine that hasn't
12:20even hit the market yet. How do I explain HS to a new romantic or sexual partner without feeling
12:26embarrassed or ashamed? Choosing to share your HS diagnosis with someone is very personal. Having
12:32them understand what you're going through gives them an opportunity to really relate to you on a deeper
12:38level. I think you can feel empowered to say that I may have scarring there, but the right person
12:45isn't going to mind. HS isn't a hygiene issue, and it's nothing that you've done wrong. It's not
12:50because of anything other than genetics and some environmental factors. Is it safe to wear deodorant
12:57if I have HS in my armpits? It's completely safe to wear deodorant. In fact, it's highly recommended,
13:04but it's important to find the right deodorant. A lot of deodorants have fragrance in them, and that
13:09fragrance is alcohol, which, if you think about open wounds, can be really, really irritating.
13:16I recommend to my patients Vanicream deodorant. Vanicream is made free of any scents, any parabens,
13:27any fragrances, any lanolin, any of those allergic triggers, but it also makes it great for HS skin.
13:35Previously, Vanicream only came as a deodorant, but they recently added an antiperspirant, which is
13:41great for reducing sweat. Another tip is using your acne medicine under your armpit. I recommend acne
13:49spray and benzoyl peroxide wash with aloe vera. The acne spray has salicylic acid in it, as well as
13:59glycolic acid. With that, it'll help to exfoliate the skin, but also act as an antimicrobial,
14:05killing bacteria that causes smell and drainage. The benzoyl peroxide wash works the same way.
14:12Benzoyl peroxide wash by itself can be a little harsh, but it works. We compound ours with aloe vera
14:18to make it a nice and soothing experience. What happens to the pus if a boil bursts under my skin?
14:26When the boils burst under the skin, your own immune system clears it out. Your cells come in,
14:32and they eat away at it, and it drains through your lymphatic system, so you don't have to worry
14:37about it sticking around for too long. What should I use for my daily skincare routine?
14:42When you have HS, it's important to use products that are fragrance-free.
14:49Vanicream has an amazing collection of cleansers and moisturizers, even the deodorants, that are
14:55fragrance-free. It's important to remember, fragrance can also be in your laundry detergent.
15:00I prefer Free and Clear by Tide, no fragrance, no irritation. I recommend a sensitive body wash.
15:08Check out Dove Sensitive Skin Collection with no fragrance or Vanicream body wash.
15:14Another important part of managing HS is wound care.
15:21A few of my favorite treatments are barriers for the skin. Good old-fashioned Vaseline occludes the
15:28open wound and allows it to heal. You can also use Aquaphor. The thicker, more ointment-like,
15:35the better. And if you want to reduce the appearance of scarring, silicone. Silicone's a natural ingredient
15:41that mimics the way our body heals. So as your body heals, it will do so naturally, decreasing
15:48inflammation and hyperpigmentation. And the most important part of any daily routine is sunscreen.
15:56You don't necessarily need sunscreen for under your armpits, but a lot of the medications that we take
16:02can make you a little bit more sensitive to the sun, especially the antibiotics. So make sure you're
16:07applying your sunscreen every two hours. Is it actually safe to use Ictamol or Vicks VapoRub on a
16:13painful bump to draw it out? Ictamol and Vicks VapoRub? Let me see those. Ictamol does have some
16:22evidence for decreasing inflammation. There was actually a case series back in 2020, and now they're
16:29doing an entire clinical trial. So there could be some thin evidence here. But Vicks VapoRub? I mean,
16:36it literally says, don't apply it to broken skin. Not a lot of evidence here. Maybe it works
16:42anecdotally, but not dermatologist approved. With that being said, there's so much information online,
16:49it's kind of hard to figure out what's the myth and what's the fact. It's super important to see a
16:54board certified dermatologist to help you cut through the noise and to help you figure out what's worth the
17:00hype and what's not.