Hidradenitis Suppurativa

I can usually tell within the first few sentences of a consultation that a woman has been carrying this alone for years, because of exactly how she describes it. She doesn’t say “Hidradenitis Suppurativa.” She says “boils that keep coming back,” or “something wrong with my underarms,” or she just lifts her arm and shows me without saying much at all, because she’s rehearsed this moment before and it’s gone badly. Almost every one of them has already been told, by someone, that it’s a hygiene problem. I want to say the true thing immediately, before we go any further: it is not, and it never was. My goal for this page is that if you were diagnosed today, or if you’ve had this for twenty years and never had it properly explained, you could spend twenty minutes here and finally understand your own disease.

You did not cause this. You are not imagining how much it hurts.

What I’m actually looking at, most of the time, is Hidradenitis Suppurativa — a chronic inflammatory disease, not an infection, that causes painful lumps, abscesses, and eventually tunnels under the skin, almost always in the places where skin rubs against skin: underarms, groin, inner thighs, under the breasts, sometimes the buttocks. In its early stages it looks so much like a stubborn ingrown hair or a bad breakout that I’ve had clients carry a wrong assumption about their own body for a decade before anyone said the real name of what they had.

What HS Actually Is, and Why It Isn’t Your Fault

Why it isn’t a hygiene problem. HS begins deep in the hair follicle, not on the surface of the skin, which is exactly why washing more, or differently, has no effect on it. A follicle becomes blocked, and the body’s immune response to that blockage is aggressive — more aggressive than the situation calls for, in a way researchers still don’t fully understand. That inflammation becomes a painful nodule, and over time, without the right care, those nodules can become abscesses that rupture and tunnel beneath the skin. This is why HS is classified as an inflammatory disease, not an infection: the damage is coming from your own immune system’s overreaction, not from bacteria you failed to wash away. None of this list includes “didn’t wash enough,” and I need that to land, because I have watched women flinch with shame in my chair over something that was never within their control to prevent.

Why hair follicles are involved at all. HS develops in areas dense with a specific type of hair follicle — the same follicles connected to the sweat glands concentrated in the underarms, groin, and skin folds. That follicle involvement is exactly why hair removal, done correctly, can play a real supporting role in management, and it’s also part of why HS is so often mistaken early on for an ingrown hair or folliculitis problem rather than recognized as its own disease.

Why it often begins after puberty. HS is closely tied to the same hormonal shifts that change follicle behavior at puberty, which is why it’s rare before then and so often begins in the teenage years or early twenties — a timing pattern that frequently gets confused with ordinary teenage acne or ingrown hairs, delaying an accurate diagnosis even further.

Why hormones influence flares. Many of my clients notice HS worsening around their menstrual cycle, and that’s a real, recognized pattern, not a coincidence — hormonal fluctuation affects the same inflammatory processes involved in HS. This is also part of why hormonal therapy is sometimes used medically to help manage it.

Why women with PCOS appear to have HS more often. PCOS and HS are both linked to excess androgen activity, and in my own clinical experience — consistent with what’s increasingly recognized in dermatology — women with PCOS do seem to develop HS more frequently than the general population. If you have PCOS and are noticing recurring lumps in your skin folds, that connection is worth mentioning to your doctor directly, not dismissing as unrelated.

Why obesity can worsen it. Increased skin-on-skin friction in body folds, combined with obesity’s independent effects on inflammation and hormone levels, both feed directly into the same processes that drive HS flares. I say this the same way I’d say it about any physiological factor: not as judgment, but because understanding what’s actually driving your flares is what makes managing them possible.

Why smoking increases the risk. Smoking is one of the most consistently identified risk factors for HS and for more severe disease course, tied to its effects on follicle function and inflammation. If you smoke and have HS, stopping is one of the few lifestyle factors genuinely within your control that can meaningfully affect how active your disease is.

Why friction makes lesions worse. The same friction mechanism behind ordinary irritation is amplified in HS, because the follicle is already inflamed and vulnerable — which is exactly why tight clothing, and hair removal methods that add trauma on top of that, provoke new flares so reliably.

Why so many patients are misdiagnosed for years. Early HS looks like a boil, a cyst, or bad acne, and it’s genuinely difficult to distinguish at that stage without specific familiarity with the disease. On melanin-rich skin specifically, the visible signs also present differently than the textbook photos most providers trained on, which is a documented, broader pattern of dark-skin conditions being recognized more slowly across medicine generally — part of why diagnosis so often takes years instead of one or two visits.

Why I See It More Often, and More Severely, in Black Women

HS affects an estimated 1 to 4% of the population, and in my clinic, it shows up disproportionately in Black women and other women with melanin-rich skin — more often, and more severely, and diagnosed later than it should be, for the same reasons described above. I’ve built forty years of specifically looking at melanin-rich skin, and it’s exactly this kind of gap — a real disease, hiding in plain sight because it wasn’t described for your skin — that I built my practice to close.

My Opinion After 40 Years: Why I Don’t Wait on the First Ingrown Hair

I want to tell you something plainly, as my own professional opinion from forty years of treating unwanted hair — not as an established medical fact, because it isn’t one yet, but as something I believe strongly enough to say to every Black or dark-skinned client, and every client with curly, coily, or naturally strong body hair, who comes to me with their very first ingrown hair, anywhere on the body: don’t wait. Do everything you reasonably can to start laser hair removal as soon as possible.

Here is why I feel this strongly. Nobody — not me, not dermatology, not medicine as a whole — can yet tell you which specific ingrown hair might be the one that starts a chain reaction into Hidradenitis Suppurativa, and which one will simply resolve and be forgotten, the way the overwhelming majority of ingrown hairs do. Medicine genuinely doesn’t yet know why some follicles cascade into a full HS disease process and most don’t. What I do know, from decades of watching this happen in real clients, is that it can take only one. Once that cascade actually starts, in my experience, it doesn’t reverse itself back to where things were before. That gap — between what I’ve watched happen in my own chair and what science can currently explain — is exactly why I’d rather see someone start treatment early and never need this warning, than wait and find out the hard way.

I also want you to know something else I’ve observed, because I think it’s useful context, not a reason to feel more afraid: I have treated two sisters, raised in the same house, sharing a great deal of the same genetics, where one developed HS and the other never has. There is no reliable way, today, to know in advance which of two sisters that will be. Genetics does appear to play a real role alongside everything else — if a parent or another family member has had HS, there’s a meaningfully higher likelihood that someone in the next generation will develop it too — but genetics alone doesn’t decide it, which is exactly why I don’t think this is something to simply wait and watch. Watching families like that over the years taught me just how much we still don’t understand about why HS begins in one person and not another.

I want to be honest about what this is and isn’t. It’s my professional opinion, formed from a career spent specifically in this territory — not a guarantee, and not a diagnosis. Most ingrown hairs will never become HS. But if you’re in one of the groups I’ve described here, looking at your very first one, I don’t believe waiting costs you nothing. That’s exactly why I say what I say, to every client it applies to, every time.

How HS Is Actually Treated: The Full Picture

I think this is the section most patients never get to see laid out clearly, so I want to walk through it step by step, the way dermatology actually approaches HS management — not as a menu you pick one item from, but as a ladder, often used in combination, tailored to how severe your disease is. Your dermatologist will assess how advanced your case is and use that to guide which of the steps below make the most sense for you — that assessment, and what it means for your specific case, is a conversation worth having directly with them.

1. Lifestyle changes. Loose clothing, reducing friction in affected areas, and gentle skin care form the foundation everything else builds on.
2. Weight management, when appropriate. Because of the friction and inflammation connection described above, this can meaningfully reduce flare frequency for some patients — not a requirement, and not appropriate or relevant for everyone.
3. Smoking cessation. Given how consistently smoking is linked to more severe HS, this is one of the highest-impact changes within a patient’s control.
4. Topical medications. Prescription topical treatments, including antibiotics applied directly to the skin, are often the first medical step for milder disease.
5. Oral antibiotics. Used both for their antibacterial effect and, in some cases, for their separate anti-inflammatory properties — a real, recognized part of HS management, not just an infection treatment.
6. Hormonal therapy, in selected women. Given the hormonal influence on flares described above, hormonal treatment is sometimes used medically, particularly when flares track closely with the menstrual cycle.
7. Biologics. For moderate to severe HS, or when the steps above haven’t been enough, a newer class of medication called biologics — which target the specific immune activity driving HS inflammation, rather than affecting the whole body broadly — is now a real option many dermatologists consider. More on this below.
8. Surgery. For more advanced or scarred disease, a surgeon may perform procedures ranging from simple drainage to more extensive surgical removal of affected tissue, depending on severity.
9. Laser hair removal. This is where I come in — and I want to be completely explicit about what this does and does not do.

Laser hair removal is not a cure for HS, and I never want to imply otherwise. Reducing coarse hair and follicular irritation in affected areas may help reduce one of the contributing factors to flares, in selected patients — fewer active hair follicles can mean fewer sites for that blocked-follicle cycle to restart. It does not treat the underlying immune disease driving HS, and it is not a substitute for any of the eight steps above. I see it as exactly one tool among many, appropriate for some patients as part of a broader plan, never as the whole plan by itself.

I also want to be honest about something most patients aren’t told in advance: treating skin that’s actively affected by HS — whether with laser or with high-frequency — is genuinely more painful than the same treatment on unaffected skin. HS-affected tissue is already inflamed, often tender, and sometimes still healing from a recent flare, and that heightened sensitivity means both technologies are felt far more intensely there than in a routine hair removal session or an ordinary acne-calming treatment elsewhere on the body. I’d rather you know that walking in than be caught off guard by it, and I adjust pacing and technique accordingly on affected areas rather than treating them exactly like unaffected skin.

Where My Role Begins and Ends

Modern HS treatment is often a team effort. Depending on how severe the disease is, a patient may be treated by a dermatologist for medical management, including newer medications like biologics, and by a surgeon when procedures are necessary. My role is different from either of those, and I want to be completely clear about it rather than leave it vague. I do not treat the underlying inflammatory disease, prescribe medication, or perform HS surgery. I work alongside a patient’s medical team by treating one of the factors that can contribute to ongoing problems: coarse hair, recurrent ingrown hairs, follicular irritation, and the post-inflammatory discoloration that often remains after repeated flare-ups. Laser hair removal is not a cure for HS, but for appropriately selected patients, it may be one component of a comprehensive treatment plan developed with their physician or surgeon — complementary to that care, never a replacement for it.

What Makes It Worse

Waxing and tweezing in affected areas is one of the most common things I have to gently redirect clients away from, because it increases exactly the friction and follicle irritation that HS reacts to worst. Harsh scrubs or aggressive exfoliation in affected skin folds tend to provoke a flare rather than help it. And the single most costly mistake I see is simply time — years spent assuming this is just stubborn acne or ingrown hairs, before anyone gives it its real name, while the scarring underneath quietly gets worse.

What Getting Better Actually Looks Like

I’d rather tell you the honest shape of this than a comforting one. HS is chronic, and the real goal of treatment — medical and cosmetic together — is meaningful flare reduction and a real improvement in quality of life, not a guaranteed permanent cure. Laser hair removal for HS management usually takes a longer course than ordinary cosmetic hair removal, with results building gradually over months, not weeks. The patients I’ve seen do best are the ones getting real medical management for the disease itself, from a physician, at the same time as the cosmetic side — not choosing one instead of the other.

When to Stop Waiting

Any recurring, painful lump in the underarms, groin, or other skin-fold areas — especially if it keeps coming back in the same spot, month after month or year after year — deserves a physician’s evaluation, not more time spent managing it alone as “bad ingrown hairs.” If you already have an HS diagnosis and you’re considering laser as part of managing it, look specifically for a laser provider who understands HS and melanin-rich skin — not every provider does. And if things are suddenly worsening, spreading, or you’re running a fever, that’s not a wait-and-see situation; see a physician promptly.

Frequently Asked Questions

Is HS contagious? No. It’s an inflammatory disease driven by your own immune system’s response within the follicle, not an infection you can pass to or catch from anyone else.

Will losing weight cure my HS? Not on its own for most patients, but it can meaningfully reduce flare frequency for some, because of the friction and inflammation connection — it’s a contributing factor worth addressing, not a guaranteed fix.

If I start a biologic, can I stop everything else? That’s a decision for your prescribing physician, not something I’d ever advise on — but in my experience, most patients still benefit from combining medical treatment with the lifestyle and cosmetic pieces, not replacing one with the other.

Can laser hair removal alone control my HS? No, and I want to be very direct about this: laser addresses one contributing factor — hair and follicular irritation — not the underlying immune disease. It is not a substitute for medical management.

Why did it take years for anyone to diagnose this correctly? Unfortunately, that’s extremely common, for the reasons explained above — early HS resembles other, more familiar skin issues, and recognition on melanin-rich skin specifically still lags behind. You are far from the only woman this has happened to.

Related Conditions and Treatments

HS rarely shows up in isolation from the rest of what I treat. If you’re dealing with HS, you may also find these pages relevant: PCOS, given the hormonal overlap described above; Ingrown Hairs and Hyperpigmentation, both common alongside HS in affected areas; and on the treatment side, Laser Hair Removal and Electrolysis, for the hair-related piece of management described above.

What I Tell Every Patient, and My Clinical Experience After 40 Years

HS is one of the most isolating diseases I treat, because so many of my clients have spent years being told, directly or by silence, that it’s their fault — that they’re not clean enough, that they’re exaggerating how much it hurts. I want to say this as plainly as I know how: I have never once believed that about a client, and neither should you. What I’ve learned over decades of treating this is that patience, and the right combination of care working together — medical and cosmetic, not one instead of the other — makes a real difference, even on the days a full cure isn’t realistic. I see every HS client personally, not because it’s required of me, but because this is not a disease I think anyone should have to explain themselves for — least of all to me. If you’d like to talk through what your specific pattern looks like, I’d like the chance to listen.