Hidradenitis Suppurativa: Why Painful Bumps Keep Coming Back and What Treats Them

Painful bumps in the armpits, groin, or under the breasts are easy to dismiss as boils or ingrown hairs. When they keep coming back in the same places, though, something else may be going on. Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition, not an infection and not a hygiene problem. It is also treatable, and earlier treatment tends to mean fewer scars and fewer flares.

What hidradenitis suppurativa actually is

HS starts in the hair follicles. The follicle gets blocked and inflamed, and the immune system overreacts. The result is deep, tender nodules, sometimes abscesses, in areas where skin folds or rubs together: the armpits, groin, buttocks, and under the breasts.

Over time, nodules can connect under the skin through tunnels (called sinus tracts) and leave scars. That is why the condition can get harder to treat the longer it goes untreated. Researchers describe it as an immune-driven disease, with many inflammatory pathways involved (Vossen et al., Frontiers in Immunology).

A few things we want you to know up front:

• It is not contagious.
• It is not caused by poor hygiene or by anything you did.
• Many people wait years for the right diagnosis, often after being treated for repeated "boils."

Signs it may be HS and not a one-time boil

Ask yourself these questions:

• Do the bumps return in the same spots, such as both armpits or both sides of the groin?
• Do they hurt deeply, and sometimes drain pus or blood?
• Have you had more than two flares in six months?
• Do you notice scars, ropey tissue, or paired blackheads in the area?

If you answer yes to several of these, it is worth a proper evaluation. The diagnosis is clinical, which means it rests on what the skin looks like, where it shows up, and how often it comes back. There is no single blood test for it. That makes it well suited to a careful history and good photos during a telehealth visit.

Lifestyle factors: what helps and what we can say honestly

Lifestyle changes are real but modest tools. They do not cause HS, and they will not cure it.

• Smoking. HS is linked with smoking, and North American guidelines recommend smoking cessation as part of care (Alikhan et al., J Am Acad Dermatol, Part I).
• Weight. A systematic review found people with HS were about four times more likely to be living with obesity than the general population (Choi et al., Int J Dermatol (2019)). Evidence on weight loss as treatment is mixed, though some people see their disease improve when they lose weight.
• Diet. Early evidence suggests that some people improve when they cut back on dairy or brewer's yeast, but the studies are small. We would not promise it works for you.
• Friction and heat. Loose clothing and avoiding shaving over active areas helps some people. The evidence here is thin, but the changes cost little.

The point is not to blame you. These are levers worth pulling alongside medical treatment, not instead of it.

Medical treatment, from mild to severe

Treatment depends on how widespread and how deep your disease is. Dermatology guidelines generally step up from topical options to systemic medicines as severity increases (Alikhan et al., J Am Acad Dermatol, Part II; Zouboulis et al., J Eur Acad Dermatol Venereol (2015)).

Mild disease. Often starts with a topical antibiotic such as clindamycin, plus pain control and a plan for flares. A short injection of a steroid into one painful nodule can calm it quickly.

Moderate disease. Longer courses of oral antibiotics (often tetracyclines) are common. They are used here for their anti-inflammatory effect, not just to fight bacteria. Some people also benefit from hormonal therapy or other add-on options.

Moderate to severe disease. This is where biologic medicines come in. Two have the strongest trial support:

• Adalimumab. In two large phase 3 trials, 41.8% and 58.9% of people on weekly adalimumab met the clinical response target at 12 weeks, compared with 26.0% and 27.6% on placebo (Kimball et al., N Engl J Med (2016)).
• Secukinumab. In two phase 3 trials, the every-2-weeks dose produced a clinical response in about 45% and 42% of people at week 16, compared with about 34% and 31% on placebo. Benefits were sustained to week 52 (Kimball et al., Lancet (2023)).

Read those numbers honestly: biologics help many people, but they do not work for everyone, and a placebo response of around one in three shows how variable this disease is. Biologics also carry risks, including infection risk, so they need monitoring.

Surgery. For tunnels and scarred areas that medicine cannot reach, surgery is often part of the plan. Procedures like drainage or excision need hands-on care, so we coordinate a referral to a local dermatologist or surgeon when you need one.

How a telehealth visit helps

Most of the work in HS is pattern recognition and long-term management, and a lot of it happens through video and secure photos. In a visit, we:

• Review your history, flare pattern, and what has and has not worked.
• Look at the affected areas by video or photo and note stage and severity.
• Screen for related issues such as acne, metabolic health, and mood, since living with chronic pain and drainage takes a toll.
• Start treatment when it fits, and refer for biologics or procedures when the disease calls for it.

We will also tell you plainly when something is outside what we can do remotely.

Next steps

If you have recurring, painful bumps in the armpits or groin, do not wait for the next flare to get answers. Learn more about our medical dermatology care and book a visit. Most major plans are accepted, including Medicare.

Seek urgent care if you have a fast-spreading red area, fever, or severe pain. Those can signal a serious infection that needs same-day, hands-on attention.