Hidradenitis Suppurativa in Men: Managing Groin and Underarm Flares

What Is Hidradenitis Suppurativa?

HS is not a simple skin infection — it's a chronic inflammatory disease of the hair follicle. The process begins when hair follicles in skin fold areas become blocked, rupture beneath the skin surface, and trigger an intense immune response. Over time, this creates:

• Nodules: Deep, painful lumps under the skin (often mistaken for boils or ingrown hairs)
• Abscesses: Pus-filled collections that may drain spontaneously, producing foul-smelling discharge
• Sinus tracts (tunnels): Channels connecting abscesses beneath the skin surface — a hallmark of advanced HS
• Scarring: Thick, rope-like scars that can restrict movement in severe cases

HS in Men: Specific Concerns

While HS is more common in women overall, men have distinct patterns:

• Groin and perianal area: More commonly affected in men than women. Nodules around the groin, buttocks, and perianal region can be severely painful and interfere with sitting, walking, and physical activity.
• Axillary (underarm) involvement: Common in both sexes but can be particularly problematic for men who are physically active.
• Delayed diagnosis: Men wait an average of 7-10 years before being diagnosed, often because they assume recurrent boils are infections or ingrown hairs. The average HS patient sees 3-4 doctors before receiving the correct diagnosis.
• Smoking: Up to 70-90% of HS patients smoke, and smoking is a major modifiable risk factor. Nicotine promotes follicular plugging and inflammation. Quitting is one of the most impactful interventions.

Staging (Hurley Classification)

• Stage I (mild): Single or multiple abscesses without sinus tracts or scarring (majority of patients)
• Stage II (moderate): Recurrent abscesses with sinus tracts and scarring in one or more areas
• Stage III (severe): Diffuse involvement with multiple interconnected sinus tracts and extensive scarring

Treatment Options

Lifestyle modifications (all stages):

• Quit smoking — the single most impactful lifestyle change
• Weight management: Obesity worsens HS through increased friction and inflammation. Even 10% weight loss can reduce flare frequency.
• Gentle cleansing: Use benzoyl peroxide (5-10%) wash or chlorhexidine wash on affected areas daily
• Loose clothing: Reduce friction with breathable, non-restrictive fabrics
• Avoid shaving affected areas — trimming or laser hair removal are safer alternatives

Medical treatments:

• Topical clindamycin: First-line for mild HS. Apply twice daily to affected areas.
• Oral antibiotics: Doxycycline for mild-moderate HS. Clindamycin + rifampicin combination for moderate disease (10-12 week courses).
• Adalimumab (Humira): The first FDA-approved biologic for HS. Blocks TNF-alpha inflammation. Significant improvement in about 50% of moderate-to-severe patients.
• Secukinumab (Cosentyx): IL-17A inhibitor, FDA-approved for HS in 2023. Another biologic option for moderate-to-severe disease.
• Intralesional corticosteroids: Injection directly into acute nodules for rapid relief.

Surgical options:

• Incision and drainage for acute painful abscesses (temporary relief)
• Deroofing of sinus tracts (removing the "roof" of tunnels)
• Wide excision for severely affected areas — most definitive but creates larger wounds

Frequently Asked Questions

Is HS contagious?

No. HS is an inflammatory condition, not an infection. It cannot be transmitted to others through contact, shared clothing, or sexual activity. Despite the pus and drainage, the condition is driven by immune dysfunction, not bacterial transmission.

Will HS ever go away?

HS is a chronic condition that tends to fluctuate over decades. Some patients experience periods of remission, while others have continuous disease. Early aggressive treatment can prevent progression to more severe stages. About 20-30% of patients with mild HS may have long remissions.

Can diet affect HS?

Some patients report improvement with dairy elimination or reduced refined sugar intake, though evidence is limited. Brewer's yeast avoidance has shown benefit in small studies. A food diary can help identify personal dietary triggers.