Hidradenitis Suppurativa: The Condition Nobody Talks About

Chapter 42 · Vihang Rahul Vasa

I live with this condition, so I will say plainly what most books leave out. Hidradenitis suppurativa, HS for short, is a chronic inflammatory skin disease. It causes painful lumps, boils, and abscesses that keep coming back, usually where skin rubs against skin: the armpits, the groin, under the breasts, the inner thighs. The lumps can burst, leak, heal slowly, and leave scars and tunnels under the skin. It can go quiet for months and then flare again.

It is a very painful condition, and a difficult one to live with. The pain, the discharge, and the fear of a flare in a public place wear a person down. Many people with HS stop going out, avoid company, and slowly withdraw from social life, and depression is common alongside it. If this is happening to you, it is part of the condition, not a weakness: tell your doctor, because your mind needs care as much as your skin does.

What it is not. It is not caused by poor hygiene. It is not contagious. It is not an ordinary boil that a course of medicine will finish. And it is not caused by diabetes alone, but HS, insulin resistance, and metabolic disease travel together far more often than chance, and high plasma glucose (blood sugar) and extra inflammation in the body make it flare more often and heal more slowly. HS is also seen more often in people with Crohn’s disease, an inflammatory condition of the bowel: one more sign that it is a whole-body inflammatory problem, not a skin problem alone. Notice, too, that acanthosis nigricans, the dark velvety patches caused by insulin resistance, appears in the very same places as HS: the armpits, the groin, the folds. The two conditions share an address because they share a cause.

Why it is hard. There is no blood test for HS: the diagnosis is made by an experienced doctor looking at the skin and listening to the history. There is no 100% confirmed cure yet. Treatment is about control: reducing flares, managing pain, preventing infection and scarring. Because it is not common, many doctors see it rarely. Find a dermatologist who knows HS well, and, because of the metabolic link, a hepatologist, the liver doctor, for MASLD (Metabolic dysfunction–associated steatotic liver disease, liver fat linked to metabolic problems like obesity, diabetes, cholesterol or insulin resistance), should be part of the picture too. Understand every treatment offered first: never accept one without understanding it. Ask for the simplest explanation, and if any doubt remains, ask again. Some options carry serious risks of their own, and the decision belongs to you and your treating doctors together.

What helps, in my experience. Keeping insulin resistance in check, and keeping the areas clean: these two are the key. Keeping plasma glucose (blood sugar) in range. Keeping weight down. No smoking, and no tobacco in any form. Loose, breathable clothing (see Chapter 37). Keeping the affected areas clean and dry without scrubbing. Never squeezing or cutting a lump yourself. Reporting a new flare early, before it grows.

What to watch. Fever with a flare, a lump that grows fast, spreading redness, a discharge that smells, or tunnels forming under the skin: these need a doctor the same day, not next week.

This chapter is here because for a long time I treated each flare as a separate misfortune and never connected it to what was happening inside. I never realised it was connected with diabetes and MASLD (Metabolic dysfunction–associated steatotic liver disease: liver fat linked to metabolic problems like obesity, diabetes, cholesterol or insulin resistance). If you have recurring boils in these areas, tell your doctor about your diabetes and your liver, and ask whether the boils are connected to them. It took me a long time to see the connection and ask that question: you can ask it today.

(References for this chapter, the hidradenitis suppurativa primer and the meta-analysis of its link with diabetes, are listed in Appendix B.)

Illustration: Chapter 42 illustrated summary. Hidradenitis suppurativa can cause painful lumps in armpits, underbreast folds and groin folds.

Chapter 42 Hidradenitis suppurativa can cause painful lumps in armpits, underbreast folds and groin folds. It is not poor hygiene and is not contagious. The figure combines emotional wellbeing, gentle care, breathable clothing and dermatologist-led care. Fever or spreading redness needs same-day review.

Chapter at a glance: an AI-generated illustration to be read with the chapter, not instead of it. The people shown are not real.