Hidradenitis Suppurativa (HS) in Black People: Why It’s More Common

Hidradenitis suppurativa (HS) is a chronic skin condition that’s often undiagnosed for many years. And it’s especially common on the skin of Black people. HS can cause significant inflammation and scarring, so early detection is best. Knowing the signs to look for can help you know when to get treatment.

What is hidradenitis suppurativa? 

Hidradenitis suppurativa (HS) is a condition that causes long-term inflammation of the skin. It results in lesions underneath the skin that often look like pimples or boils, but it’s much more severe. It often comes and goes, and can cause intense pain and scarring of the skin. 

HS usually occurs where skin touches skin or in skin folds. That’s why it’s common to see HS in these areas:

• Armpits

• Groin

• Perianal (around the anus)

• Under the breasts

Experts believe HS starts in the hair follicles. When these follicles become clogged with skin protein (like keratin), sweat, or bacteria, deep nodules can develop under the skin.  

Lesions of HS can grow into an abscess (pocket of pus), which can be painful. If the abscess ruptures, it can drain pus or bloody fluid. And it can also form tunnels underneath the skin (sinus tracts) that can lead to scarring. Because of the serious lesions and pain, HS can be physically and emotionally distressing for some people. 

What causes hidradenitis suppurativa? 

HS may be an autoimmune condition, but it’s not entirely clear. HS has been linked to some autoimmune conditions, like lupus, psoriasis, and inflammatory bowel disease. And some people with HS do have autoantibodies commonly seen in these conditions. But there may be more at play. 

It’s clear that HS is the result of systemic inflammation. Experts believe this inflammation is due to a variety of factors: genetic, environmental, and behavioral. 

Genetic factors

About 4 in 10 people living with HS have a family history of the condition. In some cases, a specific gene has been linked to HS. There may be an increased chance of developing HS if you have gene mutations (changes) leading to an overactive immune system. This can result in chronic inflammation.

Environmental factors 

There’s also a link between HS and obesity. In people with a heavier body weight, the risk of HS is greater due to:

• More skin-fold surface area

• Extra rubbing or friction of the skin

• More sweating and moisture trapped in the skin 

There’s a known association with hormone changes and HS. Women are more likely to develop HS than men. And HS symptoms are closely linked with menstruation or other hormonal changes.

Behavioral factors

Smoking is also a risk factor for HS. The exact cause is unknown, but the association is clear. And HS is more severe in people who smoke cigarettes. Smoking may also decrease how effective HS treatment is.

Are Black people more likely to have hidradenitis suppurativa? 

HS can occur in people of any race and ethnicity. But Black people are three times more likely to develop HS when compared with other races and ethnic groups. The exact reason is unclear. It could be genetic, but environmental factors also play a role. 

The rates of obesity and certain autoimmune diseases are also higher in the Black community. These are known risk factors for HS and could also contribute to higher rates of the condition. 

What does hidradenitis suppurativa look like on Black skin? 

HS often looks like nodules underneath the skin surface. In Black skin they may not always be red. They may be flesh-colored, purple, or dark depending on your skin tone. These lesions can grow, become inflamed, and develop an abscess. This can sometimes look like a pimple, boil, or ingrown hair.  

An abscess from HS can burst open and drain from the skin. And this can lead to scarring of the skin as the deep wound heals. 

HS can be misdiagnosed, especially in mild cases of the disease. That’s why it’s important to see a dermatologist, a specialist in conditions of the skin. It’s also important to see a healthcare provider who specializes in skin diseases in people of color. They may recognize the changes of HS more readily than someone who’s mostly familiar with how HS looks in lighter skin tones.

How do you diagnose hidradenitis suppurativa?

A dermatologist, or healthcare provider specializing in skin care, can make the diagnosis of HS. This involves taking a thorough medical history of your symptoms and a physical exam. Blood tests and imaging are not needed to make the diagnosis. That is why it’s important to be open and honest with your healthcare provider. They will want to know about any family history, where your lesions are, and if the lesions are recurrent over a certain time period.

HS can be classified in one of three stages, known as the Hurley stages: 

• Hurley stage 1: This stage is considered “mild.” It typically occurs with one (or several) nodules that may develop into abscesses. There are no sinus tracts or tunnel formation.

• Hurley stage 2: This stage is considered “moderate." In this stage, you may have had recurring episodes of nodules and abscesses. These abscesses may be spread apart  but connected with a tunnel or sinus tract between the affected areas.

• Hurley stage 3: This stage is considered “severe.” In this stage, you may have a wide area of disease. This skin may have had recurring abscesses and sinus tunnels across an entire area.

How do you treat hidradenitis suppurativa? 

There’s no cure for hidradenitis suppurativa. But there are many ways of treating and managing HS to stop it from advancing. Treatment options for HS depend on the Hurley stage. The earlier HS is diagnosed, the better the chances to prevent scarring and complications. 

Treatment options can include oral medications (by mouth), topical medications (applied to the skin), injectables, or surgery. These options can be used individually or in combination with each other.  

Topical medications for HS 

Topical treatments are medications that you put on top of the skin. These medications typically come in a cream or ointment. Topical options include:

• Antibiotics: Medications like clindamycin can be placed on the skin to help reduce bacteria or infection.

• Resorcinol: Resorcinol is a scrub that can help reduce inflammation by opening up clogged hair follicles.

• Steroids: Sometimes healthcare providers recommend steroid injections (like kenalog) into HS lesions to help decrease inflammation.

Oral medications for HS

Depending on the stage of your HS, your healthcare provider may recommend oral medications, like:

• Antibiotics: Instead of a topical antibiotic, you may be given a pill to help decrease bacteria and infection. This can include medications like doxycycline or dapsone to help decrease inflammation.

• Hormonal therapies: These medications can help address hormonal factors that may be contributing to HS. Birth control pills, spironolactone, and finasteride have been used to help treat HS. 

• Metformin: This medication is well known for treating diabetes. But metformin can also help treat HS by reducing inflammation.

Injectable medications for HS

In severe cases, your healthcare provider might prescribe a biologic injectable. These medications target the immune system to decrease inflammation. FDA-approved injectable medications for treating HS include: 

• Adalimumab (Humira) 

• Secukinumab (Cosentyx) 

Surgery for HS

For severe HS, your healthcare provider may refer you to a surgeon to drain or remove the affected areas. Surgical options include traditional surgery or laser surgery. Depending on how large of an area you need removed, local wound care may be enough. But if your surgeon needs to remove a very large area, they may perform a skin graft to help the wound heal.

But surgery is not a definitive treatment. In fact, it’s common for HS to recur even after surgical treatment.

Talk with your healthcare provider about your treatment options for HS. Together you can develop a treatment plan to decrease your risk of HS lesions and complications.

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Written by:

Valerie Emuakhagbon, MD

Valerie Emuakhagbon, MD, is a board-certified colorectal surgeon. A native of Dallas, Texas, she completed the six-year BA/MD program at the University of Missouri-Kansas City.

Edited by:

Karla Robinson, MD

Karla Robinson, MD, is a medical editor for GoodRx. She is a licensed, board-certified family physician with almost 20 years of experience in health through varied clinical, administrative, and educational roles.

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