Hidradenitis suppurativa or acne inversa
DO YOU HAVE PAINFUL LUMPS OR ABCESSES UNDER YOUR ARMPITS OR IN THE GROIN AREA?
Photo: © vladimirfloyd – stock.adobe.com
Author: Dr. Johannes Bisschoff · Last updated: 11 October 2026
If this is the case, you may be suffering from hidradenitis suppurativa or acne inversa, an extremely stressful condition that can reduce life quality much more than with other skin disorders.
What are the triggers and causes of acne inversa and how should it be treated? You will find answers to your questions here:
-
Why do creams and tablets for normal acne not also help with this condition?
-
What are the new treatment options for hidradenitis suppurativa?
Need an urgent appointment on short notice? Click here
What is the diagnosis of acne inversa?
Acne inversa (hidradenitis suppurativa) is characterized by chronic inflammation and purulent abscesses in the armpits, groin, genitals or buttocks. They are persistent, do not heal on their own and are accompanied with severe pain. In the advanced stage, it is not just the pain, but the scar formation that limits mobility.
If you notice these symptoms in yourself or a family member, seek the advice of a dermatologist immediately. Such skin alterations must always be examined by a doctor.
Studies show that acne inversa is one of the skin conditions that has the greatest negative impact on quality of life. This is understandable because patients suffer from acute pain and discomfort in and around highly sensitive parts of the body. In addition, acne inversa is taboo due to the affected parts of the body, which is why patients often feel shame. As a result, the disease negatively affects both social and sexual life.
Only a few people have heard of the name acne inversa. However, the condition is not uncommon. It is estimated that up to 2% of the population suffer from it. Studies have shown that the diagnosis takes an average of seven years after the onset of the disease.
Often, a visit to the doctor only happens when the conditions is already at the acute inflammatory with severe pain stage. Doctors often prescribe medication for this acute state, without diagnosing the actual condition and instead of putting the patient on the correct comprehensive course of treatment.
A diagnosis of acne or folliculitis (inflammation of the hair roots), or an acute abscess, is often made, which fails to consider the chronic abscess disease that acne inverse is. Often, the suggested treatment does not yield positive results and leaves the patient feeling frustrated and helpless. It is not uncommon for patients to suffer in silence on the assumption that their condition cannot be alleviated. The characteristics and development of the condition vary between patients to differing degrees. Research is working on classifying the disease, but valid models do not yet exist. More women than men are affected, and the disease is not limited to certain skin types. There also seems to be a hereditary component, since blood relatives (close and distant) are often affected.
What causes acne inversa?
Acne inversa (hidradenitis suppurativa) is a chronic inflammatory skin disease whose exact causes are not yet fully understood. At its core are changes in the hair follicles and an excessive inflammatory response of the immune system.
It is considered likely that a keratinisation disorder of the hair follicle leads to a blockage of the follicular duct. Over time, the hair follicle ruptures beneath the skin surface, causing painful inflammation.
Acne inversa is not classified as a classic autoimmune disease. Rather, it is an immune-mediated inflammatory disease in which various inflammatory messenger substances play an important role.
This knowledge now enables targeted treatment options. In moderate to severe acne inversa, modern biologics can be used under certain conditions. In the European Union, the active substances adalimumab, secukinumab and bimekizumab, among others, are approved for this purpose.
Acne inversa is neither contagious nor a result of poor hygiene.
Acne inversa differs from the so-called "normal" acne, referred to as acne vulgaris, mainly because of where it is found. Acne vulgaris appears on the face, chest or back, and increased sebum production is present in acne vulgaris. However, in both conditions hyperkeratosis of the hair follicle occurs.
In contrast, the areas affected by acne inversa are skin folds, usually around the groin, armpits or genitals. Only very rarely is the face affected. Often blood-related people suffer in varying degrees from the condition. The first symptoms are red, painful inflamed nodules. These then develop into abscesses. Intense flare-ups can occur from time to time and permanent scarring cannot be excluded. The resulting diminished quality of life is an additional heavy burden. Patients with inverse acne suffer from chronic inflammation, which places an enormous stress on the body. As time goes on, other symptoms appear that indicate the presence of additional diseases.
Which factors influence acne inversa?
Several factors interact in the development and course of acne inversa. A distinction should be made between an individual predisposition and influences that can aggravate the condition.
Genetic predisposition: Acne inversa occurs more frequently in some families. A family predisposition can increase the risk of developing acne inversa. However, it does not automatically mean that the disease will occur, and it is not a direct trigger of individual flare-ups.
Smoking and excess weight: Both factors are associated with acne inversa and, in some cases, with more severe disease. Stopping smoking and losing weight if overweight can therefore be important parts of a holistic treatment plan.
Mechanical friction and sweating: Friction, pressure and moisture in sensitive skin areas can aggravate existing symptoms. Loose, breathable clothing can help avoid additional skin irritation.
Stress and hormonal influences: Some patients report that their symptoms worsen during stressful periods or in connection with hormonal changes. These relationships vary from person to person and are not yet fully understood scientifically.
Important: Acne inversa is not caused by a single factor. People who do not smoke, are of normal weight and live a healthy lifestyle can also develop acne inversa.
How is acne inversa diagnosed?
Acne inversa (hidradenitis suppurativa) is diagnosed primarily through a dermatological examination. Experienced dermatologists usually recognise the condition by its characteristic skin changes, typical locations and recurring course.
Three key criteria are decisive for the diagnosis:
1. Typical skin changes
Acne inversa often presents as painful, deep-seated nodules and recurring abscesses. Over time, inflammatory tunnels under the skin (fistulas), scars and so-called double comedones (blackheads occurring in pairs) can develop.
2. Typical body regions
Areas where skin touches skin are most frequently affected, including:
- Armpits
- Groin and genital area
- Buttocks and gluteal cleft
- Area beneath the breasts
- Perineal and anal region
However, the condition can also occur in other parts of the body.
3. Recurring or chronic course
A characteristic feature is that symptoms recur repeatedly or persist over a longer period. New inflammation often develops in the same or neighbouring areas of skin.
Important: Not every recurring abscess automatically means acne inversa. Other skin conditions may need to be ruled out. An early dermatological assessment is therefore particularly important.
How is the severity of acne inversa determined?
Acne inversa does not progress the same way in everyone. Some patients only occasionally develop inflamed nodules, while others experience recurring abscesses, tunnels or pronounced scarring.
To assess the condition as accurately as possible and choose the right treatment, two scoring systems are commonly used: the Hurley classification and the IHS4 score.
Hurley classification: how much has the skin already changed?
The Hurley classification mainly describes permanent tissue changes and distinguishes three stages:
- Hurley stage I: Single or multiple abscesses without detectable tunnels or scarring.
- Hurley stage II: Recurring abscesses with tunnels and scarring. The affected areas are separated by healthy skin.
- Hurley stage III: Extensive or almost diffuse involvement of a body region with interconnected tunnels and abscesses.
This classification is particularly helpful when deciding whether surgery may be useful in addition to medical treatment.
IHS4 score: how active is the inflammation right now?
The International Hidradenitis Suppurativa Severity Score System (IHS4) assesses current inflammatory activity based on the number of inflammatory lesions. Three types of lesions are weighted differently:
- Inflammatory nodules: 1 point
- Abscesses: 2 points
- Draining tunnels: 4 points
The total score indicates the current disease activity:
- 0–3 points: mild disease activity
- 4–10 points: moderate disease activity
- 11 points or more: severe disease activity
The IHS4 score can be repeated over time to assess changes in inflammatory activity and the response to treatment.
Why are both assessments important?
The Hurley classification and the IHS4 score complement each other. While the Hurley classification mainly shows how much the skin has already been structurally changed by the disease, the IHS4 score captures how active the inflammation is at the time of the examination.
For example, a patient may already have pronounced scars and tunnels even though only a few inflamed nodules are currently present.
Treatment of acne inversa is therefore tailored to each individual. In addition to the Hurley stage and the IHS4 score, we take into account factors such as pain, affected body regions, quality of life and previous treatments.
Why is early treatment of acne inversa so important?
With acne inversa, the following applies: the earlier the disease is recognised and treated in a targeted way, the better the chances often are of controlling inflammation and avoiding permanent skin damage.
Acne inversa can progress in different ways. While some patients develop only individual inflamed nodules over a long period, others develop recurring abscesses, tunnels and scars. How the disease will develop cannot always be predicted.
This is exactly why it is important not to wait too long when the first signs appear. As long as no pronounced tunnels or scarring have formed, there are often more options for less invasive treatment. Existing structural skin changes, on the other hand, may require additional surgical measures.
An early diagnosis and individually tailored therapy can help reduce inflammatory activity, relieve symptoms and lower the risk of further disease progression.
Recurring painful nodules or abscesses should therefore be examined by a dermatologist as early as possible – even if the symptoms disappear in the meantime.
We help you recognise acne inversa early and develop a treatment plan tailored to your individual condition.
Why don't creams and tablets for normal acne also help against acne inversa (hidradenitis suppurativa?
They are two different conditions with different causes. Excessive sebum production in acne vulgaris is often caused by hormonal changes, and it is not a chronic disease that the patient suffers from for many years. In contrast, acne inversa often only appears after puberty. Acne vulgaris treatment methods, such as a high dose of vitamin A or fruit acid peels, have proven ineffective for acne inversa (hidradenitis suppurativa).
What treatment is available?
First of all, acne inversa or hidradenitis suppurativa is a chronic disease. With suitable treatment, inflammatory activity can be reduced and longer periods with few symptoms can be achieved. With a coordinated drug treatment plan, depending on the location and severity of the affected areas, the following options provide favorable opportunities for relief:
- Localized antibiotic treatment for flare ups
- Ointments applied to the acute areas
- Zinc supplements in high dosages (in combination with other treatment methods)
- Oral antibiotic treatment over a longer period (weeks, months), and in the case of severe diagnoses (double antibiosis)
- Androgen blockers (pill) in women
- Hormone treatment, only if prescribed by a specialist and with medical supervision
- Immunosuppressive therapy using antibodies / biologicals in therapy-resistant cases
Surgical procedures are not only an option in severe cases – they can also be useful for localised, recurring lesions, for example as deroofing or local excision. In extensive disease, fistulas and deep nodules can be treated surgically in a clinic specialising in acne inversa. This removes all abscesses and nodes, including the scar tissue in the affected areas. This surgery is followed by open wound healing, which, depending on the results, can take two to three months. In many cases, permanent relief (remission) is achieved because the renewed tissue no longer contains hair follicles. The danger is that there is a recurrence in the periphery of the affected areas, or that the condition has progressed to such an extent that irreversible damage cannot be avoided. This can represent an enormous psychological burden, especially for those where the genital region is affected. Because it is a chronic disease, one cannot rule out that symptoms could appear elsewhere, even after surgery.
Since 2017, LAight® therapy has been available in Europe as a CE-marked medical device for the treatment of acne inversa/hidradenitis suppurativa. This is a classification under medical device regulations – not a marketing authorisation as required for medicines. The therapy is mentioned in the current European S2k guidelines for hidradenitis suppurativa/acne inversa – particularly for mild to moderate disease.
What can I expect from the lAight therapy?
It is a combination of a special light spectrum and a radio frequency. Targeted light waves are anti-inflammatory, germicidal and reduce hyperkeratosis of the hair follicle. The radio frequency ensures a targeted attack on the abscess or fistula wall, thereby stimulating new tissue formation and regulating sebum production. This leads to the opening up of the blockages, as well as a drying up and decline of existing comedones (blackheads).
Dr. Bisschoff was able to gain a lot of experience with LAight therapy during his specialist training in Hamburg. It was a pleasure to monitor the success of the treatment in a large number of patients. With regular use, the therapy is a good option particularly for mild to moderate disease and can be combined with medical or surgical treatment where needed.
We are very pleased to offfer the lAight therapy in our office in Vienna since March 2021. We have specially trained doctor's assistants on our team who have a lot op experience with acne inversa (hidradenitis suppurativa) and lAight therapy.
What do the latest medical studies say?
Recent studies show modified colonization (microbiome) of the skin and intestines in patients affected by acne inversa. Based on analyses of the existing population of the study, a proposal for alternatives is being developed. It is assumed that a change in germ colonization will soon make it easier to understand and treat many diseases that are difficult to treat today.
What are the new treatment options for hidradenitis suppurativa?
Fortunately, there are continuously emerging treatment options for individuals affected by hidradenitis suppurativa. Currently, there are three antibodies approved by the European Medicines Agency (EMA): adalimumab, secukinumab and bimekizumab, also known as biologics, which are administered through injections. These therapies aim to modulate and alter the misdirected immune response. It is essential to undergo regular monitoring by experienced physicians, all of our doctors are well-versed in this form of treatment.
Additionally, there are ongoing developments in the field, with other medications currently being researched and developed. Our practice consistently participates in the development of new drugs to aid our patients and contribute to the advancement of medical and pharmaceutical research.
Complementary and supportive treatments
In addition to targeted medical and surgical therapies, complementary measures also play an important role in the treatment of hidradenitis suppurativa (acne inversa).
Current guidelines recommend various supportive treatment approaches that can help relieve symptoms and positively influence the course of the disease on an individual basis. These include:
- Injection treatment for hyperhidrosis (excessive sweating) to reduce sweat production and possible additional skin irritation.
- Laser hair removal to reduce inflammatory activity in affected skin areas.
- Weight reduction if overweight, which can have a positive effect on disease activity.
- Medication to support weight loss, for example GLP-1 receptor agonists. Early scientific findings suggest that these medicines may also have a positive effect on the course of hidradenitis suppurativa.
During your initial consultation, our doctors will discuss all suitable complementary treatment options with you. Together, we develop an individual treatment plan that takes into account both targeted treatment of the disease and supportive measures.
Where can I get more information?
For more information about the condition, you can contact the support group Mullewupp e.V. Excellent educational work is carried out there. Further information can be found at www.akne-inversa.at. There you can find a built-in symptom check, which provides initial insights.
We are happy to create a treatment plan with you in our office.
What can I do myself to relieve the symptoms?
Aside from medical treatment, lifestyle changes can also influence the severity of symptoms:
Stress Reduction
Avoid irritation of the skin (no tight-fitting clothes, no synthetic materials)
Germ reduction in the affected areas (e.g. disinfectant washing lotion)
Avoid wet shaving (due to the risk of micro lesions and their bacterial colonization)
Weight reduction for anyone overweight
Nicotine avoidance or reduction for smokers
We would be happy to help you create a holistic plan to alleviate your complaints.
Need an urgent appointment on short notice? Click here
Dr. Dariana Borlea focuses on the long-term care of chronic inflammatory skin diseases such as hidradenitis suppurativa, psoriasis and atopic dermatitis, and has experience in biologic therapy.
Dr. Lara Durakbaşa combines experience with biologics with extensive surgical expertise – including laser treatments (e.g. laser deroofing).
Dr. Johannes Bisschoff has been involved with hidradenitis suppurativa since his training. In addition to surgical procedures, he also uses biologics and has offered LAight therapy (radiofrequency and light) for many years, having been the first physician to introduce it in Austria.
All of our colleagues provide holistic advice based on the latest standards and current guidelines.
FAQ – Hidradenitis Suppurativa & Abscess Disorders
Here you will find answers to the most important questions about hidradenitis suppurativa, risk factors, self-management and modern treatment options.
-
What is hidradenitis suppurativa?
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that causes painful nodules, abscesses, fistulas and scarring, mainly in the armpits, groin, buttocks and genital area.
-
What causes hidradenitis suppurativa?
The exact cause is unknown. Factors include follicular occlusion, genetics, bacterial colonization, obesity, smoking and friction in skin folds.
-
Why don’t regular acne creams work?
HS does not affect facial oil glands like "normal acne" but deep follicular structures in skin folds, so standard acne treatments are largely ineffective as the cause is different for both diseases.
-
What treatment options are available?
Treatments include permanent hair-removal, topical and oral antibiotics, hormone therapy in women, biologics for severe cases, surgical removal of nodules and the LAight® therapy for mild to moderate HS.
-
Which risk factors worsen HS?
Key risk factors include obesity, smoking, friction, family history and stress. These factors increase inflammation and flare-ups.
-
Can hidradenitis suppurativa be cured?
A complete cure is currently not possible. Treatment focuses on long-term inflammation control, pain reduction and preventing scarring and relapses.
-
What can I do myself to reduce symptoms?
Stopping smoking, losing weight, using antiseptic skincare, avoiding tight clothing and friction, avoiding wet shaving in affected areas and reducing stress can help.
-
Where can I go for consultation and treatment if I suffer from hidradenitis suppurativa?
Hidradenitis suppurativa is a complex chronic condition that often requires several treatment approaches at the same time. For this reason, it is recommended to seek care at a specialized center with a clear focus on HS. Such centers provide comprehensive counselling, guideline-based diagnostics and individualized treatment plans. Since HS is a progressive disease, every day counts – early treatment greatly improves long-term outcomes.
-
How does a dermatologist recognise hidradenitis suppurativa?
A dermatologist recognises acne inversa (hidradenitis suppurativa) primarily on the basis of the medical history and a thorough examination of the skin. Three typical criteria are decisive for the diagnosis:
- Typical skin changes: Recurring, painful, deep-seated nodules and abscesses, and possibly tunnels (fistulas) and scars.
- Typical body sites: The changes occur mainly in the armpits, the groin, the genital and anal area and beneath the breasts.
- Chronic or recurring course: The inflammatory skin changes recur, for example at least twice within six months.
If all three criteria are met, this points to acne inversa. Additional examinations such as ultrasound can help detect deeper inflammation and tunnels. A blood test alone cannot confirm acne inversa.
You can find more information in the section “How is acne inversa diagnosed?”.
-
What are the stages of hidradenitis suppurativa?
The severity of acne inversa is often classified into three stages using the Hurley classification. The presence of tunnels (fistulas) and scars and the extent of the affected skin areas are particularly important.
- Hurley stage I: Single or multiple inflamed nodules and abscesses, but without tunnels or disease-typical scarring.
- Hurley stage II: Recurring abscesses with tunnels and scars. The affected areas of inflammation are separated from each other.
- Hurley stage III: Extensive skin changes with numerous interconnected tunnels and abscesses covering large parts of an affected body region.
The Hurley classification helps the dermatologist assess the extent of the disease and plan suitable treatment. As it mainly reflects tissue changes that have already developed, it does not necessarily describe current inflammatory activity.
You can find more about the classification in the section “How is acne inversa diagnosed?”.
-
What does the IHS4 score mean in hidradenitis suppurativa?
The IHS4 score (International Hidradenitis Suppurativa Severity Score System) is a scoring system that dermatologists use to assess current inflammatory disease activity in acne inversa.
Three types of skin lesions are counted and weighted differently:
- Inflammatory nodules: number × 1
- Abscesses: number × 2
- Draining tunnels: number × 4
The sum gives the IHS4 value, which is classified as follows:
- 0–3 points: mild disease activity
- 4–10 points: moderate disease activity
- 11 points or more: severe disease activity
Unlike the Hurley classification, which mainly describes structural skin changes, the IHS4 score can reflect changes in current inflammatory activity over the course of the disease. It is therefore also used to assess the response to treatment.
You can find further details in the section “How is acne inversa diagnosed?”.
More Information:
1) Our article on LAight® Therapy is online - LAight® Therapy Improves Hidradenitis Suppurativa in Patients Declining Surgical Intervention: Two Case Reports
2) Guidelines: European S2k guidelines for hidradenitis suppurativa/acne inversa (Journal of the European Academy of Dermatology and Venereology)
3) ACNE INVERSA: INTERVIEW WITH DR. JOHANNES BISSCHOFF
-middle.webp)
Read more now at fitundgesund.at (German)
