Hidradenitis Suppurativa Treatment in Kuwait
Hidradenitis suppurativa is one of the most under-diagnosed skin diseases we see; patients spend years being treated for "recurrent boils" or having abscesses drained in emergency again and again. Calling the condition by its proper name is the first real step towards controlling it and preventing permanent scarring.
What you should know
- Hidradenitis suppurativa is a chronic inflammatory disease that begins with occlusion of a hair follicle and produces painful nodules and recurrent abscesses in the body folds: the armpits, groin, under the breasts and around the buttocks. It is not an infection and has nothing to do with hygiene, and it is not contagious.
- The fact that troubles me most about this disease is the delay in diagnosis: the reported average worldwide is 7 to 10 years from the first symptom, and in one study of 285 patients the mean was 10.1 years. Most patients are treated for years as though they had recurrent boils before the condition is finally named.
- We grade severity by the three Hurley stages: stage I is single or multiple abscesses without sinus tracts or scarring; stage II is recurrent abscesses with tracts and scarring; stage III is diffuse interconnected tracts across the whole area. The stage is what decides whether we start with a topical, a biologic, or surgery.
- It affects roughly one person in a hundred, usually starts in the second or third decade after puberty, and the female-to-male ratio is about 3 to 1. One third of patients have an affected first-degree relative, which is why I always ask about family history.
- Smoking and excess weight are the strongest modifiable aggravators: smoking is linked to delayed wound healing and follicular occlusion, and excess weight increases friction and systemic inflammation. Stopping smoking and losing weight improve the outcome more than any topical cream.
- In brown skin (Fitzpatrick types III to V, the majority of my patients in Kuwait) the usual redness is absent: inflamed skin reads as violaceous, grey or brown rather than pink, so the disease can look milder than it truly is. Post-inflammatory hyperpigmentation in the flexures is evidence of previous inflammation even if the area looks quiet today.
- The disease is not confined to the skin: it is associated with metabolic syndrome, type 2 diabetes, polycystic ovary syndrome and inflammatory bowel disease, and with higher rates of depression. For that reason I check glucose and lipids and ask about mood at the first visit.
Treatment options
- For limited disease (Hurley I) I start with topical clindamycin 1% twice daily, together with an intralesional corticosteroid injection into an acutely painful nodule for fast relief. This controls flares but does not prevent new tracts from forming.
- In moderate disease we use oral antibiotics for their anti-inflammatory effect rather than as treatment of an infection: doxycycline 100 mg, or the combination of clindamycin 300 mg with rifampicin 300 mg twice daily for up to 12 weeks.
- In women whose flares track the menstrual cycle, hormonal and metabolic therapy helps: spironolactone 25–100 mg daily, metformin 2–3 g daily, or a combined oral contraceptive. The response is slower than with antibiotics and takes several months of patience.
- Biologics are the real advance in moderate-to-severe disease, but the honest numbers matter: adalimumab achieved an HiSCR50 response in 41–60% of patients versus 26–27% on placebo, secukinumab in 42–46% versus 31%, and bimekizumab in 48–52% versus 29–32%. That means about half of patients reach a meaningful response, not all of them.
- Established tracts and scars do not resolve with medication however long you take it; removing them is surgical. In a systematic review of post-surgical outcomes the average recurrence was 13% after wide excision versus 22% after local incision and 27% after deroofing, falling to 8% with flap closure and 6% with skin grafting.
- The best results come from combining both approaches: a biologic to calm the overall inflammation, then surgery to clear the worst-affected site, with laser hair reduction to reduce follicular occlusion and consistent wound care. Surgery settles the site that was operated on, while medication protects the rest of the body.
I am direct with every patient from the first visit: there is no treatment today that eradicates hidradenitis suppurativa from the body. Medication, biologics included, suppresses the inflammation and reduces flares for as long as you stay on it; surgery ends the disease in the specific area treated, but other sites may still become involved later. The realistic goal is long-term control with the least pain and the least scarring, and the earlier we start, the less permanent scarring there is.
Practical advice for patients
The practical points from the patient sheet I hand out in clinic.
- A chronic inflammation of fold areas (underarms, groins, under the breasts) causing painful nodules and recurrent abscesses; it is not poor hygiene and not contagious.
- Early diagnosis and regular treatment prevent scarring and skin tunnels — do not settle for emergency drainage each time.
- Smoking is the top trigger: quitting clearly improves the disease, and weight loss reduces flares and friction.
- Wear loose cotton clothing and avoid friction and traumatic shaving in inflamed areas (laser hair removal is often the better option).
- Use an antiseptic wash (chlorhexidine or benzoyl peroxide) on affected areas several times weekly.
- Do not squeeze the nodules; use warm compresses for painful ones, and come early for injections or medical drainage.
- Effective treatments exist by stage: courses of antibiotics, effective modern biologic injections, and surgical options for advanced cases.
- HS is emotionally exhausting — psychological support is a legitimate part of the plan, and regular follow-up changes the course of the disease.
Frequently asked questions
Is hidradenitis suppurativa contagious or caused by poor hygiene?
No, and this is the misconception that hurts patients most. It is an inflammatory disease that begins with occlusion of a hair follicle, not an infection passed on by shaking hands, sharing belongings or using swimming pools, and it has nothing to do with hygiene. The discharge and odour are a result of the inflammation, not its cause.
Does it come back after surgery?
It can, but the likelihood depends on the procedure: in a systematic review the average recurrence was 13% after wide excision, 22% after local incision and 27% after deroofing. More importantly, recurrence is usually at a new site rather than in the area that was completely excised, which is why we keep patients with widespread disease on medical treatment after surgery.
Will a biologic cure me completely?
No. A biologic suppresses the inflammation for as long as you stay on it, and the trial figures show roughly 41–60% on adalimumab and 42–46% on secukinumab reach an HiSCR50 response. So around half improve clearly, and if you are not among them we may need to switch drug. A biologic also cannot undo tracts or scars that have already formed.
When should I see a dermatologist instead of having the abscess drained in emergency each time?
If you have had two or more abscesses in the same area within six months, that is a diagnostic criterion, not bad luck. Repeated incision and drainage relieves pain for a couple of days and leaves a scar, but it does not change the course of the disease. Early diagnosis is what prevents progression to Hurley stage III with its permanent tracts and scarring.
Walk-in clinic – no appointment needed
My private clinic at Kuwait Hospital (Sabah Al-Salem) — walk-in, Sunday to Thursday, 8 am – 4 pm. Direct assessment and a treatment plan built around your case.
Ask on WhatsAppPatient advice sheets
Short, practical sheets to read before or after your visit.