Hidradenitis Suppurativa on the Face

Most Hidradenitis suppurativa (HS) nodules occur in the armpits, groin, buttocks, and breast areas. However, HS can appear on the face. HS on the face can be mistaken for several other conditions and sometimes co-occur with them.

The exact cause of HS is unknown, but several factors make it worse. While most HS treatments work on the entire body, there are also treatments specifically for hidradenitis suppurativa on the face.

In this article, you will learn the symptoms and causes of HS on the face, how HS is treated, lifestyle changes you can make to help your symptoms, products to avoid, and tips for coping with the disease.

Facial Hidradenitis Suppurativa Symptoms

Hidradenitis suppurativa on the face can accompany HS in more typical spots such as the armpits or groin or, in rare cases, it may be the only sign of HS.  

If you already have HS, you may be more familiar with how an HS nodule or abscess appears. However, for those who have nodules only on their face, it is easy to mistake it for acne in its early stages.

HS can be confused with acne because the bumps and boils that form with HS often look like pimples. Though HS is also known as acne inversa, it is not the same as the more common acne, acne vulgaris. However, the two conditions can occur together.

Although acne and HS both involve inflammation and may appear similar, they are distinctly different in their genetics and risk factors.

What to Expect

HS abscesses that appear on the face may look similar to HS abscesses that typically occur on the body. However, because they often look similar to acne when on the face, it is easy to misdiagnose them.

Common symptoms specific to the face include:

• Pitted blackheads that may appear together
• Bumps or lumps in the skin
• Tunnels or tracts that connect the bumps that may contain pus
• Slow healing abscesses, or erupted pimples
• Ropelike scarring that is interconnected

Other Conditions That Look Like HS on the Face

HS on the face can often be confused with other conditions. If your only HS symptoms appear on the face, it may take longer for a healthcare provider to rule out these other conditions.

Other conditions that appear on the face that can be mistaken for HS include:

• Acne vulgaris is typical acne that usually occurs in adolescence. It is not uncommon for it to occur alongside HS.
• Cysts on the face also occur at the hair follicle but can be resolved with treatment and removal.
• Boils form when a hair follicle becomes infected. Like HS, pus will fill the boil. However, the boil is caused by bacteria, which a healthcare provider will likely test to determine which kind.
• Folliculitis may appear like acne or HS, but upon closer examination, a healthcare provider can distinguish it from the other diseases based on the way the hair follicle is affected and the type of bacteria present in the infection.

Causes of HS on the Face

Although no one knows the exact cause of HS, there are some factors that make it more likely you’ll get it. These can include:

• Genetics
• Smoking
• Being overweight
• Lithium (mood stabilizer) therapy
• Shaving of areas that are most likely to develop HS, such as the armpits and groin, which is associated with earlier onset of the disease

While the exact cause of HS is unknown it is important to note that HS is not caused by poor hygiene, nor is it contagious.

Treating Hidradenitis Suppurativa on the Face

Treatments for HS on the face are similar to treatments that are used on other areas of the body where HS develops. These treatments help slow progression of the disease, reduce inflammation, and prevent or reduce scarring.

Medications may also be prescribed to reduce flares of the disease, prevent scarring, and calm the inflammation around HS nodules. These can include:

• Antibiotics, such as tetracyclines, clindamycin, and erythromycin may be used. Though HS is not an infectious disease, antibiotics have been shown to change the microbiome (mix of bacteria present) of the skin to help ease HS symptoms.
• Corticosteroids are used to lower inflammation and dampen the immune response.
• Retinoids (vitamin A derivatives) are used on the skin to help with inflammation.
• Metformin helps regulate blood sugar as insulin resistance (the body does not use insulin well to keep blood sugar levels consistent) is associated with HS.
• Birth control pills/hormone therapy are used to help regulate sex hormones, such as estrogen and androgens, which are associated with flares of HS. Aldactone (spironolactone) has been found effective in some studies.
• Methotrexate, a chemotherapy agent, is used to regulate the immune system
• Biologics, such as Cosentyx (secukinumab), Humira (adalimumab), and Enbrel (etanercept), also work on the immune system to control the inflammatory response.
• Janus kinase (JAK) inhibitors have been used off-label for HS, with clinical trials underway to study their safety and effectiveness in HS. These include Rinvoq (upadacitinib) and Xeljanz (tofacitinib)

Chemical peels (applied to removed the top layers of the skin), such as resorcinol, have been beneficial in reducing pain, swelling, and size of HS nodules in those whose HS is in the early stages.

Surgical removal of hidradenitis suppurativa scars may become necessary if the scarring becomes infected, covers a large area, or creates tunnels under the skin. Surgery can also restore appearance.

Types of surgery can include:

• Skin grafting
• Laser removal
• Cryosurgery (uses cold)
• Scar revision

Scar shrinking injections such as with cortisone or collagen can soften and shrink scars, or promote new skin growth.

Some scar treatments should not be used while a person has active HS. Once a person is in long-term remission, they may consider dermabrasion, microdermabrasion, laser resurfacing, and microneedling.

Lifestyle Changes and Home Remedies

Certain lifestyle changes and home remedies can help ease symptoms and slow progression of the disease.

Living With HS on the Face

Making changes to your lifestyle can help improve symptoms with HS on the face. Lifestyle changes that reduce symptoms include:

• Have laser hair removal: Irritation from shaving can cause HS flares. Laser hair removal can minimize inflammation around bumps and hair follicles.
• Stop smoking: Smoking is associated with an increased risk of HS and can increase the severity of the disease.
• Maintain a healthy weight: Obesity is a risk factor for developing HS and can also increase its severity.
• Massage scars: Massaging a scar can help even out the skin tone and decrease scar tissue to prevent raised scars. Before massaging a scar make sure that any scabbing has healed.

Products and Other Home Remedies That Might Help

There are also certain products that you can buy over the counter that may help ease symptoms as well.

These include:

• Probiotic, prebiotic, and medicated cleansers and other products with benzoyl peroxide, salicylic acid, or chlorhexidine digluconate have all been shown to minimize flares and promote healing of HS nodules.
• Warm compresses can help with pain associated with nodules as they form.
• Scar creams, lighteners, and dressings can all help with the appearance of scars. Properly caring for an open wound can prevent infection and minimize scarring. Applying topicals like Mederma, vitamin E, and cocoa butter can also help with scar appearance.
• Moisturizers and other topical products like Mederma that contain dimethicone, a silicone-based polymer, protect the skin and help prevent and reduce scarring.
• Nonsteroidal anti-inflammatories (NSAIDs) such as Advil (ibuprofen) can reduce inflammation and alleviate pain.
• Cortisone creams (topical products that contain cortisone) can reduce inflammation and minimize the appearance of scars.
• Use sunscreen that won’t irritate HS bumps and scars such as lighter powder formulations. Using sunscreen can also prevent dyspigmentation (abnormal coloring) in scars.

Products to Avoid

Certain foods and other products can cause HS to flare or increase inflammation in already formed nodules. These include:

• Brewer’s yeast: One small study found that eliminating brewer’s yeast found in products like bread and beer helped stabilize and reverse HS over the course of a year.
• Dairy products: These may elevate insulin and androgen hormones, which can increase the number of nodules.
• Razors: Shaving can cause friction and irritation of the skin and can cause nodules to form. It can also irritate already developed nodules.
• Sugary foods: These can also elevate insulin and affect weight, which are known to increase the severity of HS.
• Tobacco: Smoking is an established aggravator of HS.
• Makeup: While no link between cosmetics and HS has been made, it is possible that certain chemicals may cause a reaction. If this is true for you, you may consider not wearing makeup.

Coping With Hidradenitis Suppurativa on the Face

Living with hidradenitis suppurativa on the face is hard, especially during flare-ups. It is normal to feel embarrassed. Talking to your healthcare provider about treatment options and how to best keep HS from flaring can help give you a sense of control.

If you feel overwhelmed or alone, you might consider talking to a mental health professional or seeking out a support group full of other people living with HS.

Summary

Hidradenitis suppurativa often occurs near sweat glands and hair follicles but in some people, HS occurs on the face. HS on the face can also be mistaken for several other conditions that can occur at the same time.

There are a number of factors that make HS worse, although the exact cause is unknown. Treatments for HS on the face include medications and lifestyle changes such as quitting smoking, avoiding products that can irritate the nodules.