Condition Hub — Hidradenitis Suppurativa

HS Is Not a Skin Disease.
Here Is What It Actually Is.

Name: Understanding Hidradenitis Suppurativa
Creator: Dr. Adil Moulanchikkal

Hidradenitis Suppurativa develops from the inside out — driven by gut dysfunction, hormonal imbalance, immune dysregulation, and metabolic disruption. Understanding this changes everything about how it is approached.

Start Reading Find Your Subtype

What HS Actually Is

A Systemic Condition That Speaks Through the Skin

Hidradenitis Suppurativa is a chronic, progressive inflammatory condition that causes recurring painful nodules, abscesses, sinus tracts, and scarring — primarily in skin folds: the underarms, groin, inner thighs, buttocks, and beneath the breasts.

Most people are told it is a skin infection. Some are told it is caused by poor hygiene. Others are handed antibiotics without explanation. The reality is considerably more complex — and considerably more treatable — than those answers suggest.

HS is not caused by bacteria. It is not caused by poor hygiene. It is a systemic inflammatory-metabolic disorder that uses the skin as its primary expression site. The lesions that appear are the endpoint of a process that originates in the gut, hormones, immune system, and metabolism — systems that are rarely examined or addressed in standard dermatological care.

This is why it recurs. When only the lesion is treated, the internal process that created it continues undisturbed — building toward the next flare, and the one after that.

"HS is not a skin problem. It is a systemic inflammatory condition expressing through the skin."

Quick Reference

Also known as

Acne Inversa · Verneuil's Disease

Prevalence

Affects approximately 1% of the global population. Significantly underdiagnosed.

Average diagnosis delay

7–10 years globally

Most affected

Women 3× more than men · Ages 16–40 · PCOS-linked in women

Classification

Hurley Stage I, II, or III — based on severity

Ayurvedic Parallel — Tridoshic Dushti with Srotorodha

7–10 yrs

Average time from first symptoms to correct diagnosis

3×

More common in women than men — hormonal involvement is primary

30–40%

Of patients have a family history — genetic susceptibility, not genetic destiny

Stage II–III

Most patients presenting at EPOH — after conventional treatment has been exhausted

Root Cause Analysis

Why HS Develops — The Five Interconnected Systems

HS is not caused by a single failure. It develops when multiple body systems lose their coordination over time. Each system amplifies the others. This is why addressing one system alone produces incomplete and temporary results.

System 01

Gut Dysfunction

Agni · Ama

When digestive strength weakens — whether from poor diet, irregular eating, or chronic stress — the gut fails to process food cleanly. This produces inflammatory residue that enters the bloodstream and triggers immune activation throughout the body.

The gut–skin axis is well established in modern research: gut dysbiosis directly correlates with skin inflammation severity. In Ayurveda, this is the accumulation of Ama — metabolic toxin — that congests the body's channels and sustains the inflammatory cycle. In many HS patients, gut symptoms like bloating, irregular digestion, and food sensitivities are present years before significant skin involvement begins.

System 02

Hormonal Imbalance

Pitta · Meda Dushti

Androgens — particularly testosterone and its derivatives — drive follicular activity. When androgen levels are elevated or follicular sensitivity is heightened, hair follicles undergo increased keratinisation, making occlusion more likely. This is why HS in women often worsens before menstruation, flares in PCOS, and responds to hormonal interventions.

Insulin resistance compounds this: elevated insulin stimulates androgen production and promotes systemic inflammation simultaneously. Addressing HS without evaluating hormonal and metabolic status misses one of the most significant drivers of the condition.

System 03

Immune Dysregulation

Rakta Dushti · Ojas Kshaya

In HS, the immune system's response to a ruptured follicle is profoundly disproportionate to the triggering event. Inflammatory cytokines — TNF-α, IL-1β, IL-17, IL-23 — are elevated at levels comparable to autoimmune conditions. The body is not fighting an infection; it is fighting itself.

This misfiring becomes self-sustaining: each inflammatory episode sensitises the immune response further, lowering the threshold for the next one. Over time, the inflammatory environment itself becomes the trigger — independent of external events. This is the mechanism behind spontaneous flares that patients describe as "coming from nowhere."

System 04

Lymphatic Stagnation

Srotorodha · Rasa Dushti

HS consistently targets areas of high lymphatic density — the axilla, groin, inframammary fold, and perianal region. These are not arbitrary locations. They are sites where lymphatic drainage, immune surveillance, and mechanical friction converge. When lymphatic flow slows, inflammatory mediators and metabolic waste accumulate in precisely these locations.

Ayurveda describes this as Srotorodha — obstruction of the body's channels — a concept that aligns precisely with modern understanding of lymphatic dysfunction. Supporting lymphatic flow is an underexplored but clinically significant element of HS management.

System 05

Follicular & Tissue Vulnerability

Mamsa Dushti · Vata Kopa

The follicle is where HS becomes visible, but it is not where HS begins. Follicular occlusion — blockage and subsequent rupture of the hair follicle — is the proximate trigger of each lesion. But the question modern medicine has not fully answered is: why does this happen repeatedly in the same locations, and why in these particular patients?

The answer lies in tissue vulnerability — created by sustained inflammation from the other four systems. Once tissue has been repeatedly injured and repaired, the structural integrity of the follicular environment degrades, making recurrence progressively easier. This is why HS tends to worsen over time without internal correction, and why the same sites are consistently affected.

Ayurvedic Framework

How Ayurveda Maps the Same Mechanisms

HS is not a Pitta-only condition. It is a tridoshic spiral — Pitta drives the inflammation, Vata dictates tunneling and spread, Kapha determines cyst depth and fibrosis. No single dosha explains it.

Dr. Adil Moulanchikkal — EPOH HS Protocol™

Dosha	Role in HS	Clinical Expression
Pitta	Drives inflammation	Abscess formation, burning, tissue breakdown
Vata	Governs spread & chronicity	Tunneling, irregular flares, sinus tracts, pain
Kapha	Determines depth & fibrosis	Cystic nodules, thick scarring, suppuration

Modern Concept	Ayurvedic Equivalent
Chronic inflammation	Pitta aggravation
Toxin accumulation	Ama
Blood involvement	Rakta Dushti
Tissue destruction	Dhatu Kshaya
Sinus tracts	Srotorodha — channel blockage
Weak digestion → inflammation	Agnimandya

Modern Concept	Ayurvedic Understanding
Chronic systemic inflammation	Pitta aggravation in Rakta and Mamsa dhatus
Inflammatory toxin accumulation	Ama — metabolic residue from impaired Agni
Blood-based immune activation	Rakta Dushti — contamination of the blood tissue
Tissue destruction and scarring	Dhatu Kshaya — progressive tissue depletion
Sinus tract formation	Srotorodha — obstructed micro-channels
Lymphatic stagnation	Rasa Dushti — stagnation of interstitial fluid
Disease chronicity and spread	Vata involvement — movement of pathology through channels
Hormonal androgen sensitivity	Pitta–Meda interaction — fat tissue and metabolic fire

Different vocabulary. Identical mechanisms. Ayurveda's systems-based diagnosis allows for personalised treatment paths that a single-diagnosis framework cannot accommodate.

The organ network involved in HS — how gut, hormones, immune system and lymphatics interconnect

The Recurrence Question

Why It Keeps Coming Back After Treatment

This is the question most patients carry for years without a clear answer. Treatment happens — antibiotics suppress the flare, surgery removes the lesion, steroids reduce the swelling. And then, weeks or months later, it returns. Sometimes in the same location. Sometimes adjacent to a healed surgical site. Sometimes somewhere entirely new.

The reason is consistent: the internal process that drives HS has not been interrupted.

Think of it this way. The lesion is the expression — the visible outcome of an internal process. Removing the lesion or suppressing its inflammation temporarily does not stop the process. The gut continues producing inflammatory load. The hormonal imbalance continues driving follicular activity. The immune system continues overreacting to minor triggers. The lymphatic stagnation continues accumulating toxins in the same vulnerable areas.

When the conditions that created the first lesion remain intact, the next lesion is not a question of if — only when. HS does not recur randomly. It follows a pattern determined by the specific combination of internal drivers active in that patient. Identifying and addressing that pattern is what prevents recurrence.

"When a condition keeps recurring, it usually follows an underlying pattern that needs to be understood and addressed — not suppressed."

Why Standard Treatments Produce Recurrence

Antibiotics

Address bacterial overgrowth in the lesion, not the inflammatory environment that allowed the lesion to form. Long-term use also disrupts the gut microbiome — worsening one of HS's primary drivers. Learn more about the antibiotic escalation pattern in HS.

Surgery

Removes the existing lesion or sinus tract. Does not change the internal conditions that created it. New lesions frequently form adjacent to surgical sites because the inflammatory environment persists. Necessary in advanced cases, but not preventive on its own.

Biologics

Interrupt specific inflammatory pathways (TNF-α, IL-17). Effective suppression in many patients. Do not address gut health, hormonal balance, or metabolic drivers. Recurrence commonly follows discontinuation.

Steroids

Reduce acute inflammation temporarily. With repeated use, can suppress immune function, disrupt metabolism, and worsen insulin resistance — compounding underlying drivers rather than resolving them.

ⓘ

This is not a dismissal of these treatments. In acute and severe cases, they are necessary. The point is that without internal correction, recurrence is expected regardless of the treatment used.

Disease Progression

How HS Progresses When Left Unaddressed

HS does not remain static. Without internal correction, it follows a predictable trajectory — from isolated nodules to interconnected tunnels to systemic involvement. Understanding this progression matters for treatment timing.

Hurley Stage I — Mild

Isolated Nodules & Abscesses

Single or multiple recurring lesions in one or more areas. No sinus tract formation. Minimal scarring. Flares separated by periods of apparent resolution.

Painful recurring boils, often misidentified as folliculitis
Lesions appear in friction-prone areas
Strong hormonal and dietary trigger pattern
Most responsive to intervention — best time to begin treatment

Hurley Stage II — Moderate

Recurrent Abscesses & Early Sinus Tracts

Multiple lesions with limited sinus tract formation. Early scarring. Lesions in more than one anatomical region. Recurrence frequency increases.

Lesions beginning to connect below the skin surface
Periods of "resolution" becoming shorter
Multiple affected sites — axilla and groin simultaneously
Pus drainage becoming more frequent and difficult to manage

Hurley Stage III — Severe

Interconnected Tunnels & Diffuse Scarring

Extensive interconnected sinus tracts with thick fibrosis and constant or near-constant inflammation and drainage across affected regions.

No clear flare-free periods — condition is continuous
Extensive scarring and tissue distortion
Significant impact on mobility, sleep, and daily function
Systemic inflammatory load affecting general health and mental wellbeing

"The goal is not just to control symptoms, but to understand why the condition is occurring in the first place — before it reaches a stage where reversal is more difficult."

HS Subtypes

HS Behaves Differently in Different Patients

Two patients with the same Hurley stage can have completely different drivers, triggers, and prognoses. Location, pattern, and associated conditions all determine the treatment approach. Understanding your subtype is the starting point for personalised care.

Location-Based

Axillary HS

HS in the underarm — the most common presentation. Friction, sweat, and lymphatic density make this area particularly vulnerable. Often the first site of onset.

Hormonal HS

HS strongly linked to PCOS, menstrual cycling, or androgen excess. Often presents in women with clear hormonal trigger patterns. Requires hormonal evaluation as a treatment priority.

Tunnel-Forming HS

Characterised by sinus tract development — interconnected channels forming beneath the skin. Associated with Stage II–III and a history of repeated lesion activity in the same sites.

Groin & Inguinal HS

HS in the groin region — associated with high friction, lymphatic density, and significant impact on daily mobility and quality of life.

Metabolic & Obesity-Linked HS

HS strongly associated with insulin resistance, metabolic syndrome, or significant weight. Metabolic correction is central to treatment. Often multi-site with rapid progression.

View All 10 Subtypes

Browse all →

Triggers & Drivers

What Triggers HS — and What Drives It Over Time

There is an important distinction between a trigger — something that provokes a flare — and a driver — something that sustains the underlying condition. Managing triggers helps in the short term. Addressing drivers prevents recurrence long-term.

🔥

Internal Drivers (Root Cause)

Gut imbalance and inflammatory toxin accumulation
Hormonal dysregulation — androgen excess, insulin resistance, PCOS
Immune dysregulation and self-sustaining inflammatory loops
Chronic low-grade metabolic inflammation
Lymphatic stagnation at lesion-prone sites

⚡

Lifestyle Triggers (Flare Precipitants)

Diet — dairy, refined sugar, high-glycaemic foods, alcohol
Irregular or insufficient sleep — disrupts immune regulation
Psychological stress — elevates cortisol and inflammatory load
Sedentary lifestyle — impairs metabolic and lymphatic function
Friction from tight clothing, especially in warm conditions

🌡

Environmental & Physical Triggers

Heat and humidity — increase sweating and follicular activity
Shaving in affected areas — microtrauma to follicles
Synthetic fabrics that trap heat and moisture
Seasonal changes — many patients report summer worsening
Travel disruption to sleep and diet patterns

💊

Iatrogenic & Medical Triggers

Repeated antibiotic courses — gut dysbiosis worsens the primary driver
Systemic steroids — metabolic and immune suppression long-term
Hormonal contraceptives with androgenic activity — can worsen HS
Surgery without internal correction — removes lesion, not cause
Biologic discontinuation — if internal drivers not addressed, recurrence follows

Note: identifying which triggers are most active in a specific patient requires clinical evaluation. The same trigger can have different impact on different patients depending on their internal profile and disease stage. Explore cause pages in depth →

Treatment Philosophy

Root-Cause Correction, Not Symptom Suppression

Focus: The Lesion

Lesion identified → antibiotic prescribed → lesion controlled
Persistent lesion → surgery or biologic added
Recurrence → repeat cycle
Internal drivers (gut, hormones, immunity) rarely assessed
No mechanism to interrupt the recurrence pattern

Focus: The System

Internal profile evaluated — gut, hormones, immunity, metabolism
Dominant drivers identified per patient
Phased treatment: detox → internal correction → tissue repair → prevention
Personalised formulations matched to specific systemic imbalance
Goal: interrupt the recurrence pattern, not just the current flare

Personalised Formulations

Herbal Formulations Designed for Each Phase

Treatment at EPOH uses personalised Ayurvedic formulations — designed based on each patient's systemic profile, disease stage, and dominant drivers. These are not fixed protocols or generic herbal combinations. They are targeted formulations matched to the specific phase of treatment and the specific imbalance being addressed.

Phase L · Formulation

Inflammatory Load Reduction Formula

Targeted at reducing the active systemic inflammatory burden. Supports the body's natural anti-inflammatory pathways. Used in Phase 1 to interrupt the current flare cycle and create conditions for deeper healing.

Phase I · Formulation

Gut Restoration & Internal Healing Blend

Addresses gut dysfunction — the most common primary driver. Corrects digestive strength, reduces inflammatory toxin production, and restores microbiome balance. Personalised to the specific type of gut imbalance identified.

Phase F · Formulation

Functional Detoxification Formula

Supports targeted elimination of accumulated inflammatory toxins. Works through enhanced hepatic and lymphatic clearance pathways. Calibrated to patient constitution — aggressive detox is counter-productive in most HS cases.

Phase I–II · Formulation

Hormonal Balance Support

Specifically relevant for women with PCOS-linked or menstrual-cycle-driven HS. Addresses androgen sensitivity and insulin–hormone interaction. This formulation is only prescribed where hormonal involvement is confirmed through evaluation.

Phase E · Formulation

Tissue Repair & Skin Healing Blend

Supports healing of sinus tracts, reduces scarring, and restores follicular environment integrity. Used once internal correction is underway — applying this phase too early, before systemic correction, produces limited results.

Phase S · Formulation

Remission Maintenance Rasayana

Long-term immunity-strengthening formulation. Builds systemic resilience, reduces susceptibility to flare triggers, and maintains the gains achieved through earlier phases. Continued as part of the sustained remission protocol.

ⓘ

Important: Formulations are prescribed only after a personalised evaluation. What is appropriate for one patient's profile may be contraindicated for another's. No formulation is available as an OTC product. Treatment commences only after clinical assessment.

Explore the Full EPOH Protocol How Treatment Works

Begin Here

Understanding Your Condition Is the First Step

If HS is recurring despite treatment, or if you are trying to understand what is actually driving it before it progresses further — a structured evaluation is the appropriate next step. This is a clinical conversation, not a sales process.

Discuss Your Case on WhatsApp Request an Evaluation

Dr. Adil Moulanchikkal, BAMS · EPOH · +91 88847 22246 · Personalised evaluation required before treatment begins

Go Deeper

HS Is Not a Skin Disease. Here Is What It Actually Is.