The Ultimate Guide on How to Treat HS: Unpacking the Complex Causes of Hidradenitis Suppurativa

My name is Jaap, and I am a biomedical scientist that also used to live with severe Hidradenitis Suppurativa, the kind that takes over your life. Today, I am completely asymptomatic because I learned how to heal Hidradenitis Suppurativa from within. More importantly, I’ve had the privilege of helping many other individuals with HS get their lives back too.

How to Treat Hidradenitis Suppurativa: A Deep Dive into the New Science of Healing

Introduction

Have you ever felt like your body is a puzzle you just can’t solve? For those of us with Hidradenitis Suppurativa (HS), that feeling is a daily reality. This disease is more than just painful lesions; it’s a complex, often mystifying condition that can leave you feeling isolated and misunderstood. For decades, the science was lagging, but I’m here to tell you that’s changing, fast. A brilliant new review paper by Dr. John W. Frew is helping to unravel the intricate web of HS, and it confirms so much of what we’ve been exploring in the HS Armor community. This review by Dr. John W. Frew contains some really amazing illustrations which we will go trough together and thereby learn everything about Hidradenitis Suppurativa and how we can use that knowledge to treat ourselves naturally.

We’ll explore the genetic clues, the hormonal triggers, and the complex immune signals that drive this disease. This isn’t just an academic exercise; this is about empowering you with the knowledge to take back control of your health.

The Genetic Clues involved in Hidradenitis Suppurativa

For years, many of us were told HS was just bad luck or a hygiene issue. Science now tells us a much different story. It is common to have a family member with the disease, hinting at a genetic component. While early research pointed to rare mutations in genes related to something called the “gamma-secretase complex,” we now know that’s only a tiny piece of the puzzle for most people.

Recent, large-scale genetic studies have uncovered several key genes that are more common in people with HS, including SOX9, INAVA, and KLF5. Now, I know those sound like robot names, but they hold powerful clues.

• SOX9: Think of this as the master architect for your hair follicles. It also responds to androgen hormones, which helps explain why HS often kicks off around puberty and can be linked to conditions like Polycystic Ovarian Syndrome (PCOS). Dysregulation here could be why our follicles become the epicenter of the inflammation and why those dreadful tunnels form.
• INAVA and KLF5: These genes are like the security guards for your body’s barriers, and they’ve also been linked to Inflammatory Bowel Disease (IBD), a common comorbidity with HS. When these genes aren’t working right, it can lead to a hyper-reactive immune system, one that sounds the alarm bells way too easily.

This is what’s happening at a genetic level. It’s not your fault. Your body is simply predisposed to an overactive immune response.

Figure 1: This diagram is like a blueprint of the genetic predispositions in HS. On the left, we see how genes like SOX9 can cause Hair Follicle Stem Cell Fate Alterations. This is a fancy way of saying it messes with the normal life cycle of the hair follicle, leading to epithelial out-pouchings and the formation of those dreaded tunnels. On the right, genes like INAVA and KLF5 are shown to be involved with the innate immune system’s alarm bells. When bacterial products trigger a Toll-like receptor (TLR) on the cell surface, these genes help activate the inflammasome and tell the nucleus (via NF-κB) to pump out inflammatory signals. At the top, you see ADAM 17 and GAMMA SECRETASE. Think of these as molecular scissors that snip off inflammatory messengers (like TNF-α and IL-6R) that are attached to the cell surface, releasing them to cause inflammation in the surrounding tissue. In short, this image shows how our own genetics can set the stage for faulty hair follicles and an over-reactive immune system. Illustration by Dr. John W. Frew.

The Inflammatory Cascade: More Than Just a Skin Issue

So, you have the genetic predisposition. What happens next? The paper beautifully illustrates that HS isn’t one single event but a cascade of inflammation that involves your entire immune system. It’s a whole-body issue that gets triggered and then spirals.

Figure 2: This flowchart elegantly maps out the tragic story of an HS lesion. It begins with Predisposing Factors (our genetic blueprint, hormones, smoking, etc.). Then, a ‘Trigger’ Event (like puberty, stress, or hormonal shifts) ignites the first spark, leading to Perifollicular Inflammation, an immune cell rush hour around the hair follicle. From there, the process branches into three devastating outcomes. Dermal Inflammation is the all-out immune war, with cells like Dendritic Cells (DC) and Macrophages (Mø) releasing signals (TNF-α, IL-23) to activate Th17 cells. Dermal Liquefaction and Remodelling is the messy result, where enzymes (MMPs) break down tissue, creating pus and abscesses. Fibrosis is the body’s attempt to heal, but it results in thick, dysfunctional scar tissue. The bottom bar shows the ultimate consequence: Tunnel Growth, chronic inflammation, and the formation of Tertiary Lymphoid Organs (TLOs), which are like permanent, rogue immune bases in your skin. Illustration by Dr. John W. Frew.

The Inflammatory Cascade: More Than Just a Skin Issue

The process is a complex symphony of immune cells gone rogue. We used to think it was all about one pathway (the Th17 axis, which is also involved in psoriasis), but we now know it’s much more nuanced. B-cells, plasma cells, monocytes, and even our own skin cells and fibroblasts get pulled into the fight, creating a self-perpetuating cycle of damage.

Figure 3: This image provides a stunning visual of how HS escalates from mild to severe. On the Mild end (left), the inflammation starts around the hair follicle. The SOX9 gene plays a key role, and initial immune cells release signals like TNF-α, IL-1β, IL-6, and IL-23. As the disease progresses to Moderate, these signals activate more specialized immune cells. You see the production of IL-17A and IL-17F, key drivers of inflammation, and fibroblasts start producing chemokines like CXCL13 that call in even more immune troops. In the Severe stage (right), the war becomes entrenched. The body starts producing Autoantibodies (your immune system attacking its own proteins), and Tertiary Lymphoid Organs (TLOs) form. These are highly organized structures that act as local command centers, sustaining the inflammatory attack long-term. This image powerfully shows that HS is a progressive disease where the immune response becomes more complex and destructive over time. Illustration by Dr. John W. Frew.

How to Treat HS by Understanding Your Hormones

The hormonal connection in HS is undeniable. Flares around menstrual cycles, onset at puberty, and improvement during pregnancy are all common experiences. For a long time, we didn’t understand the “how.” This paper provides some incredible insights.

It’s not as simple as too much testosterone. Instead, it appears sex hormones, particularly estradiol (a form of estrogen), can directly influence the behavior of our immune cells, specifically monocytes and macrophages.

The researchers propose a fascinating paradigm:

• High Estradiol Environment: Often seen in females or those with more adipose (fat) tissue, this can lead to an IL-23-independent type of inflammation. Here, the immune response is driven primarily by other signals like IL-1β and IL-6.
• Low Estradiol Environment: More common in males or those with lower body fat, this may lead to an IL-23-dependent pathway.

Figure 4 Legend: This is a crucial diagram that helps explain why HS can be so different from person to person. It shows two distinct ways the inflammation can be driven. The top panel illustrates an IL-23-independent phenotype, more common in females (F > M) with a higher BMI. Here, immune cells are triggered by signals like IL-1β and IL-6 to activate Th17 cells, leading to inflammation. The bottom panel shows an IL-23-dependent phenotype, more common in males (M > F) with a lower BMI. In this case, the key trigger is IL-23. This is a massive insight because it suggests that a biologic drug designed to block IL-23 might be very effective for the person in the bottom scenario but do very little for the person in the top one. It’s a perfect illustration that a personalized approach to treating HS is not just a nice idea—it’s a scientific necessity. Illustration by Dr. John W. Frew.

How to Treat HS by Understanding Your Hormones

Figure 5 Legend: This figure beautifully connects the dots between our hormones, fat tissue, and the immune system. The top-left box shows that factors like genetics (SOX9) and adipose tissue can increase the production of Estradiol (E2). On the right, we see how E2 enters an immune cell, binds to its receptor (ER-β), and travels to the nucleus. There, it teams up with the inflammatory master switch, NF-κB, to amplify the production of inflammatory molecules like TNF-α and IL-17. On the left, it shows how the amount of E2 in the environment can determine what type of immune cell a monocyte becomes: low E2 favors Monocyte-derived Dendritic Cells (mo-DC), while high E2 favors Macrophages. This visualizes how our metabolic health and hormonal balance are not separate from HS, they are key players fueling the inflammatory fire. Illustration by Dr. John W. Frew.

And on the topic of hormonal triggers, one user’s comment perfectly mirrors the science:

“My flares are like clockwork with my cycle. I can predict them to the day. Yet my doctor just shrugs and offers more antibiotics.”

It means your unique hormonal makeup could be determining which specific inflammatory pathway is most active in your body. Understanding this is a core principle we put into practice every day in the HS Armor community, where we work to identify these personal patterns to create a targeted healing strategy.

The Role of the Microbiome and the Antibiotic Paradox

We can’t talk about HS without talking about bacteria. But it’s not an infection in the traditional sense. It’s about dysbiosis, an imbalance in the community of microbes on our skin and in our gut. Studies consistently show that HS patients have less bacterial diversity, with an overgrowth of certain species like Porphyromonas.¹⁰

This dysbiosis sends alarm signals to our already-primed immune system, triggering those inflammasome pathways we talked about earlier. But here’s the paradox: why do antibiotics work, even when there’s no “infection” to kill?

The paper suggests that antibiotics may work not by killing bacteria, but by having a direct, anti-inflammatory effect on our immune cells. They might be silencing the Toll-like receptors (TLRs) on our monocytes and macrophages, preventing them from overreacting. This would explain why they can provide temporary relief but don’t solve the underlying problem.

Figure 6 Legend: This diagram explains the complex role our microbes play. The microbiome in our gut and on our skin can directly trigger our immune system’s “danger sensors” called Toll-like Receptors (TLR), setting off an inflammatory cascade (right side). Our gut microbes also produce Short-Chain Fatty Acids (SCFAs) from the fiber we eat, which can send complex signals to our immune cells (left side). The image then presents the great antibiotic debate. The arrow for “Antibiotic Action Directly Upon Microbes” shows the traditional view. But the more intriguing possibility is the “Antibiotic Action Indirectly Through Inflammatory Modulation”. This suggests that many antibiotics may work by directly interrupting the inflammatory signaling pathway inside our cells (specifically by blocking NF-κB), essentially acting as anti-inflammatory drugs, which explains their temporary effect even in the absence of a classic infection. Illustration by Dr. John W. Frew.

The HS Armor Philosophy: From Science to Natural Healing

Dr. Frew’s paper is a gift to the HS community, but it also highlights what I call the knowledge gap. The research is advancing at lightning speed, but clinical practice is often years behind. The conventional model is built on suppressing symptoms with drugs and surgery. It’s a powerful and often necessary approach to control a raging fire, but it’s like constantly silencing a fire alarm while the house burns down around you.

The focus is almost entirely on the downstream effects (the painful lesions) while ignoring the upstream causes (the genetic, hormonal, and lifestyle triggers that start the fire). This is where the HS Armor philosophy comes in. We believe that true, lasting remission is only possible when you reverse the model.

At HS Armor, we focus on putting out the fire itself. Our entire approach is about taking all hidradenitis suppurativa scientific knowledge and turning it into a concrete, actionable plan for natural healing. We don’t see drugs and surgery as the foundation; we see them as powerful, temporary shields. Pharmaceutical drugs all lose effect very quickly and also have severe side effects. The true foundation is a resilient, balanced body.

A HS patient speaks to the failure of the symptom-suppression model:

“On my fourth biologic. Each one works for a year or so and then just… stops. It feels like I’m just playing whack-a-mole with my immune system while the real problem gets worse.”

Building Your Defenses, Layer by Layer

Think of HS Armor not as a single cure, but as a protective shield you build for yourself, piece by piece. Each choice you make is another layer of that armor. It’s a holistic (multidisciplinary) approach that recognizes that managing an autoimmune condition like HS requires more than just one solution. It’s about combining multiple powerful strategies to create a comprehensive defense.

These layers in HS Armor include:

• Foundational Nutrition: This is the cornerstone. We use the science of immunology to help you identify and remove your personal food triggers while flooding your body with the nutrient-dense foods it needs to calm inflammation and heal. This is how we address the dysbiosis and metabolic issues that fuel HS from the inside.
• Strategic Lifestyle Changes: We go beyond generic advice. We teach you how to incorporate specific, science-backed practices to manage stress (which directly impacts your immune system), improve sleep (critical for cellular repair), and reduce your exposure to environmental toxins.
• Natural Therapies & Skincare: This is about harnessing the power of nature from both the inside and out. We focus on potent, science-backed natural compounds and supplements that help balance the immune system and reduce systemic inflammation. This inside-out approach is complemented by targeted natural remedies and skincare routines to soothe the skin, aid wound and scar healing, and manage symptoms externally.
• Accountability & Support: Let’s be honest: this healing journey is challenging. True, lasting change requires commitment reinforced by a strong support network. In our community, you get accountability to stay on track, the support of others who truly understand, and the guidance to adjust your plan as your body heals.
• Targeted Medical Testing: We empower you with information. We provide guidance on specific medical tests you can discuss with your doctor to identify key hurdles, triggers, and underlying problems, speeding up your healing process and enabling you to have more effective conversations about your treatment options.

This is how we bridge the gap. We take the incredible “what” and “why” from papers like this one and provide the “how.” We focus on highly effective evidence-based nutrition and lifestyle change, and natural therapies and practices, because that is what creates lasting change.

Key Takeaways

• HS is a Complex Genetic and Immune Disease: It’s not a simple infection or hygiene issue. It’s a polygenic autoinflammatory and environmentally induced condition.
• Hormones Directly Influence Inflammation: Sex hormones like estradiol can steer your immune cells down different inflammatory pathways, which may explain differences in disease presentation and treatment response.
• It’s About Dysbiosis, Not Infection: An imbalance in your whole body is a key trigger for the inflammatory cascade. Antibiotics may offer temporary relief but come with side effects and lose their effect.
• A Foundational Approach is Essential: The conventional model focuses on suppressing symptoms. To achieve lasting remission, you must address the root causes, the fire, not just the smoke alarm. This is the core mission of our work at HS Armor.

Conclusion

So, how to treat HS in a way that leads to lasting freedom? You start by understanding the incredible, complex story your body is telling you. This new science doesn’t just give us answers; it gives us the right questions to ask. It validates our experiences and empowers us to look beyond the surface.

Can you cure HS? We know we can stop its progression, manage it, and achieve a state of deep, sustainable remission where it no longer controls our lives. The path isn’t a magic pill; it’s a journey of rebuilding your health from the inside out, layer by layer. And you don’t have to walk it alone. Seeing how these foundational changes have helped me and so many following the HS armor protocol truly brings this research to life. Healing is possible.

Important Medical Disclaimer

1. Not Medical Advice: All content and information on this website is for informational and educational purposes only. It does not constitute medical advice and is not a substitute for professional diagnosis, treatment, or consultation with a qualified healthcare provider.

2. My Role and Qualifications: I am a biomedical scientist and PhD candidate and share information from that perspective, combined with my personal experience as a patient with Hidradenitis Suppurativa. However, I am not a medical doctor, physician, or registered healthcare professional. Do not consider our relationship a doctor-patient relationship.

3. Consult Your Doctor: Always seek the advice of your medical doctor or another qualified health professional with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you have read on this website. If you suspect you are experiencing a medical emergency, or a severe infection, do not rely on this website or the HS Armor community, please call your local emergency services or go to the nearest emergency room immediately.

4. A Critical Warning on Medication: Pharmaceutical drugs are a crucial tool in managing Hidradenitis Suppurativa for many people. Under absolutely no circumstances should you ever alter, reduce, or stop taking your prescribed medication without the explicit direction of the doctor who prescribed it. Doing so can be dangerous. Always consult with your doctor before doing anything related to your treatment plan.

5. No Liability: Your use of this website and reliance on any information provided is solely at your own risk.

6. Individual Results May Vary: Every patient’s biological baseline, genetics, and adherence to the protocol is different. Therefore, I cannot guarantee specific results, cures, or timelines for your Hidradenitis Suppurativa.

7. Scientific and Expressive Freedom: The articles published on this blog are distinct from formal peer-reviewed academic literature. They serve as an independent platform for my personal viewpoints, scientific hypotheses, and philosophical reflections as an independent scientist and HS patient. While grounded in biomedical research, I exercise a degree of expressive freedom to translate rigid academic data into insights from a patient perspective. These writings are my personal meditations on the science of HS and should be read as my individual perspective, not as universally accepted clinical consensus or formal peer-reviewed literature.