The Post Almost Nobody in This Industry Writes
Most people with hidradenitis suppurativa have already been turned away by somebody like me.
Sometimes politely. Sometimes with a look. Occasionally they were not turned away at all, which was worse, because they were waxed by a practitioner who did not know what they were looking at and spent the next three weeks paying for it.
So I want to be useful here rather than cautious. HS is a follicular disease. Hair removal is not a cosmetic afterthought bolted onto the side of it. Destroying the follicle is one of the few things in this whole field where the mechanism of a hair removal treatment lines up exactly with the mechanism of the disease, and there are randomised controlled trials to show for it.
There are also methods that make HS measurably worse, and one of them is the single most common thing a salon will offer you.
Here is all of it.
The Eleven Questions I Actually Get Asked
Short answers first. The detail is underneath, and every one of these is expanded further down the page.
How do you get it?
You largely inherit the tendency. Roughly a third of people with HS have a first-degree relative who has it, and the underlying problem is a follicle that occludes, ruptures and provokes an immune response out of all proportion to the trigger. Smoking and higher body weight are both strongly associated. Hormones play a part, which is why onset clusters after puberty and why many people flare with their cycle.
You did not get it from being unclean, from shaving, from a gym, from a pool or from another person. I need that said before anything else, because a lot of people arrive having been told otherwise.
When do you get it?
After puberty, usually in your twenties. Peak prevalence is ages 30 to 39, at 172 per 100,000. Under 18 it is uncommon, at 15 per 100,000. Onset after 60 is unusual enough that it should prompt a proper look for something else.
The gap between first symptom and diagnosis is notoriously long. Years of "recurring boils" is the standard story.
Is it contagious?
No. Not by contact, not by towels, not by sharing a bed, not by anything. It is not a sexually transmitted infection, despite living in the groin. It is not even primarily an infection. Bacteria arrive after the follicle has already ruptured and make an existing problem worse.
How is it treated?
In layers, and usually several at once:
- Topical. Clindamycin 1 per cent, and antibacterial washes containing benzoyl peroxide or zinc pyrithione.
- Oral antibiotics. Doxycycline or minocycline for mild to moderate disease, clindamycin with rifampicin for more severe disease.
- Injected. Intralesional triamcinolone into individual stubborn lesions.
- Biologics. Adalimumab, secukinumab and bimekizumab are all licensed for HS.
- Oral targeted therapy. Povorcitinib, a JAK1 inhibitor, reported positive phase 3 results this year.
- Surgery. Deroofing for a recurrent localised tract, wide excision for established disease.
- Adjuncts. Laser hair removal, smoking cessation, weight management.
What makes it worse?
Friction is the big one. Skin rubbing skin, skin rubbing seams, tight waistbands, tight bra bands, tight underwear. Then heat and sweat, which is why summer and the gym are hard. Then smoking, which has one of the strongest associations in the whole condition. Then weight, hormonal cycling, and stress.
On the hair removal side specifically: waxing, sugaring, epilators, tweezing and depilatory creams all make it worse on skin HS is currently affecting. Careless shaving does too, though careful shaving does not.
Does wax or laser help or hurt?
This is the cleanest answer in the whole post. Laser helps. Wax hurts.
Laser hair removal has randomised controlled trial evidence in HS, with each patient's untreated side used as the comparison, and the treated sites did measurably better. Waxing rips the hair out of a follicle in a disease defined by follicular rupture, which is why the American Academy of Dermatology's public guidance is "never wax."
I will not wax an area HS is currently affecting. I will laser it, in the right window, with the right wavelength.
There is a second half to that answer which almost nobody gives you. Waxing can become possible later. I have a client whose underarms I wax now and could not have waxed a year ago, and what changed in between was three sessions of laser. Laser first, control second, waxing considered afterwards if the area has genuinely settled. The full reasoning is further down.
Is there medication that can be taken?
Yes, and considerably more of it than there was five years ago. Three licensed biologics, an oral JAK inhibitor in late-stage trials, plus antibiotics, intralesional steroid, and off-label use of metformin, spironolactone, dapsone, acitretin and isotretinoin depending on the picture. HS went from a neglected condition to an active drug-development area in about a decade.
Can you have hair removal while on the medication?
Usually yes, with conditions.
- Biologics and JAK inhibitors. Yes, with your prescriber's written agreement. They are immunosuppressive or immunomodulating, so my infection control matters more than usual. Never stop your biologic to have hair removal.
- Doxycycline and minocycline. Yes for laser at 755, 810 and 1064 nm. Their photosensitivity is a UVA phenomenon, roughly 320 to 400 nm, and those wavelengths sit well outside it. IPL is the exception, since it overlaps.
- Isotretinoin. No waxing for six months after finishing. Laser is a case-by-case conversation.
- Spironolactone, metformin, GLP-1 medications. Not a barrier.
Full detail is in the medications and hair removal guide.
Is it for life?
Honestly, usually. HS is chronic and relapsing, and I am not going to tell you otherwise.
The kinder half of that answer is that the course changes. Activity commonly declines after menopause. Stopping smoking reduces flares and has occasionally been reported to clear the condition entirely. Weight reduction reduces flare frequency for many people, with some studies reporting full remission. Modern biologics have moved a lot of people from constant disease to long quiet stretches.
What does not reverse on its own is structural damage already done. Established sinus tracts and scarring need a procedure, not patience. That is an argument for treating early rather than an argument for despair.
Does having less hair help?
Yes, and that is the entire reason this post exists. The hair follicle is where the lesion starts. Fewer follicles means fewer things that can occlude and rupture, less friction in the fold, and a smaller bacterial reservoir held against the skin.
This is not a theory. In the trials, sites cleared of hair by laser improved while the untreated sites on the same person did not.
Is it treatable?
Very. It is not usually curable, and those are two different words that get confused constantly.
The distance between untreated HS and well-managed HS is enormous. Most of the suffering I see is not from a condition that resisted treatment. It is from a condition nobody named for eight years.
What HS Actually Is
It is not a sweat gland infection. The name is a nineteenth century mistake that stuck. HS begins with occlusion of the hair follicle, which then ruptures into the surrounding tissue and triggers a disproportionate inflammatory response. Bacteria show up afterwards and make things worse. They are not the cause. This is why antibiotics help some people and cure almost nobody.
It is not a hygiene problem. I want that stated flatly, because a large share of people with HS have been told or made to feel otherwise, often by a healthcare professional. Washing harder does not fix follicular occlusion. Washing harder is friction, and friction is a trigger.
It is not contagious, and it is not an STI. It shows up in the groin and under the arms, and people draw the obvious wrong conclusion.
It is common, and badly underdiagnosed. The best population-adjusted American estimate puts prevalence at about 98 per 100,000, roughly one in a thousand people. Global estimates run from 0.1 to 4 per cent depending on the method used, which tells you how much of it goes unnamed. Roughly a third of people with HS have a first-degree relative who has it too.
Who gets it. Women at about 137 per 100,000 against men at 58, a ratio near 3 to 1 in Western populations. Peak prevalence sits in the thirties, at 172 per 100,000 for ages 30 to 39. Onset is usually after puberty, in the twenties.
This next part matters enormously for what device I reach for. In the same American dataset, prevalence among African American patients was 296 per 100,000 and among biracial patients 218 per 100,000, against 95 for white patients. That is roughly three times the rate. HS disproportionately affects darker skin, and the practitioner sitting across from you needs to have thought about Fitzpatrick type before they turn anything on. If you have not read it, my post on laser hair removal on dark skin and the Fitzpatrick scale explainer both apply directly here.
Where It Shows Up
HS lives in apocrine gland-bearing, intertriginous skin, which is a technical way of saying the places that fold, rub and stay warm:
- Underarms
- Groin, including the mons and the inner fold of the thigh
- Buttocks and the perianal area
- Inner thighs
- Under the breasts and the inframammary fold
- Vulva, scrotum and perineum
- Back of the neck, and occasionally behind the ears
Look at that list, then look at the list of areas people most commonly book hair removal for. They are almost the same list. That overlap is the entire reason this post exists.
The Hurley Stages, and Why Your Stage Decides Everything I Do
Hurley staging is crude, it is nearly fifty years old, and it is still the fastest way for me to know what I am dealing with.
Hurley Stage I
Abscesses or inflammatory nodules, single or multiple, with no sinus tracts and no scarring. Many people at this stage have never been diagnosed. They think they get bad ingrown hairs, or recurring boils.
Hurley Stage II
Recurrent abscesses with sinus tract formation and scarring, but the lesions are still separated from one another, with normal skin in between.
Hurley Stage III
Diffuse involvement, with multiple interconnected tracts and abscesses across an entire anatomical area. There is very little unaffected skin left in the region.
IHS4, the more useful number
Hurley describes the worst thing present and never improves on paper even when you are having a good month. The International HS Severity Score System counts what is actually there today: nodules count 1, abscesses count 2, and draining tunnels count 4. A total of 3 or under is mild, 4 to 10 is moderate, 11 or more is severe.
I care about IHS4 because it moves. Someone can be Hurley II forever and still walk in on a day when their IHS4 is 2, and that day is a day I can work.
Why Hair Removal Is Part of the Treatment Conversation At All
The logic is unusually clean.
The lesion starts in the follicle. Hair removal lasers destroy the follicle, or damage it enough that it stops producing terminal hair. Remove the follicle and you have removed the structure that occludes, ruptures and starts the whole cascade.
There are three separate benefits stacked on top of each other:
1. Fewer follicles left to occlude. The direct mechanism.
2. Less friction. Coarse hair in a skin fold is an abrasive. Skin-on-skin in a hairless armpit moves more easily than skin-on-stubble.
3. Lower bacterial load. Hair holds bacteria against the skin, and reduced follicular density reduces the reservoir.
This is why the medical literature treats laser hair removal in HS as adjuvant therapy, a real part of management rather than a cosmetic extra. It is also why I need to say the next sentence loudly.
It is adjuvant. It is not a cure, and it does not replace your dermatologist. Anybody who tells you laser will fix your HS is selling you something. What the evidence supports is meaningful reduction in inflammatory lesions in treated areas, in people who are also being managed medically.
The Evidence, Plainly
I am going to give you the actual numbers, because you will not find them on most clinic websites and you deserve to judge them yourself.
Nd:YAG 1064 nm, the strongest case
The foundational study is a prospective randomised controlled trial in 22 patients with Hurley Stage II to III disease, using a long-pulsed 1064 nm Nd:YAG at monthly intervals for three sessions, with untreated control sites on the same patients.
Overall improvement was 65.3 per cent. Broken down by area: inguinal 73.4 per cent, axillary 62.0 per cent, inframammary 53.1 per cent. The untreated control sites showed no meaningful change over the same period. That contralateral control design is what makes this convincing, since each patient is their own comparison and you cannot blame the result on a good month.
A later multicentre, prospective, randomised, intra-individual comparative trial using a long-pulsed Nd:YAG hair removal laser reached the same conclusion in a larger and better-controlled setting. A 2025 review of energy-based devices in HS describes the evidence for Nd:YAG in reducing inflammatory lesions as strong, which is not a word that gets used loosely about laser in dermatology.
Alexandrite 755 nm, good evidence, narrower window
A 2024 randomised controlled trial ran four monthly treatments to one side of the body with the contralateral side as an untreated control. At week 24, eight weeks after the final session, HiSCR (the standard clinical response measure in HS) was reached by 75 per cent of treated sites against 33.33 per cent of controls, p = 0.0046. By site: 72.73 per cent axillary, 70 per cent inguinal, 100 per cent inframammary.
A separate analysis of the alexandrite data reported 50 per cent of patients reaching HiSCR at 15 weeks, rising to 70 per cent by week 30, in mild to moderate disease treated as an adjuvant.
The authors' own conclusion is worth quoting for what it includes: the laser was effective both at resolving existing lesions and at preventing new ones. Prevention is the part clients care about most and the part most treatment plans never promise.
The catch is skin type. Alexandrite at 755 nm has strong melanin absorption, which is exactly what makes it effective and exactly what makes it a poor choice on Fitzpatrick V and VI. Given who HS disproportionately affects, this is not an academic point.
Diode 810 nm
The workhorse of commercial hair removal, and the wavelength with the least HS-specific published evidence of the three. That is a gap in the literature rather than a demonstrated failure. Diode sits between alexandrite and Nd:YAG on melanin absorption and is a defensible choice for lighter and mid-range skin types, though if you want the treatment that has actually been tested on your disease, it is not this one.
IPL
IPL has some HS literature, including combination work with radiofrequency, and a broad-spectrum output that overlaps far more of the melanin absorption curve. On the skin types HS most commonly affects, that is a liability. This is the one modality where I think the evidence and the demographics point in opposite directions, and I would not choose it for HS.
CO2 laser
Worth knowing about even though it is not hair removal. CO2 is used in dermatology for deroofing sinus tracts and excising diseased tissue, and the evidence for it in reducing inflammatory lesions is also described as strong. That is a surgical procedure performed by a physician. It is not something a hair removal studio does, and if somebody offers you CO2 for HS in a salon setting, leave.
Electrolysis, and the honest answer
I searched for this properly, because I am an electrologist and I wanted there to be something.
There is no peer-reviewed evidence for electrolysis in hidradenitis suppurativa. No trials, no case series worth the name. What exists is clinic marketing, some of it mine-adjacent, asserting a benefit by analogy with laser.
The analogy is not unreasonable. Electrolysis destroys the follicle permanently and works on any hair colour and any skin tone, which sidesteps the entire melanin problem that constrains device choice in exactly the population most affected. It is also slow, it involves inserting a probe into individual follicles, and the areas involved are the ones where inserting anything into inflamed tissue is a bad idea.
So here is my position. Electrolysis has a real role here, and I am not going to present it to you as a treatment for your HS. If you want hair gone permanently in a region the laser cannot safely reach, or your hair is grey, white, red or blonde and the laser has nothing to target, electrolysis is the answer to that question. It is not an answer to the HS question, and I am not going to pretend otherwise to make a sale.
Method by Method: What I Will and Will Not Do
Shaving
The realistic default for most people with HS, and the AAD's own guidance treats it as acceptable when done carefully rather than as something to avoid. Its virtue is that it does not extract anything from the follicle.
If you are shaving affected skin:
- Wash first with an antibacterial cleanser containing benzoyl peroxide or zinc pyrithione. Both are recommended in HS self-care to reduce surface bacterial load.
- Use a proper shaving gel, never a dry pass and never soap.
- Sharp blade, single pass, with the grain. Repeat passes and against-the-grain shaving are how you turn a shave into a series of micro-injuries.
- Never shave over a nodule, an abscess or a tunnel. Go around it.
- Rinse, dry properly, do not apply an alcohol-based product.
Trimming, which is underrated
A guarded trimmer taking the hair down to two or three millimetres removes most of the friction and almost all of the trapped bacteria, and it never touches the skin. For active disease, or for the week before a flare settles, trimming is very often the correct answer and nobody suggests it.
Waxing and sugaring
No. Not on skin that HS is currently affecting, at any Hurley stage.
The AAD's public guidance on HS says "never wax," and the reasoning is the reasoning of the disease itself. Waxing rips the hair out of the follicle, traumatising the follicular unit and the surrounding tissue in a condition defined by follicular rupture and disproportionate inflammatory response. It also strips the stratum corneum in skin that already sits warm, moist and occluded.
Sugaring is the same mechanical event with a different medium. The lower application temperature and the with-the-grain removal make it gentler on ordinary skin, and it is still epilation. It is still pulling hair out of a follicle that is inflamed.
I know this is the hardest section to read, since waxing is what most people book. If HS is currently affecting an area, I will not wax that area.
Unaffected areas are a separate conversation. HS in the groin does not make your legs off limits.
Waxing is not where you start. It can be where you end up.
Here is the part almost nobody tells you, and it is the reason I wrote this post as a pathway rather than a list of refusals.
I have a client whose underarms I now wax, and I could not have waxed them a year ago. What changed in between was three sessions of laser. The flares settled, the follicular density dropped, and the same skin that would have reacted badly to a strip became skin that handles one without incident.
The mechanism is not mysterious. Waxing harms HS skin because epilation traumatises the follicle in a disease defined by follicular rupture. A laser course removes a large share of those follicles and reduces flare frequency, which is precisely what the trials measure. Wax that area afterwards and the mechanical event is smaller, on fewer and finer hairs, in tissue that is no longer inflamed. The risk that created the rule has partly been engineered out of the way.
Three sessions is worth noting on its own. The foundational Nd:YAG trial in HS ran three monthly treatments and reported 65.3 per cent overall improvement. My own experience landed at the same number without my planning it that way, which is the sort of agreement between a study and a treatment room that makes me trust both a little more.
Two honest qualifications.
This is my clinical observation, not published evidence. No trial has looked at waxing after laser clearance in HS. I am telling you what I have seen rather than what has been demonstrated, and you should weigh it accordingly.
The area matters more than the person does. Someone can have a groin that will never be a candidate and an underarm that has been quiet for a year. Those are two different answers on the same client, on the same day.
So the sequence I offer is laser first, control second, and waxing considered afterwards if the area has genuinely settled. It is earned rather than requested, it is assessed area by area, and it is never a substitute for the laser course that made it possible.
Depilatory creams
No. Nair, Veet and everything in that family work by chemically dissolving the keratin bonds in the hair shaft using thioglycolate salts at an alkaline pH, typically 11 to 12.5. They irritate normal skin routinely. In an intertriginous fold, on skin that is already inflamed, with occlusion from clothing and a warm moist environment holding the product against the skin, the risk of a chemical burn goes up sharply and the barrier damage is exactly what you do not need. I covered the full mechanism and the failure modes in the medications and hair removal post.
Epilators, threading and tweezing
All epilation, all the same objection as waxing, and tweezing has an additional problem specific to HS. Chasing an individual hair with forceps traumatises the same follicle repeatedly over months. Repeated follicular trauma is the last thing this disease needs.
Laser, and how I choose the wavelength
Given everything above, my order of preference for HS is:
1. Nd:YAG 1064 nm. The best HS evidence, and the safest wavelength on Fitzpatrick IV to VI, which is the population most affected. This is my default.
2. Alexandrite 755 nm. Strong HS-specific trial data, appropriate for Fitzpatrick I to III with fine or lighter hair where Nd:YAG would struggle for a target.
3. Diode 810 nm. Reasonable, well tolerated, thin HS-specific evidence.
4. IPL. Not for this.
What Actually Happens If You Book With Me
Before you arrive
I want to know four things, and I would rather have them in writing than remember them in a room:
1. Have you been diagnosed, and by whom. A dermatologist's diagnosis and a self-diagnosis from the internet are both useful information. They are not the same information, and I will treat them differently.
2. Your stage, if you know it, or a description of what is actually there: nodules, abscesses, tunnels, scarring, and whether anything is currently draining.
3. Everything you take. Biologics, antibiotics, isotretinoin, metformin, spironolactone, hormones, GLP-1 medications, supplements. The dose and how long you have been on it.
4. Where you are in the cycle of it. Flaring, settling, or genuinely quiet.
What I will treat
Hurley Stage I, and Stage II in a quiet window, I will treat with laser.
By quiet window I mean no active abscess, nothing draining, and no new inflammatory nodule in the treatment area for at least a couple of weeks. This is where IHS4 beats Hurley. Your stage is a permanent label; your quiet window is a real thing that comes and goes, and it is what I am actually booking around.
Hurley Stage III is a conversation rather than a booking. Come in and let me look at it. At Stage III there is very little unaffected skin left in the region and the tissue architecture is genuinely altered, so I want to see the area myself and I will often want your dermatologist's view before we start. What I am not going to do is turn you away by email on the strength of a label, since the people with the most advanced disease are also the people with the fewest options and the most experience of being refused.
What I will not touch
Anything actively draining, or the skin immediately beside it. An open tunnel is a wound. Firing a laser at the edge of a wound in a warm, occluded fold is asking for a complication I have no business creating.
Fresh surgical sites. Deroofing heals by secondary intention over weeks. Wide excision takes longer. I want the site fully closed and the dermatologist's clearance before I go near the margins.
An area during a flare, even a mild one. We reschedule. There is no version of this where pushing through a flare produces a better outcome.
The sessions
Every published HS protocol I trust runs at monthly intervals, which is closer together than a standard cosmetic hair removal course. The Nd:YAG trial ran three monthly sessions. The alexandrite trial ran four. The clinical response in the alexandrite study kept improving between week 15 and week 30, well after the last treatment, which tells you the benefit accumulates rather than arriving all at once.
Plan for a course, not a session. Plan on assessing at four sessions rather than deciding after one.
What to expect afterwards
Some perifollicular erythema and swelling for a day or two, as with any laser hair removal. The thing to watch for in HS specifically is whether treatment provokes a flare in the treated area. In the trials it generally did not, and individual experience varies. If it happens to you, tell me and we change the plan.
Medications: What HS Clients Are Usually On
This deserves its own section because HS is one of the most heavily medicated dermatological conditions there is, and several of those medications change what I can do.
Biologics
Three are licensed for HS: adalimumab (a TNF inhibitor, Humira and its biosimilars), secukinumab (IL-17A, Cosentyx) and bimekizumab (IL-17A and IL-17F, Bimzelx). Canadian real-world chart review data on bimekizumab in HS was published this year.
All three are immunosuppressive. That does not mean I cannot treat you. It means any breach of the epidermis carries more weight than it would otherwise, my infection control has to be beyond reproach, and I want your prescriber to have signed off in writing. That is the same standard I published in the medications and hair removal guide for immunosuppressants generally, and I am applying it here consistently.
Do not stop your biologic to have hair removal. I have never asked anyone to do this and I never will. Interrupting an HS biologic to book a laser appointment is a bad trade in every direction, and with TNF inhibitors specifically there is a real risk of losing response on restart.
JAK inhibitors, the new arrival
Povorcitinib, an oral selective JAK1 inhibitor, reported positive phase 3 results in the STOP-HS1 and STOP-HS2 trials this year, across more than 1,200 patients. Both 45 mg and 75 mg doses beat placebo on HiSCR50 at week 12, with responses sustained through week 54. An oral option matters to a lot of people who do not want an injectable.
If you are on it, treat it the way I treat the biologics: it is immunomodulating, tell me, and I want the prescriber's agreement.
Antibiotics
Topical clindamycin 1 per cent, oral doxycycline or minocycline for mild to moderate disease, and clindamycin with rifampicin for more severe disease.
The tetracyclines carry a photosensitivity warning, which is the one clinics get wrong most often. Doxycycline photosensitivity is a UVA phenomenon, roughly 320 to 400 nm, with some visible-range involvement. Alexandrite at 755 nm, diode at 810 and Nd:YAG at 1064 all sit well outside that band. The blanket "you are on doxycycline, no laser" rule is not supported by the physics for those wavelengths. IPL is the exception, since its output spans roughly 500 to 1200 nm and does overlap. That is one more reason IPL is not my choice here. The full reasoning is in the medications post.
Everything else
Intralesional triamcinolone for individual lesions, isotretinoin in some cases, plus metformin, spironolactone, dapsone, acitretin and hormonal treatment depending on the picture.
Two of those matter to me directly. Isotretinoin thins the epidermis and impairs wound healing, and the conservative wax standard is six months clear, which I apply. Spironolactone shows up frequently in HS clients who also have PMOS, and the two conditions overlap more than most people realise.
GLP-1 medications are increasingly part of HS management, since weight reduction genuinely reduces flare frequency for many people. They are not a hair removal problem in themselves. Rapid weight loss changes skin laxity, which changes how well I can hold skin taut, which changes what waxing feels like in unaffected areas. Worth mentioning at intake.
Surgery, and the Hair Around It
Many people with established HS have had incision and drainage (high recurrence, largely out of favour as a definitive step), deroofing (the tract is opened and left to heal from the base, and it is the best evidence-based procedure for a recurrent localised lesion) or wide local excision.
Two things follow for hair removal.
Scar tissue does not behave like skin. It has different vascularity, different sensation, sometimes none, and different heat dissipation. I treat around a mature scar rather than through it unless there is a specific reason.
Hair at the margins is worth clearing. Recurrence at the edge of an excision is common, and the follicles at that margin are the same follicles that started the problem. Clearing them once the site is fully healed is one of the most defensible things laser can do in this disease.
Aftercare in Skin That Folds
Standard laser aftercare assumes an arm. An armpit or a groin is a different environment: warm, moist, occluded, in constant motion and rubbing against itself.
- Cool, not cold. No ice directly on the skin.
- Loose clothing for 48 hours. Cotton. Nothing with a seam sitting in the fold.
- No gym, no sauna, no hot tub, no swimming for 48 hours. Sweat and chlorine both.
- No antiperspirant on treated underarms for 24 hours. Deodorant without aluminium salts is fine after the first day.
- A bland, fragrance-free moisturiser, not an occlusive ointment sitting in a fold.
- Do not shave the area for at least 3 days. Trim if you must.
- Watch for the difference between post-laser erythema and a flare. Post-treatment redness fades over a day or two. A flare builds, becomes tender and deep rather than surface-warm, and does not settle. Message me either way and I will tell you which one it is.
Warnings and Hard Limits
If it is draining, it is a wound. No laser, no probe, no wax, no cream. This is not negotiable and it is not a scheduling preference.
Do not let anyone laser through an active abscess. The energy goes into inflamed tissue with a compromised barrier and you have gained nothing.
Post-inflammatory hyperpigmentation is a real risk here, more so given the skin types HS most commonly affects. Inflamed, previously inflamed and recently healed skin pigments more readily. Conservative fluences, appropriate wavelength, and a test patch that I actually wait to read.
Long-standing HS carries a small but genuine squamous cell carcinoma risk, particularly in perianal and buttock disease of many years' duration. I raise this not to frighten anyone but because I do a full visual and dermoscopic assessment of the treatment area before I start, and if something in a chronic HS field looks wrong to me I am going to tell you and send you to a dermatologist. That is what the dermoscopy training is for.
Lymphoedema. Chronic HS in the groin can obstruct lymphatic drainage. A limb with established lymphoedema needs medical input before I treat it.
Piercings, and jewellery in the field. Genital, navel and nipple jewellery all come out before laser, for the same reason all metal does. In HS specifically, a piercing tract in or near an affected area is another epithelialised channel in skin that already makes too many of them.
If you are flaring, we reschedule, and I will not charge you a late cancellation fee for it. I would rather lose the slot than treat you on the wrong day.
What I Need From You, and What You Get From Me
From you: tell me before the appointment, not on the table. Tell me the diagnosis, the stage if you have one, every medication with the dose and duration, and where you are in the cycle of it today. Photograph the labels if it is easier. I am not going to judge you and I am not going to refuse you for being honest. The only thing that gets someone refused is an active flare, and that is a rescheduling problem rather than a rejection.
From me: a clear answer on what I will treat and what I will not, the reasoning behind it, the wavelength I have chosen and why, a written note to your dermatologist if you want one, and no pretence that I am curing anything.
You have probably had enough of being told this is your fault. It is not, it never was, and there is a version of hair removal that helps rather than harms.
Hidradenitis suppurativa starts in the follicle, which is the one thing in this field I am actually equipped to remove. That is why laser hair removal appears in the HS literature as adjuvant therapy with randomised controlled trial support, and why waxing appears in the patient guidance as something to never do.
The short version: Nd:YAG first, monthly, in a quiet window, alongside your medical treatment and not instead of it. No wax, no sugar, no depilatory cream and no epilator on skin HS is currently affecting. Shave carefully or trim while you are managing it at home. Electrolysis has a place at the borders and on grey or fair hair, and I will not oversell it.
Then, once the area has genuinely settled, the door reopens. Waxing is not the way in. It can be the destination, and getting somebody there is the most satisfying thing I do.
Book a consultation before you book a treatment. I will look at the area properly, tell you what I think, and if the answer is that today is not the day, I will tell you that too.
Related reading: laser on dark skin, the Fitzpatrick scale, medications and hair removal, PMOS and unwanted hair, folliculitis and what those bumps are, ingrown hairs and aftercare.
If this is your situation, these go together. the pain map, every area ranked, the diabetes and hair removal guide, acne, folliculitis and hair removal, fistulas in the buttocks and how often you should actually exfoliate.