HS in Men: Unique Presentation, Challenges, and Care
While HS is more common in women, men with HS often experience more severe disease, face greater diagnostic delays, and encounter unique challenges in seeking care. This guide is written specifically for male patients and the clinicians who treat them.
Medical Disclaimer: This article is for educational purposes only and does not replace professional medical evaluation and care. Read full disclaimer.
Hidradenitis suppurativa is often discussed primarily in the context of women's health, given its higher prevalence in female patients. But the approximately one-third of HS patients who are male face a distinct set of challenges: a different anatomical distribution of lesions, higher rates of severe disease, longer diagnostic delays, and significant barriers related to the cultural expectation that men should not seek help for health problems.
This article addresses HS specifically as it presents and is experienced by male patients, covering the clinical differences, common misdiagnoses, treatment considerations, and the often-overlooked emotional and psychological impact of HS on men. For a broader overview of how HS affects mental health across all patients, see our guide to HS and mental health. Understanding the Hurley staging system can also help men better understand their disease severity.
How HS Presents Differently in Men
Disease Severity
Anatomical Distribution
Why the severity difference? Several factors may contribute, including longer delays before seeking care (allowing disease to progress), higher rates of smoking (a significant HS risk factor), higher BMI on average, and potentially different hormonal influences. Men are also less likely to be prescribed hormonal treatments that may benefit some patients.
Common Misdiagnoses in Male HS Patients
The perianal and gluteal distribution common in men leads to frequent misdiagnosis, often resulting in referrals to colorectal surgeons rather than dermatologists. The average diagnostic delay for HS is 7-10 years, and men may experience even longer delays due to these misdiagnoses and reluctance to seek care.
Pilonidal Cysts
Lesions in the gluteal cleft are often attributed to pilonidal disease. While pilonidal cysts can coexist with HS, they are a distinct condition. HS lesions in this area are typically multiple, recurrent, and associated with lesions elsewhere.
Key distinction: HS lesions occur at multiple sites; pilonidal cysts are typically solitary and midline
Perianal Abscesses / Fistulas
Perianal HS lesions are frequently misdiagnosed as cryptoglandular abscesses or fistula-in-ano, leading to surgical drainage procedures that do not address the underlying disease.
Key distinction: HS fistulas arise from skin, not from the anal crypts; HS lesions are typically superficial to the sphincter
Crohn's Disease
Perianal fistulas and abscesses in HS can mimic Crohn's disease perianal involvement. Importantly, HS and Crohn's disease can coexist - the association between the two conditions is well-established.
Key distinction: Colonoscopy and imaging can help distinguish; HS does not cause luminal GI disease
Folliculitis
Early HS lesions may be dismissed as recurrent folliculitis, particularly in the beard area, chest, or back.
Key distinction: HS lesions recur in the same locations, involve deeper structures, and are associated with tunneling and scarring
Treatment Considerations for Male HS Patients
The core HS treatment approach is the same for men and women, but there are some important differences and considerations for male patients.
Biologics
Adalimumab (Humira) and bimekizumab (Bimzelx) are FDA-approved for HS in adults and are equally effective in men and women. Men with severe or extensive disease should discuss biologic therapy with their dermatologist early rather than waiting for multiple surgical procedures.
See all HS treatment optionsAnti-Androgens: Not Typically Used in Men
Spironolactone and other anti-androgen treatments used in women are generally not appropriate for men due to feminizing side effects (gynecomastia, sexual dysfunction). Finasteride (a 5-alpha reductase inhibitor) is occasionally used in men and has some case report evidence for HS, but data are limited.
Surgical Options
Men with perianal and gluteal HS often require surgical intervention. Wide local excision remains the most effective surgical approach for advanced disease. It is important that surgery is performed by a surgeon experienced with HS - ideally in coordination with a dermatologist - to minimize recurrence.
Learn about HS surgery optionsLifestyle Modifications
Smoking cessation is particularly important for male HS patients, as smoking is a major modifiable risk factor and men with HS have higher smoking rates than the general population. Weight management is also important, as obesity is associated with more severe disease.
The Emotional Impact of HS on Men
The psychological burden of HS is significant for all patients, but men face additional barriers related to cultural expectations around masculinity, stoicism, and help-seeking behavior. Many male HS patients describe years of suffering in silence before seeking care.
Shame and Masculinity
HS in intimate body areas challenges many men's sense of masculinity and self-worth. The inability to engage in physical activity, sports, or manual work due to pain can be particularly distressing.
Delayed Help-Seeking
Men are statistically less likely to seek medical care for skin conditions. Cultural messaging that men should 'tough it out' contributes to longer diagnostic delays and more advanced disease at presentation.
Intimacy and Relationships
Lesions in the groin and perianal areas directly affect sexual function and intimacy. Many men with HS avoid relationships or sexual activity due to shame and fear of rejection.
Work and Identity
Physical jobs that involve sitting, heavy lifting, or outdoor work can be severely impacted by HS. For men whose identity is tied to their work capacity, this loss can be devastating.
You are not alone. HS is a recognized medical condition, not a hygiene problem or personal failure. Seeking medical care and mental health support is a sign of strength, not weakness. If you are struggling with the emotional impact of HS, please see our HS Mental Health guide for evidence-based support strategies.