Is Waxing Good for Hidradenitis Suppurativa？

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic, inflammatory skin condition that affects the hair follicles and apocrine glands, typically in areas rich in these structures such as the axillae (armpits), groin, and under the breasts. It is characterized by painful, recurrent boils or abscesses that can rupture, leading to draining sinuses, scarring, and a significant impact on patients’ quality of life.

The pathophysiology of HS is complex, involving factors like abnormal follicular keratinization, which blocks the hair follicles and leads to the accumulation of sebum and keratin debris. This obstruction then triggers an inflammatory response, with immune cells infiltrating the affected area, exacerbating the condition. HS can progress through different stages, starting from mild comedonal forms with simple follicular occlusion, advancing to more severe stages with extensive abscess formation and interconnecting tunnels beneath the skin

The prevalence of HS varies across different populations, affecting approximately 1% to 4% of the general population, with a higher incidence in women and those with a family history of the disease. Given its chronic nature and potential for severe disfigurement and discomfort, proper management and understanding of activities that might affect its course are crucial. One such area of concern is hair removal, particularly waxing, which is a popular method but may have implications for HS patients.

There are two main types of waxing: hot wax and cold wax. Hot wax is typically heated to a molten state before application. It adheres firmly to the hair, allowing for effective removal even of short hairs. When cooled and hardened slightly, it is quickly pulled off in the opposite direction of hair growth, taking the hairs with it. Cold wax, on the other hand, comes in pre-made strips that are already impregnated with wax. The user simply presses the strip onto the skin, rubs it to warm the wax and improve adhesion, and then pulls it off briskly. Cold wax is more convenient as it doesn’t require heating equipment, but hot wax may offer a more thorough hair removal, especially for thicker or coarser hair.

Before waxing, the skin is usually cleansed to remove any dirt, oils, or lotions that could interfere with the wax’s adhesion. A thin layer of powder may be applied in some cases to further absorb moisture and enhance the grip of the wax. The wax is then evenly spread onto the skin in the direction of hair growth, ensuring complete coverage of the area to be treated. After allowing the wax to set according to the product instructions (usually a few seconds for cold wax and longer for hot wax until it reaches an appropriate consistency), the strip or hardened wax is yanked off swiftly and parallel to the skin surface, minimizing skin trauma.

Even for individuals without HS, waxing can cause immediate skin irritation. The forceful removal of hairs can lead to redness, swelling, and a stinging or burning sensation. This occurs because the hair follicles are essentially being yanked out, causing micro-tears in the surrounding skin tissue. The skin’s natural barrier function is temporarily disrupted, making it more susceptible to external irritants and potential infections. In some cases, if the wax is too hot or left on for too long, it can cause burns, resulting in blisters and more severe pain, which can further compromise the skin’s integrity.

Waxing can damage the hair follicles themselves. The sudden and forceful extraction can distort the follicular structure, potentially leading to improper hair regrowth. Sometimes, hairs may grow back curly or ingrown, where they re-enter the skin instead of growing outwards normally. Ingrown hairs can then trigger a local inflammatory response similar to a mild form of folliculitis, with red bumps, pus formation, and tenderness. This follicular trauma is a significant concern as it mimics some of the early signs of HS and can exacerbate existing skin issues in HS patients.

For HS patients, the skin is already in a state of chronic inflammation. Waxing can introduce additional trauma, triggering a more severe inflammatory flare-up. The act of pulling hairs out can disrupt the delicate balance in the affected areas, causing immune cells to flood the site in response to the perceived injury. This influx of immune cells releases cytokines and other inflammatory mediators, worsening the redness, swelling, and pain associated with HS. The inflamed hair follicles in HS are more fragile, and waxing can cause them to rupture more easily, leading to the spread of bacteria and pus within the skin layers, potentially advancing the disease stage.

HS lesions are often colonized with bacteria such as Staphylococcus aureus and other opportunistic pathogens. Waxing can introduce these bacteria deeper into the skin or transfer them to adjacent, previously unaffected follicles. The broken skin surface from waxing provides an entry point for bacteria, increasing the likelihood of secondary infections. These infections can manifest as cellulitis, with spreading redness, warmth, and systemic symptoms like fever if left untreated. Moreover, the occlusive nature of wax can trap moisture and bacteria on the skin, creating a favorable environment for bacterial growth and further infection, which is especially dangerous for HS patients with compromised skin barriers.

As mentioned earlier, abnormal follicular keratinization is a key factor in HS pathogenesis. Waxing can exacerbate this process. The remnants of wax left in the hair follicles can mix with sebum and keratin, further clogging the follicles and impeding normal drainage. This leads to increased pressure within the follicles, promoting the formation of more abscesses and nodules characteristic of HS. Over time, repeated waxing in HS-prone areas can contribute to the progression of the disease, with more extensive skin involvement and more severe symptoms.

Shaving is a relatively gentle hair removal method for HS patients. It involves using a razor to cut the hair at the skin’s surface, minimizing the trauma to the hair follicles compared to waxing. However, it needs to be done carefully to avoid nicking or cutting the already inflamed skin. Using a sharp, clean razor and a shaving gel or cream with soothing ingredients can reduce irritation. Shaving should be done in the direction of hair growth to prevent ingrown hairs, and the skin should be rinsed thoroughly afterward and moisturized to maintain its barrier function.

Depilatory creams work by chemically breaking down the protein structure of the hair, allowing it to be easily wiped or rinsed away. They are painless and do not involve physical pulling of hairs like waxing. However, patients need to be cautious as some depilatory creams may contain harsh chemicals that could irritate sensitive HS skin. It’s advisable to do a patch test first and choose products formulated for sensitive skin, leaving the cream on for the recommended time only to avoid overexposure and skin damage.

Laser hair removal offers a more long-term solution. It uses concentrated light energy to target the hair follicles, heating and destroying them to inhibit future hair growth. For HS patients, it can be beneficial as it reduces the need for frequent hair removal, minimizing repeated skin trauma. However, multiple sessions are usually required, and it can be costly. Additionally, patients with active HS flare-ups may need to postpone treatment until the inflammation subsides, as the laser could potentially worsen the condition if the skin is too inflamed.

A gentle skin care routine is essential for HS patients. This includes using mild, fragrance-free cleansers to avoid further irritating the skin. Regular bathing with lukewarm water helps keep the skin clean and reduces bacterial colonization. After bathing, applying a moisturizer suitable for sensitive skin, such as those containing ceramides or hyaluronic acid, helps restore the skin’s barrier function. Avoiding tight clothing that can rub against and irritate HS lesions, especially in areas like the armpits and groin, is also crucial.

Some dietary changes may help manage HS symptoms. A diet rich in anti-inflammatory foods like fruits, vegetables, whole grains, and omega-3 fatty acids from sources such as fish and flaxseeds can potentially reduce inflammation in the body. On the other hand, limiting the intake of sugary, processed foods and dairy products (as some patients report a correlation between dairy consumption and HS flares) may also have a positive impact. Staying hydrated is equally important to maintain skin health and support the body’s natural detoxification processes.

HS patients should be under the regular care of a dermatologist. Medical treatments range from topical antibiotics and anti-inflammatory medications for mild cases to systemic antibiotics, hormonal therapies (in cases where hormonal imbalances are suspected to contribute to HS), and in severe cases, biologics that target specific immune pathways involved in the disease. Regular follow-up appointments allow for monitoring of the disease progress, adjustment of treatment plans, and early detection of any complications or infections.

Waxing is generally not advisable for patients with hidradenitis suppurativa due to the high risks of aggravating inflammation, increasing the likelihood of infection, and contributing to follicular occlusion and disease progression. Instead, alternative hair removal methods, along with a comprehensive management and prevention strategy, should be adopted to better control HS symptoms and improve patients’ quality of life. Awareness among both patients and beauty professionals about the potential harm of waxing in HS cases is crucial to avoid unnecessary skin complications and ensure proper care for this chronic and often debilitating skin condition