Hidradenitis Suppurativa (HS), an inflammatory skin condition, is caused by an overactive immune system. HS causes painful boils and abscesses. It can occur anywhere you have hair follicles, including behind your ears.

Hidradenitis Suppurativa (HS) is a chronic or long-lasting inflammatory skin condition characterized by painful red bumps, boils, and abscesses. It is also known as acne inversa.

HS is not an infection. It most commonly occurs in areas of the body where there are skin folds coupled with hair follicles and sweat glands, such as the groin, armpits, buttocks, and thighs. While less common, HS can also occur behind the ears.

HS behind the ear is thought to be caused by an overactive immune system, which signals the skin to attack microbes living on its surface, but the exact causes are still being researched.

A healthy and functional skin microbiome contains bacteria, fungi, and other microbes. If you have HS behind your ears, your skin cells mistake these organisms for dangerous intruders. This overreaction causes inflammation within skin cells.

Inflamed skin cells build up inside individual hair follicles, causing them to widen, weaken, and rupture. The result is severe inflammation and pus-filled discharge.

HS is less common behind the ears than in other parts of the body. However, this condition can occur behind the ears as well as in the nape (back) of the neck.

HS can cause these symptoms behind the ear:

HS can also cause additional symptoms of systemic inflammation throughout the body, such as:

The exact cause or trigger for HS behind the ear is unknown, although having a family history of this condition is a strong indicator. People who are born female are at a higher risk than males. People who are Black or African American are also at a greater risk for HS than other ethnic groups. The average age of onset for this condition is 23, although it can occur at any age.

A combination of genetics and environmental factors most likely plays a strong role in the cause of HS behind the ear. In some instances, mutations (variants) in specific genes have been identified as being causative of this condition. These genes include the NCSTN, PSEN1, and PSENEN genes.

Causes or risk factors for HS include:

There is no specific diagnostic test for hidradenitis suppurativa. Usually, a visual exam is all that is required to make a diagnosis.

To diagnose HS, your healthcare professional will examine the backs of your ears and neck. They may also examine other parts of your body where HS is common, such as the groin area or your underarms.

They will ask about your health history, lifestyle habits, and other symptoms you may be experiencing. They’ll also ask about your family history of this condition.

Additional testing may be done to rule out infection and other conditions that might mimic the symptoms of HS. These tests include laboratory analysis of fluid extracted from an HS lesion or a blood test.

Untreated HS worsens over time. If your symptoms are mild to moderate, your healthcare professional may recommend lifestyle changes, such as smoking cessation or weight loss. Often, these recommendations are part of a treatment plan that includes medication.

If you have an underlying condition that increases your risk for HS, treatments may be recommended that directly address it. For example, if you have PCOS, your healthcare professional may recommend using metformin or birth control pills along with HS treatments.

Topical treatments

Your healthcare professional may recommend topical medications or washes that you apply directly to the affected area, behind your ear. These medications kill bacteria and reduce inflammation and include:

  • Antibiotics: Medications such as clindamycin and fusidic acid.
  • Antiseptics: These are medications that include ingredients like benzoyl peroxide and chlorhexidine.
  • Topical keratolytics: Topicals such as azelaic acid (Finacea) and resorcinol may also be recommended for use behind the ear. These medications work by sloughing off dead skin cells and opening up follicle blockages.
  • Lidocaine ointment: This may be recommended to reduce pain in the affected area.
  • Topical corticosteroids: These may also be used to reduce inflammation and alleviate pain and itching.

Oral medications

Oral antibiotics may be recommended for mild, moderate, or severe symptoms. Oral medication may be especially helpful if the symptom area is widespread or diverse.

  • Oral antibiotics include metronidazole (Flagyl), clindamycin, and tetracycline (Doxycycline).
  • Steroids, such as oral prednisone, may be helpful for reducing inflammation.
  • Retinoids are another common oral medication that may be effective for HS behind the ear. Retinoids are a form of vitamin A that is also used to treat acne.
  • Over-the-counter (OTC) oral pain medication may also be used. OTC drugs like Tylenol may be recommended.
  • Prescription pain medication may also be used if your discomfort is severe and doesn’t respond to OTC treatment.

Injectable medications

If you have severe or painful lesions behind your ear that don’t respond to topical or oral treatment, your healthcare professional may recommend injectable medications, such as:

  • Cortisone injections with medications like triamcinolone acetonide (brand name: Kenalog).
  • Biologic medications, given by injection or infusion, may also be tried. Biologics work directly on the immune system. These medications will not be administered directly into HS lesions but rather into nearby skin, typically in your arm. Biologic medications currently used to treat HS are:
    • adalimumab (Humira)
    • secukinumab (Cosentyx)
    • bimekizumab-bkzx (Bimzelx)
    • Infliximab (this medication is often given through IV infusion)
  • Surgical procedures: Severe HS may respond best to medication combined with procedures that alter the skin’s structure. The most common types of surgery used to treat HS are: deroofing procedures and lesion excision.
    • Deroofing procedure: Deroofing is typically done under local anesthesia. During this procedure, your surgeon will remove the exterior skin that covers a sinus tract (tunnel), so the pus and inflamed skin within it can be removed. This procedure leaves a shallow wound, rather than a thick, deep one.
    • Excision: Excision is done to remove whole lesions. The skin layer underneath the lesion is also removed during an excision.

HS can be chronic, or long-lasting. However, the treatments used for this condition can be very successful, especially if you seek treatment early. HS is not curable, however, and your symptoms may return, requiring treatment again. Scarring may also be permanent in some instances.

HS that is not treated can cause complications, like sepsis or cellulitis. Staying on top of your treatment plan and communicating with your healthcare professional about recurrences is your best way of alleviating pain and symptom escalation.

Hidradenitis suppurativa behind the ear is a chronic condition that causes lesions, boils, and discomfort. This condition is chronic, but responds well to treatment.

Having a family history of this condition is a risk factor. So is smoking cigarettes, having obesity, or having hormonal conditions like PCOS.