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You’re doing everything right when it comes to keeping your energy levels steady: maintaining a consistent sleep schedule, eating nutritious foods, getting regular exercise, and reducing stress when you can. But you’re still dragging. What’s going on?

One surprising factor could be your skin. If you’re seeing lumps and bumps lingering near your armpits or groin (and particularly if they break open), you might be looking at the source of your fatigue.

What Is Hidradenitis Suppurativa?

Those lumps and bumps could be a condition called hidradenitis suppurativa, or HS. The telltale symptoms can develop when hair follicles become blocked and turn into lumps—especially in places where the skin rubs together like the groin, armpits, and beneath breasts and butt cheeks—that may grow larger and become painful.

If the condition becomes more severe, those lumps can connect beneath the skin in a series of tunnels, and also fill with pus that can leak from open sores.

The exact cause for why a few blocked follicles turn into such a problem, rather than a series of painless blackheads, isn’t known, but some potential variables may be family history, excess weight, and smoking, says Tien Nguyen, MD, a dermatologist at MemorialCare Orange Coast Medical Center in Fountain Valley, California. The condition is also more common in people who have chronic conditions like arthritis, diabetes, inflammatory bowel disease, and metabolic syndrome.

“When HS goes untreated, it can worsen over time, and the tunnels can become larger and more prominent, which can lead to scarring, pain, and more abscesses,” he says. “That’s why it’s important to see your doctor and get this checked if you’re having symptoms.”

In the meantime, there are several reasons why HS can make you fatigued. Here’s a look at the potential reasons for the connection.

Reason #1: Lack of activity

Let’s face it: Having painful, pus-filled lumps under your armpits and in your groin doesn’t exactly inspire you to sign up for group fitness classes. Plus, one of the potential effects of HS is scar tissue that can limit your movement.

“There’s some embarrassment with this condition, and that may cause people to stay home as much as possible, especially if they have pus that’s draining,” Dr. Nguyen says. “It can lead to less activity, which in turn may increase tiredness.”

Reason #2: Sleep disruption

Even if you’re on track with good sleep hygiene like going to bed and waking up at the same time every day, avoiding screens before sleep, and having a wind-down routine, you may still be struggling with getting a restful night. “Fatigue is an extremely common symptom of HS,” says dermatologist Adam Mamelak, MD, founder of Sanova Dermatology in Austin, Texas, “and a major factor can be interrupted sleep that translates to tiredness during the day.”

HS symptoms can make sleeping difficult. “Although the lumps themselves might be uncomfortable, it’s usually the pain that might keep people awake, or disturb sleep in general,” Dr. Mamelak says. In addition, itching can be another potential problem, which can also make the pain worse, if it becomes severe.

“In some cases, drainage can be an issue because it can wake you up when your clothing sticks to the skin or rubs against active injuries,” he says. “That’s why controlling [your symptoms from flaring up] is so important, because it can reduce pain dramatically, and help you sleep as a result.”

Reason #3: Your immune system is fighting harder

If HS lesions become infected, it can lead to feeling run down and tired in a way that’s similar to any cold or flu, Dr. Mamelak says. Your immune system is working to address the issue and that can wipe you out.

HS is an inflammatory and chronic condition, which means you are likely to have some degree of an “always on” immune response, he adds. To study in Frontiers in Immunology found that inflammation on its own can create debilitating fatigue, and it can have a ripple effect on your cardiovascular and muscular systems. Simply put, your body is always in fight mode without a break, and you’re probably feeling worn out.

Reason #4: You’re stressed

When it comes to any chronic condition, psychological stress is a major factor for tiredness, Dr. Mamelak says. It’s particularly true with something like HS because the appearance of the lesions can affect your self-esteem, which is very common.

There tends to be a high frequency of mood disorders, such as depression and anxiety among people living with HS, according to a study published in the Journal of the American Academy of Dermatology. That may be traced to dealing with the condition itself, but a significant number of participants in that study also felt dissatisfied with their medical treatment, which may add another layer of frustration.

Stress and fatigue are strongly linked, Dr. Mamelak says. The more you deal with struggles over self-consciousness about your condition and dissatisfaction about medical care, the more you’re likely to feel emotionally exhausted.

Reason #5: It’s a warning of what’s to come

If your HS seems controlled and you’re not experiencing much pain or discomfort right now, tiredness might be a sign that’s about to change, says Dr. Mamelak.

“Fatigue has been associated with what’s called the prodrome phase of HS breakouts,” he notes. “That’s the period immediately before active lesions develop.”

Consider it an early warning system, and if you notice that you actually do flare right after that wave of fatigue, that can be a helpful way to track your condition over time.

How to Fight the Fatigue

Strategies that help reduce overall weariness can be helpful, but if you think your tiredness might be linked to HS, be sure to check in with a dermatologist, suggests Dr. Nguyen.

Often, HS doesn’t get diagnosed until it’s hugely problematic, because it can get mistaken for boils or acne, he says, and in some cases a primary care doctor may recommend surgery or antibiotics—which Nguyen says are ineffective and may cause more scarring .

Get your energy boosters in place like sleep and stress reduction, but also take care of yourself by seeing a specialist who can provide the right treatment.

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