Inclusion Criteria:
* Age \>13 and \<75
* established diagnosis of HS
* HS skin lesions of duration at least 1 year
* HS lesions in at least two distinct body areas
* inadequate response to a trial of an oral antibiotic or exhibited recurrence after discontinuation of antibiotics
* abscess and nodule (AN) count ≥ 5 at baseline
* draining tunnel count of \<20 at baseline
* ability to provide written informed consent and/or assent
Exclusion Criteria:
* pregnant or breastfeeding
* history of neuromuscular disorder (ex. ALS, myasthenia gravis, Lambert-Eaton syndrome, myopathy
* medical co-morbidity ex. end stage congestive heart failure or coagulopathy that is a relative contradiction to skin biopsy procedure
* received systemic steroids or started a new systemic (biologic or non-biologic immunomodulator, oral retinoid) therapy with potential therapeutic impact for HS \<12 weeks prior to baseline visit
* use of opioid or non-opioid oral analgesics within 14 days of baseline visit (exception: at a stable dose for at least 14 days prior to baseline)
* receiving anti-IL-17A/F, anti-IL-23, or anti-IL-1 biologic therapy or oral JAK inhibitor, TYK inhibitor
* active COVID-19 infection or history of COVID-19 infection within 4 weeks prior to baseline
* oral or IV antibiotic use during the treatment period (exception: stable dose of doxycycline or minocycline upto 100mg PO BID for 28 days prior to baseline and throughout the 6 month treatment and observation period
* initiation of topical therapies for HS within 14 days or baseline visit (may continue stable use of topical therapies started \> 14 days prior to baseline visit), -laser surgery, laser hair removal, or elective surgery to treatment areas within 4 weeks prior to baseline visit
* current participation in another clinical study involving the administration of an investigative drug for the treatment of HS, or prior participation in such a study within 60 days prior to baseline visit,
* active bacterial, fungal, or viral infection in the treatment area at baseline visit, -immunocompromised state
* known hypersensitivity to botulinum toxin A preparations or any of their components (human albumin, saline, lactose, sodium succinate).
