Stages of Hidradenitis Suppurativa (HS)
Published on December 11, 2024
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Hidradenitis suppurativa (HS) is a chronic inflammatory condition in which painful nodules form under your skin. These lesions tend to occur in areas where skin touches skin, such as the armpits, groin area, buttocks, and breasts.
Many people live for years with hidradenitis suppurativa before getting an accurate diagnosis, sometimes believing that they have acne (pimples). But HS is not acne, and it can get worse without proper treatment, so it’s essential to get a diagnosis as early as possible.
To diagnose hidradenitis suppurativa, your doctor will evaluate the severity of the condition using the Hurley staging system. Here’s an overview of the stages of HS and what they mean for treatment.
Understanding the Hurley Staging System
The Hurley staging system consists of three stages of HS:
- Stage 1 (Mild) You have one or more abscesses, but no scarring or tunnels under the skin.
- Stage 2 (Moderate) You have one or more recurring abscesses that have caused scarring and tunnels under the skin.
- Stage 3 (Severe) You have recurring abscesses with scarring and tunnels covering or nearly covering an area, or interconnected abscesses or tunnels across the affected area.
A number of factors have been linked to more severe HS, including having had the condition for a longer period of time, being male, and having a higher body mass index.
In people whose hidradenitis suppurativa progresses beyond stage 1, it typically takes years to progress from one stage of to another. A survey of 225 people with HS found that those with stage 3 disease had a more aggressive disease course than was seen in people whose HS remained in stages 1 or 2 — so it’s important for everyone with the condition to get treatment as soon as possible, with the goal of preventing HS progression.
Stage 1
In stage 1, one or more nodules or lesions appear under the skin, without scarring or tunnels (sinus tracts). These lesions may gradually heal and eventually go away. But in some people, they come back and can get worse over time — potentially progressing to stage 2.
In all stages of hidradenitis suppurativa, treatment should be individualized based on what type of lesions or sores you have, how painful they are, and how they interfere with your life. Your doctor may add or stop prescribing treatments over time, depending on how well they are working for you.
Doctors typically treat people in stage 1 with topical ointments or creams, as well as hormone therapies. You may also be prescribed oral (taken by mouth) antibiotics at this stage. Treatments for stage 1 may include:
- Clindamycin When used as a topical treatment, clindamycin can help reduce or shrink lesions, including those that contain pus.
- Resorcinol Applying a resorcinol cream has been shown to reduce inflammation and pain in HS, but it may take several months to help clear the affected area.
- Hormone Therapies Some hormone treatments are sex-specific, while others may be given to women or men. These therapies treat HS by counteracting other hormones that may contribute to inflammation. They may include estrogen, spironolactone, cyproterone acetate, metformin, or finasteride.
- Oral Antibiotics Taken orally once or twice a day, antibiotics may help reduce inflammation and bacteria that can cause HS flare-ups. Commonly prescribed oral antibiotics for HS include doxycycline, clindamycin, and rifampin.
- Oral Retinoids For some people with HS that resembles acne, drugs such as isotretinoin may be an option — but these drugs carry significant risks related to pregnancy.
- Steroid Injections To reduce swelling and inflammation, your doctor may inject a steroid such as triamcinolone into your HS sores.
At any stage of hidradenitis suppurativa, your doctor may recommend or prescribe topical hygiene or comfort measures such as using an antiseptic wash or applying a warm compress. Your doctor may also recommend surgery if other medications aren’t working and lesions and scarring persist. Types of surgical procedures include incision and drainage (cutting through the skin to the abscess to drain fluid), local excision (removing a small area of skin), laser hair removal, or using a specialized laser (known as a carbon dioxide laser) to destroy a lesion.
Stage 2
In stage 2, one or more recurring nodules appear under the skin and lead to scarring or tunnels (sinus tracts). HS sores that are connected by tunnels tend to heal slowly, if at all, and also drain blood and pus.
Treatments used in stage 1, such as steroids or hormone therapy, may be continued or started in stage 2, depending on the person’s individual needs. Treatments may be increased — for example, someone may start taking two different kinds of oral antibiotics.
Treatments for stage 2 include:
Biologic Drugs These injected or infused drugs work by altering your immune system’s response and can improve HS symptoms within a few weeks.
The following are approved to treat moderate-to-severe HS:
- Adalimumab (Humira)
- Secukinumab (Cosentyx)
- Bimekizumab (Bimzelx)
- Infliximab (Remicade), which is not approved by the U.S. Food and Drug Administration but has been used in clinical trials and studies
Intravenous (IV) Antibiotics Your doctor may give you the antibiotic ertapenem to reduce bacteria and inflammation.
Other Treatments Your doctor may use injected steroids or surgical procedures, such as deroofing, to treat persistent HS lesions (just as in stage 1).
Stage 3
In stage 3, multiple interconnected lesions appear under the skin, covering or nearly covering an area (sinus tracts). Just as in stage 2, these abscesses tend to drain blood and pus, but more so in this stage. The pain from HS sores in stage 3 can be debilitating.
Again, treatments used in stage 1 and stage 2 may be continued or started in stage 3. Biologic drugs and antibiotics, in particular, are often given in this stage. Treating HS in stage 3 can be challenging. If other treatments aren’t working, your doctor may recommend surgically removing an area of skin.
If a large enough area of skin is removed, you may need a skin graft to help close the wound. While surgical treatment tends to prevent HS sores from coming back in the affected area, you may still get sores in other areas of your body.
When You Should See Your Healthcare Provider
If you notice any potential signs of hidradenitis suppurativa — including more subtle symptoms that could indicate a different health condition, such as acne — it’s a good idea to see a dermatologist as soon as possible. Do this if you experience any of the following issues in areas where skin touches skin (such as your armpits, groin area, buttocks, or breasts):
- Blackheads
- Painful nodules
- Nodules or sores that leak fluid or pus
It’s especially important to see a dermatologist if any of the following applies to your condition:
- Painful
- Makes it difficult to move
- Doesn’t improve after a few weeks
- Returns within weeks of treatment
- Affects more than one location on your body
- Flares up often
Your doctor will work with you to develop a treatment plan based on your symptoms and individual needs and desires.
Lifestyle Changes for Hidradenitis Suppurativa
At any stage of hidradenitis suppurativa, a number of lifestyle changes may help reduce your symptoms.
Diet and Lifestyle Modifications
Making certain changes to your diet, as well as your lifestyle more broadly, may help reduce HS symptoms. The following dietary changes may help:
- Limit dairy products.
- Limit red meat.
- Avoid simple carbs like white rice, white pasta, juice, soda, and candy.
- Avoid alcohol, gluten, and yeast.
Other lifestyle measures that might help:
- Quit smoking.
- Lose excess body weight.
- Stay physically active, while taking care not to irritate your skin.
Personal Care and Hygiene
Keeping affected areas of your body clean, while taking care not to irritate them, can help reduce symptoms and improve your comfort. Consider taking these steps:
- Use an antimicrobial wash.
- Don’t scrub your skin (wash gently).
- Be careful and gentle with shaving or waxing.
- Consider laser hair removal (as an alternative to waxing or shaving).
- Avoid sweating or getting too hot.
- Wear loose clothing that doesn’t rub against affected areas.
Ask your doctor for recommendations about what kind of antimicrobial wash to use. Active ingredients in these products can include chlorhexidine or benzoyl peroxide. If you’re not using an antimicrobial wash, use a gentle soap-free cleanser.
Coping With Symptoms
For some people with HS, the pain and other symptoms can take a heavy emotional toll. Here are some steps that might help you cope with your condition:
- Make sure you’re getting HS treatment that works.
- Ask about options for odor control if this concerns you.
- Join an HS support group (virtually or in person).
- Get screened and treated for depression.
Psychotherapy (talk therapy) is an effective treatment for many people with depression related to their HS. Whether virtually or in person, seeing a counselor can help you cope.
Questions to Ask Your Doctor
- What stage of HS do I have, and what does this mean for treatment options?
- How can I prevent my HS from progressing to a later stage?
- Will my HS go away with treatment?
- Can my HS spread to other areas?
- How will my treatment change if my HS gets worse or stops responding to treatments?
The Takeaway
- Hidradenitis suppurativa can be diagnosed as stage 1 (mild), stage 2 (moderate), or stage 3 (severe), with different treatment options in each stage.
- See a dermatologist if you have any symptoms that could indicate HS, including what looks like acne or painful nodules in your armpits, groin area, buttocks, or breasts.
- Certain lifestyle changes may help reduce HS symptoms, including recommended hygiene practices, quitting smoking, and losing excess body weight.
Meet Our Experts
Susan Bard, MD
Medical Reviewer
Susan Bard, MD, is a clinical instructor in the department of dermatology at Weill Cornell Medicine and an adjunct clinical instructor in the department of dermatology at Mount Sinai in New York City. Her professional interests include Mohs micrographic surgery, cosmetic and laser procedures, and immunodermatology.
She is a procedural dermatologist with the American Board of Dermatology and a fellow of the American College of Mohs Surgery.
Dr. Bard has written numerous book chapters and articles for many prominent peer-reviewed journals, and authored the textbook The Laser Treatment of Vascular Lesions.
Quinn Phillips
Author
A freelance health writer and editor based in Wisconsin, Quinn Phillips has a degree in government from Harvard University. He writes on a variety of topics, but is especially interested in the intersection of health and public policy. Phillips has written for various publications and websites, such as Diabetes Self-Management, Practical Diabetology, and Gluten-Free Living, among others.
EDITORIAL SOURCES
Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy. We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.
Resources
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- Woodruff CM et al. Hidradenitis Suppurativa: A Guide for the Practicing Physician. Mayo Clinic Proceedings. December 2015.
- Ludmann P. Hidradenitis Suppurativa: Diagnosis and Treatment. American Academy of Dermatology. July 22, 2024.
- Alikhan A et al. North American Clinical Management Guidelines for Hidradenitis Suppurativa: A Publication From the United States and Canadian Hidradenitis Suppurativa Foundations. Journal of the American Academy of Dermatology. July 2019.
- Hidradenitis Suppurativa: Diagnosis. Mayo Clinic. June 21, 2024.
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- Humira: Highlights of Prescribing Information. U.S. Food and Drug Administration. November 2023.
- Cosentyx: Highlights of Prescribing Information. U.S. Food and Drug Administration. October 2023.
- Bimzelx: Highlights of Prescribing Information. U.S. Food and Drug Administration. November 2024.
- Shih T et al. Biologics and Small Molecule Immunomodulators. HS Patient Guide. March 23, 2023.
- Is There a Diet for Hidradenitis Suppurativa? American Academy of Dermatology.
- Ludmann P. Hidradenitis Suppurativa: Self-Care. American Academy of Dermatology. May 3, 2022.
- Hidradenitis Suppurativa: How to Cope When Depression Hits. American Academy of Dermatology.