Hidradenitis Suppurativa

Hidradenitis Suppurativa (HS) is a chronic inflammatory skin condition that causes recurring boils in the folds of your skin and is characterised by painful nodules, abscesses, sinus tract formation, and scarring.

Diagnosing Hidradenitis Suppurativa

Diagnosis is clinical and often delayed due to misidentification, particularly in early stages.

A diagnosis of HS can typically be made when the following are present:

Typical lesions: painful nodules; abscesses; sinus tracts; and/or scars

Anatomical sites: axilla, groin, perianal, inner thigh, buttocks

Chronicity and recurrence: Two or more outbreaks in 6 months.

Assessment and Clinical History

When assessing for HS, clinicians should take into account:

Onset and duration of symptoms

Frequency and severity of flare-ups

Impact on quality of life

Family history

Other factors – obesity, smoking, hormonal changes, and comorbidities.

Physical Examination

Examination should include:

Inspection of all high-risk anatomical sites, even if the patient reports lesions in only one area.

Documentation of:

1. Nodules and abscesses
2. Sinus tracts and scarring
3. Discharge, malodour, or signs of secondary infection

Investigations

While HS is a clinical diagnosis, the following may support management:

Swabs: If secondary infection is suspected.

Ultrasound: To assess extent of subcutaneous tunnels not visible on the surface.

Blood tests: To screen for associated conditions.

Common Pitfalls in Diagnosis

Mistaking HS for recurrent bacterial infection of hair follicles, infected cysts, or pilonidal disease.

Failure to examine all high-risk anatomical sites.

Overlooking the chronic and relapsing nature of lesions.

Early recognition is essential to limit disease progression, prevent scarring, prevent sinus tracts from becoming established and initiate timely referral to dermatology.

Mangement

Hidradenitis Suppurativa (HS) is a chronic skin condition that develops in stages. Recognising the three stages of HS (Hurley Stages I–III) can help patients and healthcare professionals make informed decisions about treatment and care.

Stage 1 – Mild (Early Stage)

One or a few painful lumps or abscesses under the skin.

No sinus tracts or visible scarring.

Outbreaks may heal on their own but can return.

Early signs can often be mistaken for boils or ingrown hairs. Seeking advice early can make a big difference.

Stage 2 – Moderate

Recurrent lumps and abscesses in multiple areas.

Some sinus tracts form under the skin.

Scarring begins to appear between flare ups.

This stage can significantly affect comfort and mobility. Managing HS at this point often involves a combination of medical treatments and lifestyle changes.

Stage 3 – Severe

Widespread inflammation with interconnected sinus tracts.

Chronic abscesses that drain continuously.

Thickened skin and extensive scarring.

Severe HS can be debilitating. Specialist care is usually needed, and surgery may be recommended to manage symptoms and improve quality of life.

Treatment

In the UK, treatment for Hidradenitis Suppurativa (HS) is typically led by a dermatologist. Treatment is tailored to the severity and stage of the condition and focuses on reducing inflammation, managing symptoms, and preventing progression.

GP referral to dermatology is essential for moderate to severe HS

Here’s an overview of treatment options available to the patient:

Lifestyle and Self-Care

Weight management

Stopping smoking

Warm compresses or antiseptic washes

Pain management: paracetamol, and NSAIDs

Medical Treatments

Topical therapies

Oral antibiotics

Hormonal therapy

Biologics