Stages of Hidradenitis Suppurativa: How the Condition Progresses

Hidradenitis Suppurativa (HS) is a chronic inflammatory skin condition that develops in areas where skin rubs together, such as the armpits, groin, buttocks, and under the breasts. It begins with small, painful lumps under the skin, but over time, these lumps can worsen, forming deep abscesses, tunnels, and extensive scarring. Because HS is a progressive condition, understanding its stages is essential for early diagnosis, effective treatment, and long-term management.

The progression of HS is categorized into three stages, known as the Hurley Stages, which help doctors assess the severity of the disease and determine the best treatment approach. While some individuals may remain in the early stage with mild symptoms, others may experience worsening flare-ups that require medical intervention. Identifying HS early and seeking treatment can help slow or even prevent progression to more severe stages.

Hurley Stage 1: Early Symptoms and Mild Disease

The first stage of HS is often mistaken for acne, boils, or ingrown hairs. At this stage, treatment may include lifestyle changes, topical treatments, and antibiotics to manage inflammation.

Hurley Stage 2: Recurrent Flare-Ups and Scarring

As HS progresses, flare-ups become more frequent and severe, with multiple abscesses forming in the same areas.

Hurley Stage 3: Severe and Widespread HS

The most advanced stage of HS involves extensive, interconnected tunnels and chronic abscesses that rarely heal.

In this article, we’ll explore each stage of HS in detail, discuss how the condition progresses, and explain available treatment options to help patients take control of their symptoms and improve their well-being.

What Are the Stages of HS?

Hidradenitis Suppurativa (HS) is a chronic skin condition that progresses over time, affecting people differently based on severity and frequency of flare-ups. To better understand how HS develops, doctors use a classification system known as the Hurley Stages, which outlines three distinct levels of disease progression. These stages help medical professionals determine appropriate treatment strategies and predict how the condition may evolve if left untreated.

The Hurley system categorizes HS based on the number of lesions, the presence of scarring, and the formation of tunnels (sinus tracts) under the skin. While some people may experience only mild symptoms throughout their lives, others may face more severe complications, requiring medical intervention to prevent worsening symptoms.

Hurley Stage 1: Mild HS

The earliest stage of HS is characterized by isolated nodules, abscesses, or small lumps that develop under the skin. These lumps may be painful, swollen, and sometimes drain pus, but they typically heal on their own without leaving significant scars. At this point, flare-ups may be infrequent, and many people mistake their symptoms for acne, boils, or ingrown hairs.

Hurley Stage 2: Moderate HS

As HS progresses, symptoms become more persistent and severe. Flare-ups occur more frequently, and multiple abscesses may develop in the same areas. At this stage, painful lumps can lead to permanent scarring, and sinus tracts may begin to form under the skin, creating tunnels that connect old and new lesions. These tracts make healing more difficult and increase the likelihood of recurring infections.

Hurley Stage 3: Severe HS

The most advanced stage of HS is marked by widespread, deep abscesses and extensive sinus tract formation. The affected areas may become severely inflamed, making movement painful and everyday activities challenging. Large sections of skin may be damaged due to chronic infections, and scarring can become extensive. At this stage, medical intervention is often necessary, including surgical procedures, prescription medications, or advanced therapies to help manage symptoms.

Understanding these stages is essential for recognizing how HS progresses and why early treatment is crucial. By identifying symptoms and seeking medical care in the early stages, individuals can take proactive steps to prevent the condition from worsening. In the next sections, we will explore each stage in detail, outlining specific symptoms and available treatment options.

Hurley Stage 1: Mild HS

Hurley Stage 1 is the earliest and mildest form of Hidradenitis Suppurativa (HS). At this stage, symptoms may be sporadic and relatively manageable, but recognizing them early is crucial to preventing the condition from worsening. Many people with Stage 1 HS do not yet realize they have a chronic skin condition, as symptoms often resemble minor skin issues like acne, boils, or ingrown hairs. However, even in this early phase, proper care and treatment can help control flare-ups and slow disease progression.

Symptoms of Hurley Stage 1 HS

In this stage, individuals may experience:

Small, painful lumps or nodules under the skin, usually in areas where skin rubs together (armpits, groin, inner thighs, buttocks, and under the breasts).
Lumps that resemble pimples or boils but tend to recur in the same locations.
Occasional redness, tenderness, or mild swelling in the affected area.
Some lumps may drain pus or fluid, but they usually heal on their own without forming tunnels under the skin.
No permanent scarring or sinus tract formation (tunnels that connect abscesses beneath the skin).

Flare-ups in Stage 1 may be infrequent, but for some, they become persistent and progressively more painful over time. Because these symptoms can be easily mistaken for other conditions, many people go undiagnosed until the disease advances to later stages.

Treatment Options for Stage 1 HS

While there is no cure for HS, early intervention can help control symptoms, reduce flare-ups, and prevent progression to more severe stages.

Lifestyle and Skincare Adjustments

Good hygiene: Washing affected areas with antibacterial or gentle cleansers can help reduce irritation.
Loose-fitting clothing: Reducing friction can minimize flare-ups and discomfort.
Weight management: Excess weight may contribute to increased skin friction and inflammation.
Avoiding irritants: Harsh soaps, deodorants, and shaving can aggravate symptoms.

Medical Treatments

Topical antibiotics (like clindamycin): Helps control bacterial growth and reduce inflammation.
Oral antibiotics: If flare-ups become more frequent, a doctor may prescribe antibiotics to prevent infection.
Steroid injections: Can reduce inflammation and shrink painful nodules.
Pain management: Over-the-counter medications like ibuprofen may help relieve discomfort.

Dietary and Lifestyle Modifications

Smoking cessation: Smoking has been linked to increased HS severity.
Anti-inflammatory diet: Some individuals find relief by avoiding dairy, refined sugar, and processed foods.

When to See a Doctor

If flare-ups become more frequent or painful, or if the lumps fail to heal properly, seeking medical advice is essential. A dermatologist or primary care provider can help confirm a diagnosis and recommend a personalized treatment plan. Early treatment can make a significant difference in managing symptoms and slowing progression to more advanced stages.

Hurley Stage 2: Moderate HS

Hurley Stage 2 is the intermediate phase of Hidradenitis Suppurativa (HS), where symptoms become more persistent, painful, and difficult to manage. At this stage, flare-ups occur more frequently, and lesions may take longer to heal. Unlike Stage 1, where lumps may come and go with little scarring, Stage 2 is marked by the formation of abscesses, scarring, and sinus tracts (tunnels under the skin). While still manageable, Stage 2 HS requires more aggressive treatment to prevent further progression.

Symptoms of Hurley Stage 2 HS

People with Stage 2 HS experience symptoms that go beyond isolated nodules and occasional flare-ups. These include:

Multiple abscesses in the same areas, occurring repeatedly and often not fully healing.
Formation of sinus tracts, which are tunnels under the skin that connect inflamed lumps, leading to chronic drainage.
Increased pain and swelling, as lesions become larger and more inflamed.
Scarring and skin thickening in areas affected by repeated flare-ups.
More frequent and severe flare-ups, sometimes triggered by hormonal changes, stress, or friction from clothing.
Fluid drainage, which may have an unpleasant odor due to infection or prolonged inflammation.

Stage 2 HS is often emotionally and physically challenging, as pain and scarring can begin to affect daily activities. At this stage, it is essential to work with a healthcare provider to develop a treatment plan that manages symptoms and slows progression.

Treatment Options for Stage 2 HS

Since symptoms in this stage are more severe than in Stage 1, treatment typically includes a combination of medical, lifestyle, and procedural interventions.

Medical Treatments

Oral antibiotics (such as doxycycline or clindamycin) – Used long-term to help reduce bacterial growth and inflammation.
Anti-inflammatory medications – Some doctors prescribe retinoids or hormonal treatments, such as birth control or metformin, if HS is linked to hormonal changes.
Biologic medications (like Adalimumab/Humira) – Target the immune system to reduce inflammation and prevent new lesions.
Pain management – Over-the-counter pain relievers, corticosteroid injections, or nerve-blocking medications may be recommended.

Procedural Treatments

Drainage and incision – Large abscesses can be opened and drained to relieve pain and pressure.
Laser therapy – Helps remove hair follicles and reduce the frequency of flare-ups.
Electrosurgery or skin grafting – In some cases, removing damaged tissue may help manage chronic wounds.

Lifestyle and Self-Care Adjustments

Weight management and anti-inflammatory diet – Some people find relief by reducing processed foods, dairy, and refined sugars.
Wearing loose-fitting clothing – Reducing friction can help prevent irritation.
Quitting smoking – Studies suggest that smoking increases HS severity.

When to See a Doctor

If flare-ups become more frequent, painful, or lead to extensive scarring, it’s important to seek medical care. Dermatologists and specialists can offer targeted treatments to help control the condition. While there is no cure for HS, proper management can reduce flare-ups, minimize pain, and slow progression to Stage 3.

Hurley Stage 3: Severe HS

Hurley Stage 3 is the most advanced and severe form of Hidradenitis Suppurativa (HS). At this stage, the condition becomes widespread, deeply painful, and significantly impacts daily life. People with Stage 3 HS experience chronic inflammation, extensive skin damage, and severe scarring, which can lead to limited mobility and ongoing pain. The condition is often physically debilitating and emotionally distressing, requiring intensive medical intervention to manage symptoms and improve quality of life.

Symptoms of Hurley Stage 3 HS

Stage 3 HS is marked by severe and persistent symptoms that are far more intense than in earlier stages. These symptoms include:

Widespread interconnected abscesses and sinus tracts, leading to extensive tunnels beneath the skin.
Severe pain and inflammation, often making movement difficult, especially in areas like the armpits and groin.
Chronic open wounds that fail to heal, increasing the risk of infections.
Extensive scarring and skin thickening, causing permanent tissue damage.
Persistent drainage of pus and fluid, which may have a strong odor due to bacterial overgrowth.
Significant discomfort when sitting, walking, or performing daily activities, especially when flare-ups affect multiple areas.

At this stage, daily life becomes more challenging, as the physical symptoms often interfere with work, relationships, and mental well-being. Many people with Stage 3 HS experience severe depression and anxiety, as the pain and visible symptoms can lead to social withdrawal and emotional distress.

Treatment Options for Stage 3 HS

Because Stage 3 HS is highly complex, treatment requires a combination of medical therapy, surgical intervention, and lifestyle adjustments. The goal is to control inflammation, reduce pain, and prevent further skin damage.

Medical Treatments

Biologic medications (like Adalimumab/Humira or Infliximab/Remicade) – These drugs target the immune system to reduce inflammation and slow the progression of HS.
Systemic antibiotics (such as clindamycin and rifampin) – Long-term antibiotic therapy may help prevent secondary infections.
Corticosteroids – These can be used for short-term relief of severe inflammation and pain.
Pain management – Prescription pain relievers, nerve block treatments, or antidepressants (for chronic pain relief) may be necessary.

Surgical and Procedural Interventions

Wide excision surgery – This procedure removes the most severely affected skin areas, sometimes requiring skin grafts to help the wound heal.
Deroofing surgery – Involves removing the top layers of tunnels and abscesses to promote healing.
Laser therapy – Can help reduce active lesions and prevent new ones from forming.
Wound care management – Specialized dressings and treatments help keep chronic wounds clean and reduce infection risk.

Lifestyle and Support Strategies

Physical therapy may help restore mobility in affected areas.
Nutritional support can assist in managing inflammation through diet.
Mental health counseling and support groups can help manage the emotional toll of HS.

Seeking Medical Help

At this stage, self-care alone is not enough, and medical intervention is critical. If you are experiencing severe pain, chronic wounds, or limited mobility, working closely with a healthcare team—including dermatologists, surgeons, and pain specialists—can help improve symptoms and enhance quality of life.

Why Understanding HS Stages and Treatment Options is Essential

Recognizing the stages of Hidradenitis Suppurativa (HS) and understanding the available treatment options is crucial for managing symptoms, preventing progression, and improving quality of life. HS is a chronic and progressive condition, meaning that if left untreated, it can worsen over time, leading to increased pain, scarring, and physical limitations. By identifying the signs of each stage early and seeking appropriate medical care, individuals can take proactive steps to slow the disease’s progression and reduce its impact on daily life.

One of the biggest challenges with HS is that it is often misdiagnosed or ignored in its early stages. Many people mistake Stage 1 HS for simple acne, boils, or ingrown hairs, delaying treatment until the condition worsens. This delay can result in more frequent flare-ups, the development of sinus tracts, and extensive scarring, making the condition harder to manage. Early diagnosis and treatment can help control inflammation, reduce pain, and prevent HS from progressing to the more severe stages.

Understanding the different treatment options available at each stage is just as important as recognizing the symptoms. While mild HS may be managed with lifestyle changes and topical treatments, moderate and severe cases require more advanced medical interventions. Treatments such as antibiotics, biologic medications, surgery, and laser therapy can significantly improve symptoms, but they are most effective when started before HS reaches its most severe stage. The sooner an individual receives treatment, the better their chances of controlling the condition and minimizing long-term damage.

Beyond physical symptoms, HS also has a profound impact on mental and emotional well-being. The pain, scarring, and chronic nature of the disease can lead to anxiety, depression, and social withdrawal. Seeking early medical care not only helps manage the physical symptoms but also provides access to support groups, counseling, and resources that can help individuals cope with the emotional aspects of living with HS.

By knowing the stages of HS and the treatments available, individuals can become advocates for their own health. Whether it means speaking with a doctor about new symptoms, seeking specialized care, or making lifestyle adjustments to reduce flare-ups, knowledge empowers people to take control of their condition. Education and awareness are key to improving the lives of those with HS, ensuring they receive the proper treatment, support, and care they deserve.

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