The Stages of Hidradenitis Suppurativa

Medically reviewed by Deeptej Singh, MDMedically reviewed by Deeptej Singh, MD

Hidradenitis suppurativa (HS) is a chronic (long-term) inflammatory skin condition that causes painful lesions on the skin that touches other skin. These lesions can look like small, inflamed lumps, pus-filled abscesses, pus-filled tunnels, or sinus tracts that cause permanent scarring. However, your exact symptoms will depend on what stage of the HS you're in.

A staging system called the Hurley Clinical Staging System, developed in 1989, helps determine the severity of HS and offers appropriate treatment options depending on your symptoms. Stage I is mild, stage II is moderate, and stage III is severe. If left untreated, HS progresses quickly to stage III and can result in serious complications such as difficulty performing daily activities, anemia, arthritis, or skin cancer.

How To Determine What HS Stage You're In

Diagnosing hidradenitis suppurativa (HS) can sometimes be challenging because no specific diagnostic tests can confirm whether you have the condition. Symptoms of HS can also mimic signs of other skin conditions, making diagnosis even more difficult. However, your primary healthcare provider or dermatologist (a doctor who specializes in skin conditions) can determine if you have HS by looking for lesions that cause symptoms like:

• Small, inflamed lumps or nodules

• Abscesses, or painful pockets of pus

• Scarring, due to your abscesses breaking open

• Sinus tracts, or pus-filled tunnels that develop when the abscess affects the same part of your skin

• Blackhead-like spots or bumps

These skin lesions often develop in areas of the body where the skin touches the skin, such as your armpits, inner thighs, genitals, or under the breasts. In some cases, lesions can also develop on the face, back, or ear.

To determine the exact stage of HS you're in, your healthcare team will use the Hurley Clinical Staging System. This is the most commonly used staging system for HS and is also helpful in telehealth appointments where physical examinations are not possible.

Here's a brief overview of each stage in the Hurley Clinical Staging System:

Hurley Stage I

Hurley stage I is mild hidradenitis suppurativa, which can cause the following symptoms:

• Small lumps that look like acne or boils

• Burning or itching on the skin where the lumps appear

• Painful, pus-filled lumps (known as abscesses)

Treatment

To treat stage I HS, healthcare providers may recommend the following options:

• Lifestyle changes: Maintain a weight that's right for you and avoid smoking

• Skincare: Use mild antimicrobial washes, wear loose-fitted clothes, avoid waxing or shaving affected skin, and limit exposure to hot weather to avoid sweating

• Topical medications: Apply antibiotics such as Cleocin (clindamycin) and antiseptics like Resinol (resorcinol) on the skin to treat inflammation and reduce the number of lesions

• Oral medications: Take medicines like Sumycin (tetracycline) to help improve symptoms when topical treatments aren't helping your skin

• Corticosteroid injections: Get steroid injections to relieve inflammation if other treatments haven't worked

Treatment in this stage is necessary and important. Without treatment, stage I of HS can quickly progress to stage II.

Hurley Stage II

Hurley stage II is moderate HS, which causes symptoms such as:

• Recurring lumps and pus-filled abscesses

• Lumps that appear in more than one part of the body

• Abscesses that may break open and form a scar when they heal

• Repeated abscesses and scarring on the same part of your skin, which can cause sinus tracts

Treatment

Treatment options for stage II HS include:

• Oral antibiotics: Sumycin (tetracycline) or a combination of Cleocin (clindamycin) and Rifadin (rifampin) can help reduce lesions and treat infections.

• Oral retinoids: Neotigason (acitretin) reduces inflammation.

• Hormone therapy: Aldactone (spironolactone) or other birth control pills can reduce the presence of lesions and improve inflammation/

• Other drugs: Axpinet (metformin) is a common diabetes medication that can also help reduce inflammation for people with HS/

• Surgery: Removing the lesions via incision and drainage, electrosurgery, or cryosurgery may be necessary to prevent your HS from progressing to stage III/

Hurley Stage III

Hurley stage III is severe Hs, which is challenging to treat. In this stage, lesions are quite widespread, with multiple interconnected sinus tracts. These symptoms may also cause:

• Painful lumps that are spread across the body

• Blackhead-like spots that appear in pairs

• Permanent scarring

• Difficulty moving if lesions are causing too much pain

Treatment

Healthcare providers use these treatments to help reduce symptoms during stage III:

• Biologics: Humira (adalimumab) targets the immune system and helps reduce symptoms of current lesions and prevent the recurrence of new ones

• Surgery: Wide surgical excision and laser surgery can remove lesions

It's worth noting that despite these treatments, HS in this stage can still come back. Getting early treatment for HS is key, as treatments in previous stages can improve symptoms and quality of life significantly.

How To Slow HS Progression

Although there is currently no cure for HS, following specific tips can slow disease progression and prevent complications. Consider the following strategies:

• Avoid smoking

• Lose weight if you live with obesity

• Eat nutritious foods, such as a diet high in lean protein, vegetables, and fruit

• Avoid dairy, processed foods, and foods made with yeast (e.g., breads, pastas, and certain alcohols)

• Wear loose-fitted clothing that don't rub against your skin

• Avoid sweating and staying indoors on hot days

• Use mild antimicrobial washes and deodorants

• Don't squeeze or pop the lumps

• Apply warm compresses to the affected skin

Life Through the Stages

Living with HS can be challenging since the condition can affect your quality of life, especially at later stages. For some people, the boils and lumps on the skin can feel embarrassing or affect emotional health. This may cause behaviors like social isolation, decreased work performance, and mood changes. Severe cases of HS may also lead to chronic pain along with difficulty in walking or sitting.

It's important to know that support and treatment are available to help you feel better regardless of where you are in your journey. If you notice that your condition is affecting your emotional and physical health significantly, consider the following coping strategies:

• Talking to your dermatologist and getting a customized treatment plan for you

• Joining an HS support group

• Reaching out to your loved ones about your concerns and feelings

• Meeting with a psychologist or other mental health provider for support

Hidradenitis suppurativa is a lifelong condition, but with proper treatment and support, you may be able to speed up healing and reduce the recurrences of the lesions. Researchers are also developing new biologic medications for treating HS, including Ilaris (canakinumab), Kineret (anakinra), and Stelara (ustekinumab). While these have yet to receive approval by the U.S. Food and Drug Administration (FDA), experts hope they will improve symptoms significantly.

A Quick Review

HS is a painful skin condition that occurs in three different stages: stage I, stage II, and stage III. To determine which stage of HS you're in, healthcare providers use the Hurley Clinical Staging System, which explains which symptoms you may be experiencing and what the recommended treatment options look like. Stage I is considered mild and treatable, stage II is moderate, and stage III is severe and difficult to treat.

Getting treatment and support early can improve symptoms and quality of life. Support groups, in particular, can help you feel less alone and remind you that many other people struggle with this condition.

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