Hidradenitis suppurativa symptoms: What are the early signs of hidradenitis suppurativa?

Overview: What does hidradenitis suppurativa feel and look like?

Hidradenitis suppurativa (HS) is a chronic skin disease, similar to acne, that affects hair follicles in places where the skin is folded or rubs up against other skin. The most common areas of the body affected by HS include the armpits and breast folds, but HS can also appear on the inner thighs, groin, mid-waist, nipples, between the buttocks, the area around the anus, or between the anus and genitals. HS can be easily mistaken for acne—its other medical name is “acne inversa.” The earliest symptoms are blackheads, small red bumps, or cysts. Unlike acne, these lesions can be tender or painful. Their appearance is often preceded by itching, burning, pain, or excessive sweating in the area for a few days. At more advanced stages, abscesses form. The drainage from these abscesses can smell very bad. Tunnels called sinus tracts form beneath the skin. Eventually, the entire area might be covered in abscesses and nodules, and the pain can be unbearable. The lesions leave permanent scars, often violet in color, but sometimes bumpy and fibrotic. 

What are the early signs of hidradenitis suppurativa?

The early signs of hidradenitis suppurativa can be discomfort, itching, burning, stinging, pain, or excessive sweating on an area of skin within a skin fold, usually the armpits or under the breasts. Other affected body areas might include the nipples, groin, anal area, perineum, inner thighs, or between the buttocks. These earliest symptoms occur in half or more people. These symptoms are followed by the formation of a solitary blackhead or pimple (papule) that may be tender to the touch.

Other hidradenitis suppurativa symptoms

Hidradenitis suppurativa is usually a progressive and chronic condition that may spontaneously remit, often for years. As the condition worsens, symptoms will change.

Early symptoms of hidradenitis suppurativa (Hurley Stage I HS) include:

• Discomfort

• Itching

• Excessive sweating

• Solitary, tender papules, nodules, or cysts (swollen, red bumps on the skin)

• Abscesses

As the condition worsens (Hurley Stage II HS), typical symptoms include:

• Multiple nodules and cysts that keep recurring

• Pain

• Abscesses

• Bad-smelling discharge from abscesses

• Sinus tracts (tunnels beneath the skin that connect abscesses or nodules)

• Scarring

In the most severe cases (Hurley Stage III HS), symptoms include:

• Abscesses and nodules throughout the affected area

• Multiple sinus tracts connecting abscesses

• Extensive scarring

Scars typically appear as violet areas or raised scars. Sinus tracts can leave plaques or crisscrossing, raised scars that look like a net or web. Scars can be severe enough to compromise people’s ability to move certain muscles, like lifting their arms or moving their legs. 

Hidradenitis suppurativa vs. herpes symptoms

Unfortunately, it takes a long time for people to get diagnosed with HS—typically seven years. HS is easily misdiagnosed as other conditions, including acne, boils, folliculitis, ingrown hairs, bacterial infections, or genital herpes. If HS breaks out around the genitals or anus, it could be mistaken for genital herpes. Some of the early symptoms of HS are the same as those of a genital herpes outbreak, but there are differences. Herpes is more likely to directly affect the genitals, though HS can also cause lesions on the scrotum and vulva. More importantly, a genital herpes flare-up lasts about two or three weeks, then resolves. HS is chronic and worsens over time without treatment.

RELATED: Herpes treatments and medications

When to see a doctor for hidradenitis suppurativa symptoms

See a healthcare provider if you notice a tender nodule or abscess in a place where one usually doesn’t appear, such as the armpits or underneath a breast. If there are multiple painful nodules or abscesses in a skinfold area, do not hesitate to see a clinician. Go to an emergency room if the pain is severe.

Hidradenitis may initially be diagnosed by a primary care provider, but the final diagnosis may be made by a dermatologist. A dermatologist will diagnose HS based on the visual appearance of the lesions and medical history. Testing, biopsy, and imaging are rarely needed unless there’s some uncertainty. 

RELATED: When to see a dermatologist

Complications of hidradenitis suppurativa

Untreated complications of hidradenitis suppurativa include:

• Scarring

• Chronic pain

• Limited limb movement

• Impaired ability to move around or walk

• Infection

• Lymphedema

• Arthritis

• A type of skin cancer called squamous cell carcinoma

• Increased risk of other cancers

• Anemia

• Amyloidosis, is a protein build-up in vital organs like the heart or kidneys

• Rectal or urethral fistulas, small tunnels from the skin to the anus, bowel, or urethra 

• Psychosocial problems, such as reduced quality of life, depression, anxiety, social withdrawal, and an increased risk of suicide

How to treat hidradenitis suppurativa symptoms

Once hidradenitis suppurativa has been diagnosed, either a family physician or a dermatologist will treat the disease, depending on the severity. Treatment pursues four goals:

• Treating lesions

• Reducing pain

• Preventing recurrence

• Preventing any worsening of the disease

Mild cases of hidradenitis suppurativa are treated with:

• Topical antibiotics

• Topical antiseptics

• Surgical removal of bumps (punch debridement)

• Incision and drainage of abscesses

• Corticosteroid injections into the lesions

Moderate cases of hidradenitis suppurativa are treated with:

• Topical antibiotics

• Oral antibiotics

• Humira (adalimumab), a biologic drug that reduces inflammation by blocking the immune system 

• Retinoids

• Anti-androgen drugs like birth control pills in women or spironolactone

• Surgery

Severe cases of hidradenitis suppurativa are treated with:

• Topical antibiotics

• Humira (adalimumab) or other immunosuppressants, such as Cosentyx (secukinumab) and Remicade (infliximab)

• Surgery

Surgery is used to eliminate diseased follicles, abscesses, and sinus tracts. The most common surgeries for HS are:

• Incision and drainage

• Punch debridement to remove the diseased hair follicle and sweat gland

• Unroofing or deroofing, which is when the skin above a lesion is cut off, and the diseased skin below is scraped away

• Electrosurgical peeling

• Laser excision

• Laser hair removal

• Wide excision, which is when the entire area of skin is removed and replaced by a skin graft

Treatment options for HS pain include topical anesthetics, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, SNRIs, gabapentin, and, in the worst cases, opioids.

To prevent future outbreaks and disease worsening, clinicians will counsel patients to lose weight, stop smoking, and wear loose-fitting clothing over the affected area.

Living with hidradenitis suppurativa

People with HS aren’t helpless. They can take some control over the disease and its progress by making a few lifestyle changes and taking care of themselves. Here are a few tips:

• Lose weight 

• Quit smoking

• Manage stress

• Wear loose-fitting, breathable, and absorbent clothing around the affected area

• Use deodorants, soaps, laundry detergent, and skincare products that do not irritate the skin

• Avoid harsh skin-cleaning tools like loofahs

• Avoid shaving or waxing an area that has lesions

• Avoid heat and humidity

• Treat and dress lesions as instructed by a doctor or dermatologist

FAQs about hidradenitis suppurativa symptoms

What triggers hidradenitis suppurativa?

Hidradenitis suppurativa lesions start when a follicle is blocked. This can be brought on by sweating, humidity, or friction due to tight clothing, skin rubbing, or excess fat. Stress is also known to trigger or worsen HS symptoms.

What are the three stages of hidradenitis suppurativa?

Dermatologists and other healthcare providers look at HS lesions and determine their severity by assigning what they see to a stage called the Hurley Stage. The earliest stage involves isolated nodules, bumps, and possibly abscesses in the affected area. Stage II involves more nodules and abscesses in the affected area, with the beginnings of tunnels extending out from the abscesses. There may be some scarring already present. Stage III involves extensive coverage of the affected area with abscesses, nodules, and tunnels connecting the abscesses. Scarring can be very severe. 

Is hidradenitis suppurativa a long-term disability?

HS is a chronic skin condition and can cause disability because of pain, severe symptoms, or complications like joint pain or limited mobility. If these problems do not improve with treatment and make working impossible, people can qualify for disability.

What’s next? Additional resources for people with hidradenitis suppurativa symptoms

Test and diagnostics

• Hidradenitis suppurativa, StatPearls

• Hidradenitis suppurativa: a treatment challenge, American Family Physician

• Hidradenitis suppurativa: from pathogenesis to diagnosis and treatment, Clinical, Cosmetic, and Investigational Dermatology

Treatments

• Hidradenitis suppurativa, StatPearls

• Hidradenitis suppurativa: rapid evidence review, American Family Physician

• Hidradenitis suppurativa: what it is, causes, presentation, and more, Osmosis

• 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 (JAAD)

• Treatment: home remedies, HSDisease.com

Scientific studies and clinical trials

• Hidradenitis suppurativa: current understanding of pathogenic mechanisms and suggestion for treatment algorithm, Frontiers in Medicine

More information on related health conditions

• Acne treatments and medications, SingleCare

• Folliculitis treatments and medications, SingleCare