Hidradenitis Suppurativa Stages

Hidradenitis suppurativa (HS) is currently thought to affect less than 200,000 people in the US, which is around 0.1% of the population. While this figure appears low, the nature of the condition means that there could be many more undiagnosed people. HS is a deeply unpleasant condition, causing both physical and emotional stress for those living with it.

As a rare but complex condition, there’s a lot to unpack when it comes to understanding it. Here, we examine the different stages of HS, including the typical symptoms and the treatment options currently available.

What is hidradenitis suppurativa?

Hidradenitis suppurativa is a chronic inflammatory skin condition. Also known as acne inversa, it manifests itself as painful nodules, abscesses, and tunnels. These different types of lesions can cause discomfort and pain, which if left untreated and unmanaged, can also lead to negative psychological effects. HS typically appears in areas of the body where skin rubs together, such as the armpits, groin, thighs, buttocks, and under the breasts.

The causes of hidradenitis suppurativa

As a complex condition, the exact causes of hidradenitis suppurativa are not completely understood by medical professionals. However, it is thought that the causes of HS are a combination of genetics, hormones, and environmental factors.

• Genetics is thought to play a role in HS as it has been known to run in families. Studies have found that 33-40% of individuals with hidradenitis suppurativa have an affected first-degree relative, suggesting a hereditary component with an autosomal dominant transmission pattern.
• HS often becomes symptomatic after puberty, which suggests that hormonal changes and fluctuations in sex hormones have a part to play. Observations of the condition have also shown that HS affects more women than men and tends to improve after menopause, again supporting the theory that hormones impact the development and progression of it.
• Hidradenitis suppurativa is also thought to be affected by abnormalities or dysfunction in the immune system. Overreactions to normal skin bacteria can lead to inflammation and blockage of hair follicles, increasing the chance of abscesses and sinus tracts forming.
• Some environmental factors may trigger or make symptoms of HS worse in some people. It is thought that obesity, smoking, excessive sweating, friction or pressure on the skin, and exposure to certain chemicals or irritants can exacerbate symptoms.
• Some studies have suggested that microbial factors such as the bacterial colonization of the hair follicles and sweat glands in affected areas could contribute to inflammation and infection in HS cases.

Who suffers with hidradenitis suppurativa?

HS can affect anyone. It doesn’t discriminate based on age, gender, or ethnic background, but there are thought to be several factors that increase the risk of developing it. Gender, age, family history, and lifestyle factors can each have an impact.

Hidradenitis suppurativa is more likely to affect women than men, at a rate of approximately three times more. When it comes to age, HS most commonly begins after puberty but often becomes its most severe in a person’s 30s and 40s. HS also commonly runs in families, with people more likely to have it if they already have a family member with the condition.

Several lifestyle factors can increase a person’s likelihood of having HS, including obesity. Excess weight can lead to friction and sweating in skin folds, which could contribute to HS lesions developing. Smoking has also been identified as a risk factor.

Possible complications of hidradenitis suppurativa

Hidradenitis suppurativa, like many health conditions, can lead to several complications. Complications include scarring, skin infections, movement difficulty, depression, and anxiety. Many of these complications can severely impact a person’s quality of life, and in severe cases, surgery could be needed to remove the affected tissue.

Complications aren’t a normal part of living with HS, so it’s incredibly important for people living with it to seek treatment and manage their symptoms to avoid complications.

How is hidradenitis suppurativa diagnosed?

If you’ve started to experience some of the symptoms of hidradenitis suppurativa, such as painful and inflamed lesions, the first step in diagnosis is to seek medical attention. A doctor can then carry out an examination to determine whether you have HS.

Your medical professional will typically conduct a physical exam and review your medical history in the first instance. They may also request blood tests, skin biopsies, or imaging tests to rule out any other conditions that could be causing the bumps. Early diagnosis is key in being able to manage symptoms best and prevent complications.

The clinical stages of hidradenitis suppurativa

Hidaradenitis suppurativa can affect people in different ways at different times. It is often categorized into three distinct clinical stages, depending on the severity and extent of the disease. The stages are commonly referred to as Hurley stages, after A.B. Hurley who proposed his classification system in 1989.

Stage 1 hidradenitis suppurativa

In the first stage of HS, symptoms are typically mild which makes treatment options less invasive.

Symptoms of stage 1 hidradenitis suppurativa

While not everyone will experience the same symptoms at the same time, there are several common symptoms of stage 1 HS, including:

• Single or multiple lesions - in areas where skin rubs together, small, tender, and red bumps often appear. Known as lesions, they may resemble boils or acne-like pimples. Typically, these lesions will appear in the armpits, groin, buttocks, thighs, and under the breasts.
• Pain - as lesions start to appear in uncomfortable places, they could be tender to the touch and cause discomfort, especially when pressure or friction is added to the area.
• Outbreak recurrence - in the initial stages of HS, lesions can come and go. You may find you have periods of flare-ups, followed by calm skin. Some people also experience pus coming from the lesions.
• Inflammation - sometimes, mild inflammation will be present in the affected areas but widespread inflammation or scarring is uncommon in this stage.

Treatment for stage 1 hidradenitis suppurativa

Early diagnosis of hidradenitis suppurativa is essential for identifying the best treatment options. When it comes to treating stage 1 HS, the emphasis is on managing symptoms and preventing the condition from progressing to complications. General treatment options in this stage include:

• Topical treatments - topical antibiotics or antiseptics are often prescribed as a first line of defense. Medical professionals usually recommend applications to the affected areas. This can reduce inflammation and prevent infection.
• Warm compress - applying a warm compress regularly can help to reduce pain and promote drainage of pus away from lesions if they have reached this stage.
• Lifestyle changes - making changes to lifestyle factors that contribute to HS symptoms can help to treat it effectively in stage 1. Some lifestyle changes for minimizing irritation and preventing flare-ups include wearing loose-fitting clothing, maintaining good hygiene, and avoiding excessive sweating, pressure, and friction on the skin.
• Weight management - as excessive weight is a known contributor to painful symptoms of HS, those who are overweight or obese should consider losing weight to help reduce friction and sweating in the skin folds.
• Avoid smoking - as an identified risk factor, quitting smoking could help to improve HS symptoms and prevent it from progressing.
• Follow-up care - regularly following up with your healthcare practitioner can help to manage the treatment of your HS symptoms in stage 1. These regular appointments can help to monitor its progression while providing ongoing support and treatment adjustment if needed.

Stage 2 hidradenitis suppurativa

During stage 2 of hidradenitis suppurativa, symptoms are likely to be more pronounced and slightly more severe than in stage 1.

Symptoms of stage 2 hidradenitis suppurativa

The symptoms of HS in stage 2 are similar to those in stage 1 but can be worse. Here are the common symptoms of stage 2 hidradenitis suppurativa:

• Multiple connected lesions - while stage 1 sees isolated lesions, stage 2 often comprises clusters of lesions and boils or abscesses in the affected areas. They can also be larger and deeper.
• Pain - lesions in stage 2 are often more painful, tender, and inflamed. As in the initial stage, discomfort typically increases with movement, friction, and pressure.
• Sinus drainage - lesions can develop sinus tracts, which form as narrow channels under the skin, connecting to several lesions. These sinuses can lead to pus, blood, or foul-smelling fluid needing to be drained regularly.
• Scarring - stage 2 HS is the first stage of the condition where scars and thickened skin form. Constant inflammation and healing cycles can cause the affected areas to scar, which is typically much more prominent in this stage.
• Limited mobility - when lesions become severely inflamed or painful, movement and mobility are often restricted, especially in areas like the armpits or groin.
• Recurrent flare-ups - in stage 2 of HS, flare-ups are typically more frequent and could be triggered by factors including hormonal changes, friction, stress, or infection.
• Impaired quality of life - with chronic pain, discomfort, and emotional distress often coming with stage 2 HS, a person’s quality of life is usually negatively impacted.

Treatment for stage 2 hidradenitis suppurativa

Like stage 1, the treatment options in stage 2 focus on managing symptoms and preventing future complications. The options also emphasize improving the patient’s quality of life by reducing inflammation and improving movement. Most healthcare professionals will use the treatment protocols outlined in stage 1, with a few additions. The most common treatment options for stage 2 HS include:

• Topical and oral medications - oral antibiotics including tetracycline, doxycycline, and clindamycin can be prescribed to reduce bacterial colonization and inflammation. Retinoids can also help reduce inflammation in some cases, preventing new lesions from forming. Anti-inflammatory medications could be prescribed to help with pain management, while immunomodulators may be prescribed for severe or refractory cases of HS.
• Procedures - Stage 2 treatments could involve incision drainage, intralesional injections, or laser therapy to relieve pain and promote healing, while also reducing inflammation.
• Surgery - In severe cases, surgical procedures could be essential. Medics could use excision to remove the affected tissue or entire affected areas of skin in cases where lesions are not responding to other treatments. They may also perform skin grafts to cover large areas of skin that have been removed.

Stage 3 hidradenitis suppurativa

Stage 3 of hidradenitis suppurativa is the most severe stage of the condition, where symptoms have progressed and can significantly impact a person’s quality of life.

Symptoms of stage 3 hidradenitis suppurativa

As hidradenitis progresses, the symptoms tend to get worse, and stage 3 symptoms are much more severe than the first two stages. In this stage, HS is characterized by widespread interconnected lesions, more scarring, and a negatively impacted quality of life. Symptoms often include:

• Wide lesion spread - multiple areas of the body may experience large, painful lesions, abscesses, and interconnected tunnels known as sinus tracts. Many of these lesions are deep and can be difficult to manage.
• Pain - the pain in this stage can be chronic, with many people experiencing severe discomfort and tenderness due to the lesions being larger and inflamed. Movement and activities are often more restricted in this stage due to the pain.
• Drainage and foul odor - in stage 3, persistent drainage of pus, blood, and foul-smelling fluid is common. This drainage can be difficult to control which could lead to hygiene problems and emotional distress.
• Scarring and fibrosis - significant and widespread scarring and fibrosis are common in stage 3 HS. As a result of widespread scarring, movement could also be limited.
• Regular infections and complications - recurrent infections such as cellulitis are common in stage 3 of HS, which can lead to an increased risk of other complications.
• Disability - as the severity of HS increases, some individuals will experience significant disability. This could mean they are unable to perform daily activities or work due to the complications and limited mobility brought on by the condition.
• Impacted quality of life - this final stage of hidradenitis suppurativa can have a significant impact on someone’s quality of life, and much of this is negative. The pain, embarrassment, and social isolation of HS can lead to physical, emotional, and social distress. Sadly, this often results in depression, anxiety, and reduced self-esteem.

Treatment for stage 3 hidradenitis suppurativa

Stage 3 HS requires a multifaceted approach to treatment as medical professionals will aim to manage symptoms, prevent complications, and improve the person’s quality of life. With the severity of this stage, treatments can vary and will often mean a person regularly sees a variety of different healthcare professionals.

In addition to the treatments outlined in stages 1 and 2, medics may also offer a variety of the following:

• Medical therapies - antibiotics, immunomodulators, corticosteroids, and pain management medications may be used to control infections, prevent flare-ups, and reduce inflammation. These treatments can also help to reduce pain, especially for people experiencing chronic pain.
• Procedures - due to the severity of this stage, procedural interventions like photodynamic therapy (PDT) are commonplace. PDT uses photosensitizing agents and light exposure to destroy bacteria and reduce inflammation of lesions.
• Surgery - in severe or complicated cases of HS where the lymphatic system is impacted, medics may surgically remove the affected lymph nodes.
• Wound care - with more frequent lesion drainage and the possibility for more infections, wound care, and management are vital for promoting healing and minimizing scarring.

How fast can hidradenitis suppurativa progress?

As hidradenitis suppurativa is a rare condition that manifests itself in different stages and severity, its progression can also vary from person to person. It’s therefore difficult to say how fast it progresses. Some individuals with HS experience a slower progression with symptoms worsening gradually, while others could have stable periods followed by intense flare-ups or fast progression of the condition into subsequent stages.

In some cases, people may only experience new lesions forming intermittently and existing lesions worsening every so often. In other cases of the condition, people might have a faster progression, with larger and more widespread lesions appearing and increasing the pain and discomfort experienced.

While the progression of HS is not fully understood by medical professionals, it is thought that several factors can influence the speed of progression, including:

• Condition severity
• Risk factors such as smoking or obesity
• Treatment effectiveness

Without treatment, it’s possible that the progression of hidradenitis suppurativa can be much quicker. This is why it’s so important to have the condition diagnosed early so that appropriate treatments can be prescribed. Healthcare providers can support those with HS by creating a tailored treatment plan that meets their needs and regularly assessing the condition for signs of progression or complications.

Conclusion

Hidradenitis suppurativa is a complex condition, but understanding the different stages of it can help to ensure you have a treatment plan in place that supports your unique needs. Discussing your condition with a healthcare professional is vital for understanding which stage your condition is in. From here, they can work with you to develop a treatment plan that will slow down its progression and prevent it from traveling through the later stages.

Whether you already have HS, or you think you may have it but are yet to be diagnosed, understanding the stages of hidradenitis suppurativa is vital for managing the condition throughout its lifecycle.

FAQs

How do I know what stage of HS I have?

To establish which hidradenitis suppurativa stage you have, you will need to consult with a healthcare professional. They will be able to carry out a physical examination and order other tests to assess the severity of your symptoms and establish which stage you are in. From here, they can help you develop a treatment plan that’s appropriate for your symptoms.

You should keep in regular contact with your doctor to ensure symptoms are monitored and treatment plans changed accordingly.

Does HS go away on its own?

With more to understand about HS, it’s impossible to say whether it will go away by itself. As a chronic condition that varies from person to person, all individuals will experience it differently. While some people may only experience it for a short period, others may have the condition for the rest of their lives.

Does HS get worse with age?

Every person experiences HS differently, so for some, it could get worse with age. However, other people may see their symptoms get better as they age. Some factors can influence how your HS impacts your lifestyle, including whether it will get better or worse as you age and move through the stages. That’s why it’s important to carefully monitor your condition and make appropriate health and lifestyle changes that could support it.

Can you get rid of HS permanently?

At present, there is no known cure for hidradenitis suppurativa. However, the various treatment options available can help to manage the symptoms and provide long-term relief for those living with the condition. Working closely with a healthcare practitioner can help you understand which treatment options are best for you, whether that’s medication, lifestyle changes, or surgery.