What is Hidradenitis Suppurativa?

The disease

What is happening in the skin

HS begins in the hair follicle. For reasons that are partly genetic and partly immune-driven, the opening of a follicle becomes occluded by a plug of keratin (a comedone). Pressure builds, the follicle ruptures into the surrounding tissue, and the immune system responds to that ruptured material with intense inflammation — producing the tender, deep nodule the patient feels first.

In some patients the inflammation resolves and the follicle heals. In HS it does not. The same area inflames again, drains, and over months or years organizes into a sinus tract — a tunnel under the skin lined by epithelium that no antibiotic or anti-inflammatory medication can close. Multiple tracts can connect, creating the interconnected tunnel networks characteristic of advanced disease.

HS is therefore two diseases in sequence: an inflammatory disease that medical therapy can quiet, and a structural disease — the tunnels — that only a procedure can remove. Understanding this distinction is the foundation of every treatment decision on this site.

Common misdiagnoses

What HS is not

Most HS patients have been treated for something else first — often for years. The list below covers what HS is most commonly mistaken for, and how it differs.

Recurrent boils or furunculosis. Isolated bacterial follicular infections that resolve and do not recur in the same spot. HS recurs, organizes into tracts, and is not primarily infectious.
Ingrown hairs. Superficial irritation around a single hair. HS is deeper, more painful, and produces nodules under intact skin.
Pilonidal disease. A separate condition of the natal cleft caused by hair burrowing into the skin. The two can coexist, but the treatment logic differs.
Crohn's perianal fistula. An intestinal disease with perianal tracts that connect to the bowel. HS tracts do not. Distinguishing them changes treatment entirely.
Simple abscess. A one-time collection that resolves after drainage. HS abscesses come back, often in the same place.
MRSA or other skin infection. HS cultures are often sterile or grow normal skin flora. Antibiotics help by reducing inflammation, not by curing infection.
Sebaceous cysts. Discrete, well-defined cysts that do not produce surrounding inflammation or tunnels.

Staging

The Hurley staging system

The Hurley system divides HS into three stages based on the presence of tracts and scarring. It is the standard vocabulary clinicians use to plan treatment.

Hurley I

Single or multiple abscesses without sinus tracts or scarring.

Usually responds to medical therapy + follicle-directed laser.

Follicle therapy →

Hurley II

Recurrent abscesses with limited tract formation and scarring, separated lesions.

Often benefits from both follicle therapy and targeted tunnel closure.

Treatment model →

Hurley III

Diffuse involvement with multiple interconnected tracts across an entire region.

Procedural mapping and CO₂ laser closure; extent decides candidacy.

Tunnel closure →

Distribution

Where HS occurs

HS preferentially affects intertriginous skin — regions where two surfaces rub and trap heat and moisture. The same patient often has disease in more than one region.

Axillary: Under the arms. The most commonly recognized region; usually managed by dermatology.
Inframammary: Under the breasts. Mechanical friction and moisture drive recurrence.
Inguinal: Groin and upper inner thigh. Dense lymphatics; high mechanical stress.
Perianal & perineal: Around the anus and perineum. Functionally unforgiving; tunnels may approach the sphincter complex.
Gluteal & natal cleft: Buttocks and the cleft between them. Often confused with pilonidal disease.
Infragenital: Under the scrotum or labial folds. Sensitive anatomy that benefits from tissue-preserving technique.

Our program concentrates on the four regions most under-served by general HS care: perianal, perineal, gluteal, and inguinal.

Risk & triggers

Triggers and risk factors

Established risk factors

— Cigarette smoking (the single most consistent association)
— Obesity and metabolic syndrome
— Female sex (roughly 3:1)
— Family history of HS
— Certain endocrine conditions (PCOS, insulin resistance)
— Associated inflammatory conditions (IBD, spondyloarthropathy)

Common flare triggers

— Heat and humidity
— Friction from clothing, equipment, or activity
— Hormonal cycle (premenstrual flares are common)
— Psychological stress
— Certain dietary factors in some patients (dairy, refined sugar, brewer's yeast have been proposed; evidence is weak and individualized)

HS is not caused by poor hygiene. This is the single most important misconception to correct. Washing more, scrubbing harder, or using stronger soaps does not prevent or treat the disease, and can worsen the surrounding skin.

Diagnostic delay

Why HS is often missed for years

The literature consistently reports an average diagnostic delay of roughly seven to ten years between the first lesion and a correct diagnosis of HS. If you have spent years being told you have recurring boils, you are not unusual — you are the norm.

Several forces contribute. The disease occurs in regions of the body patients are reluctant to show. It presents episodically, so a clinician seeing the patient between flares may see nothing at all. Antibiotics often quiet a flare, which reinforces the (incorrect) interpretation that the problem is infectious. And HS-specific training is thin in primary care and in many surgical specialties.

None of this is the patient's fault. Recognizing the pattern — recurrence, location, and tract formation — is what makes the diagnosis, and once it is made, the treatment ladder becomes much clearer.

Diagnosis

How HS is diagnosed

HS is a clinical diagnosis. Three criteria, taken together, make it:

1. Typical lesions — deep painful nodules, abscesses, sinus tracts, or characteristic scarring.
2. Typical locations — axillary, inframammary, inguinal, perianal, perineal, or gluteal regions.
3. Recurrence and chronicity — two or more episodes in six months.

Biopsy is not required and is not specific. In advanced disease, ultrasound or MRI can be used to map sinus tracts and plan a procedure — particularly relevant before CO₂ laser tunnel closure.

Treatment overview

How HS is treated

HS treatment has two arms. Medical therapy — topical antiseptics, oral antibiotics used for their anti-inflammatory effect, hormonal modulation, and biologic agents (adalimumab and, more recently, secukinumab) — works on active inflammation. It is the foundation of long-term control and is best directed by a dermatologist or rheumatologist familiar with HS.

Procedural therapy works on structure. Follicle-directed laser therapy reduces the population of follicles that drive inflammation. Deroofing and CO₂ laser tunnel closure remove the sinus tracts that medical therapy cannot resolve. Wide local excision remains an option for extensive disease, with the trade-off of larger defects and longer recovery.

The two arms are complementary, not competitive. Our practice is the procedural arm; we expect — and prefer — that your medical team continues their work in parallel.

Read the full treatment model →

Chronicity

Living with HS

HS is a chronic disease. Most patients move through periods of relative quiet and periods of flare. Smoking cessation and weight management have the strongest evidence among modifiable factors, and we will say so plainly — but we will not pretend these alone resolve the disease, and we will not use them as gates to care.

HS has well-documented associations with depression, anxiety, and impaired quality of life. These are not personal weakness; they are part of the disease burden. Patients who arrive at our practice exhausted and skeptical are responding rationally to years of being failed by the standard system. We try to be worth the trip.

Routing

When a procedural opinion is worth getting

— You can feel tunnels under the skin that medication has not closed.
— Drainage keeps recurring in the same spot despite antibiotics or biologics.
— Scarring is starting to limit movement or comfort.
— A surgeon has recommended wide excision and you want a tissue-preserving second opinion.
— Your disease is in the perianal, perineal, gluteal, or inguinal region and no one in your area operates there comfortably.

If this describes you

A consultation will tell you whether we are the right team.

Photographs and history first; in-person or virtual. We will say no if we are not.

Call (424) 279-8222 WhatsApp

Typical response within one business day. We will never share your information.

External resources