Skin Health More Skin Conditions What Are the Stages of Hidradenitis Suppurativa? By Elizabeth Pratt Elizabeth Pratt Elizabeth Pratt is a medical journalist based in Australia. She has a Master's degree in Health Communication and a Bachelor's degree in journalism. Learn about our editorial process Published on September 29, 2021 Medically reviewed by Casey Gallagher, MD Medically reviewed by Casey Gallagher, MD Casey Gallagher, MD, is board-certified in dermatology. He is a clinical professor at the University of Colorado in Denver, and co-founder and practicing dermatologist at the Boulder Valley Center for Dermatology in Colorado. Learn about our Medical Expert Board Print Table of Contents View All Table of Contents What Is the Hurley System? Statistics About HS Symptoms by HS Stage Complications With Sinus Tracts Treatment by HS Stage Tips for Living Well Frequently Asked Questions Hidradenitis suppurativa (HS) symptoms are diagnosed based on the Hurley system, which describes abscess location and severity. Verywell / Dennis Madamba The condition can be mild, moderate, or severe and is classified by different stages, which help healthcare providers determine the best course of treatment. This article will review the Hurley system, used to stage hidradenitis suppurativa symptom progression, and how each stage is defined. What Is the Hurley System? Hidradenitis suppurativa symptoms can range from mild to severe. In 1989, a dermatologist named Hurley developed a scoring system based on the presence of wounds that have formed tunnels under the skin (sinus tracts) and scarring to diagnose the disease’s progression. Dubbed the Hurley Stages, this system is now used to classify people with hidradenitis suppurativa into three categories based on the severity of symptoms: Stage I: Mildest form of the disease, which presents with solitary pus-filled lumps (abscesses) or formations of multiple abscesses that are isolated; no sinus tracts or scarringStage II: Presents with abscesses that recur, formation of sinus tracts, single or multiple lesions that are widely spacedStage III: The most severe progression with widespread development of lesions, presenting with multiple abscesses and sinus tracts that interconnect Statistics About HS The exact prevalence of hidradenitis suppurativa is difficult to determine. A number of studies have attempted to establish how common the disease is using a variety of methods. As a result, the estimated prevalence of hidradenitis suppurativa ranges from between 0.03% to 4% of the population. Studies have reported that stages I and II of the disease are the most common stages in those diagnosed with hidradenitis suppurativa. Some studies suggest stages I and II impact between 24% and 68% of people with hidradenitis suppurativa, while other studies estimate the prevalence as between 28% and 54% of people with hidradenitis suppurativa. It is believed that stage III of the disease is the least common, affecting between 2% and 29% of those with hidradenitis suppurativa. Studies note, however, that these figures don’t account for the number of people living undiagnosed with hidradenitis suppurativa. 1:53 Click Play to Learn All About Hidradenitis Suppurativa This video has been medically reviewed by Leah Ansell, MD Symptoms by HS Stage Symptoms of hidradenitis suppurativa vary based on severity and stage of the disease. Stage I In the earliest stage of the disease, the first symptom may be itching or discomfort in the affected area. This may be followed by the development of just one or a few bumps confined to one area of the skin. Other symptoms may include: Swelling of the skinA burning sensation in the skinExcessive sweating Stage II In the second stage of hidradenitis suppurativa, symptoms may include: Single or multiple recurring lumpsLumps that appear in more than one area of the skinLumps that may be bigger than those in stage ILumps that break open, causing fluid and pus to drain from the abscess, and which may be accompanied by an unpleasant smell Stage III In the final and most severe stage of the disease, symptoms may include: Widespread lumps across multiple areas of the bodyChronic painBursting abscessesDifficulties with movementBlackhead-like spots which may appear in pairsPermanent scarring Complications With Sinus Tracts In many cases, especially if left untreated, a mild case of hidradenitis suppurativa will worsen, leading to the formation of sinus tracts and abscesses. In stages II and III of the disease, sinus tracts may appear. These are tunnel-like cavities that form under the skin and can interconnect. The tunnels often cause pain and scarring. Abscesses may also form in stages II and III of the disease. An abscess is a larger lump that holds pus. In hidradenitis suppurativa, the abscesses may join together and be very painful. They may break open and leak pus, blood, and fluid. These sores can stain clothes and also cause a foul smell. The constant bursting-then-healing of abscesses can cause permanent scarring. Treatment by HS Stage Treatment is necessary to try and prevent hidradenitis suppurativa from progressing. Treatment options vary based on the stage of the disease. Treatments include medication, procedures or surgeries, skin care, and pain management. Stage I The mildest forms of hidradenitis suppurativa may be treated by: A skincare plan, which may involve washing affected areas with a disinfectant such as benzoyl peroxide and using a more gentle antiperspirant Topical prescription medications, such as antibiotic creams to treat infection or exfoliating creams to unclog hair follicles and reduce inflammation in the area Corticosteroid injections, to reduce inflammation of early lumps that aren’t infected Laser hair removal, to reduce the development of lumps Ice packs for pain Anesthetic cream, such as Lidocaine, for pain Stage II The second stage of the disease may require stronger treatments. These may be given if earlier treatment options have been unsuccessful. Treatment options for stage II may include: Antibiotic tablets, like rifampin together with clindamycinBirth control pills to regulate hormonesSpironolactone, a diureticAn oral retinoid, like AcitretinMetformin, a drug used in diabetes that can also reduce inflammationAdalimumab, a biologic that helps stop the creation of pus and inflammation by the immune system, and the only FDA-approved treatment specifically for hidradenitis suppurativaMedical procedures, like a Botox (botolinum toxin) injection to reduce sweatingPrescription pain killers Stage III In the most severe stage of the disease, a multi-pronged approach to treatment may be necessary. As well as the above treatment options, other treatments include: IV antibiotics to treat infection and improve the likelihood of success of other treatmentsIncision and drainage of abscessesDeroofing, a medical procedure where the skin that covers an abscess or sinus tract is removed and left open to heal by itselfWide excision surgery, a procedure to remove an entire tunnel or lesionLaser surgery, used to vaporize hidradenitis suppurativaPrescription pain killers Tips for Living Well Hidradenitis suppurativa can be a challenging condition, and many with the disease may experience depression. Talking with a counselor or joining a support group may help. Other tips for living with the disease and improving symptoms include: Losing weight if you are overweightQuitting smokingUsing a warm compress or warm tea bags on painful lumpsStaying cool and trying to avoid excessive sweating in hot weatherKeeping and attending all appointments with a dermatologistWearing loose clothing and avoiding tight waistbandsPaying attention to other symptoms like joint pain, and consulting with a healthcare provider if you experience other issues for treatment options since those with hidradenitis suppurativa are at greater risk of other inflammatory diseases like arthritis A Word From Verywell Hidradenitis suppurativa is a chronic, inflammatory skin disease characterized by painful lumps on the skin. In the early stages, there may only be one or two lumps. Without treatment, the disease can progress and cause abscesses that may burst, sinus tracts that may interconnect beneath the skin, and scarring. Fortunately, treatment options are available for symptoms of hidradenitis suppurativa. Consult your healthcare provider as soon as lumps begin to appear, as early interventions can help get the condition under control and prevent it from progressing to a more painful and serious stage. Frequently Asked Questions How do HS symptoms progress? Hidradenitis suppurativa can progress over time. Symptoms may begin with itching and only a few lumps, but progress to abscesses that burst and ooze pus, interconnecting tunnels deep under the skin (sinus tracts), and eventual scarring. What triggers acne inversa? The exact cause of hidradenitis suppurativa (acne inversa) remains unknown. But researchers believe it may be related to hair follicles becoming clogged and infected with bacteria. What kind of disease is HS? Hidradenitis suppurativa is not an autoimmune disease. It is a chronic, inflammatory skin disease that may progress in severity. 9 Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. MedlinePlus. Hidradenitis suppurativa. Hessam S, Scholl L, Sand M, Schmitz L, Reitenbach S, Bechara FG. A novel severity assessment scoring system for hidradenitis suppurativa. JAMA Dermatol. 2018;154(3):330-335. doi:10.1001/jamadermatol.2017.5890 DermNet NZ. Hidradenitis suppurativa. Calao M, Wilson JL, Spelman L, et al. Hidradenitis suppurativa (HS) prevalence, demographics and management pathways in Australia: a population-based cross-sectional study. PLOS ONE. 2018;13(7):e0200683. doi:10.1371/journal.pone.0200683 American Academy of Dermatology Association. Hidradenitis suppurativa: signs and symptoms. National Organization for Rare Disorders. Hidradenitis suppurativa. American Academy of Dermatology Association. Hidradenitis suppurativa: diagnosis and treatment. American Academy of Dermatology Association. Hidradenitis suppurativa: tips for managing. American Academy of Dermatology Association. Hidradenitis suppurativa: who gets and cause. See Our Editorial Process Meet Our Medical Expert Board Share Feedback Was this page helpful? Thanks for your feedback! What is your feedback? Other Helpful Report an Error Submit