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What does Stage 2 hidradenitis suppurativa look like?

Hidradenitis suppurativa (HS) is a long-term skin condition characterized by the occurrence of inflamed and swollen lumps under the skin, typically in areas where skin rubs together, such as the armpits, groin, and under the breasts. HS occurs when hair follicles get blocked and infected. This leads to boil-like lumps developing under the skin which can be painful and lead to scarring.

HS is typically staged from 1 to 3 based on the extent and severity of symptoms. Stage 2 HS involves more extensive symptoms than stage 1, but less severe than stage 3. So what exactly does stage 2 HS look like? Let’s take a closer look.

Areas Affected in Stage 2

In stage 2 HS, there is involvement of multiple regions in addition to those affected in stage 1. This includes:

– Armpits (axillae)
– Groin and genitals
– Under the breasts (inframammary region)
– Buttocks
– Inner thighs

While stage 1 HS is limited to just one area, stage 2 involves two or more regions. The armpits, groin, and under the breasts tend to be the most commonly affected sites.

Number and Type of Lesions

Stage 2 HS is characterized by more lesions than in stage 1. These lesions include:

– Abscesses – pus-filled lumps under the skin
– Nodules – hard, painful lumps under the skin
– Fistulas – tunneled connections between abscesses
– Scarring from previously healed lesions

In stage 2, there are typically multiple recurring abscesses and nodules, along with scarring from previous flares. Fistulas may start to develop but are not extensive.


Abscesses are pus-filled swellings resulting from bacterial infection of blocked hair follicles. Abscesses are the most common type of lesion seen in stage 2 HS. They appear as tender, red, movable lumps under the skin that are filled with pus. Abscesses may be solitary but more often occur in multiples clustered together in affected areas. They can range in size from peas to golf balls.


Nodules are hard, painful lumps under the skin. Unlike abscesses which are filled with pus, nodules are solid tissue swellings. Nodules represent chronic inflammation and scarring of hair follicles. They may sometimes open up and drain pus if a secondary infection occurs. Nodules are immobile as they are tethered to deeper structures. They can persist for weeks to months.


Fistulas are less common in stage 2 HS but may start to occur. Fistulas are tunneled connections that form under the skin between abscesses and nodules. This allows drainage of pus and debris. Fistulas appear as openings in the skin that may leak pus or blood and can cause pain. Early fistulas in stage 2 HS are limited in extent.


Scarring is a hallmark of stage 2 HS as lesions heal over time. This appears as hardened, discolored areas where previous abscesses and nodules have resolved. Early scarring may be mild in stage 2 but becomes more prominent as the condition progresses. Scarring can lead to tethering of skin in folds.


In addition to the visible lesions described above, stage 2 HS also causes other symptoms including:

– Moderate to severe pain – tender, throbbing pain felt in areas with active HS lesions. Pain may worsen with friction from clothing.

– Serous drainage – leaking of clear fluid mixed with blood and pus from open lesions. Often has an unpleasant odor.

– Mild fever – low grade fever may accompany flare ups due to infection of lesions.

– Fatigue – ongoing inflammation can result in tiredness and fatigue.

– Itching – intense itching may be felt around lesions and affected areas.

– Reduced mobility – pain and scarring can make it difficult to move affected body parts.

– Emotional distress – HS can cause depression, anxiety, embarrassment, and low self-esteem.

Pain and Discomfort

Pain is one of the most common symptoms of stage 2 HS. Lesions such as abscesses and nodules are extremely painful to the touch. Pain also worsens with friction against lesions in skin folds from clothing or with movement of affected areas. Pain may preclude normal use of the arms or legs depending on location.


Openings in lesions permit serous drainage of fluid that contains blood, pus, and debris. This can stain clothing and often has an unpleasant odor. Frequent dressing changes are required. Drainage may also make the skin prone to secondary infections.

Systemic Symptoms

Fever and fatigue can result as the body tries to fight off infection associated with HS lesions. Energy levels may be decreased. Warm, reddened areas around lesions may reflect inflammation extending deeper under the skin.

Itching and Scarring

Severe itching around active lesions is common and leads to scratching that further damages skin. Scarring progressively tethers skin, making areas difficult to examine and treat. Scars are also cosmetically unappealing.

Impact on Daily Life

All of the above symptoms can negatively impact a person’s quality of life. Pain may make personal hygiene difficult and disrupt sleep. Odor and drainage stains clothing. Mobility is hampered. Individuals often feel depressed, anxious, and isolated.

Signs on Examination

On physical exam by a doctor, the following signs are typically seen in stage 2 HS:

– Multiple inflammatory lesions in multiple body areas
– boggy, tender nodules and abscesses
– Purulent, serous or serosanguineous drainage from lesions
– Early sinus tracts or fistulas starting to develop
– Scarring and skin changes from healed lesions
– Restricted mobility in affected areas
– Secondary bacterial infection may be present

Lesion Location and Character

Examining all commonly affected body areas will reveal multiple inflammatory lesions in two or more regions. The armpits, groin, and under breasts are most often involved. There are tender, swollen abscesses and nodules, some with drainage. Early tunneling fistulas may be seen.


Scarring of previously healed lesions produces hard, thickened, discolored skin. HS typically affects body folds, and scars may make skin appear tethered or rope-like. Scars can distort anatomy and limit mobility.

Signs of Infection

Redness, warmth, swelling and purulent drainage indicate secondary bacterial infection that may produce fevers. Cultures can identify the causative organisms.

Functional Impairment

Patients may have difficulty moving affected limbs normally due to pain and scarring. Activities requiring arm abduction or leg adduction can be impaired by axillary or groin HS. Gait may be affected.

Hurley Staging

HS severity is classified according to the Hurley staging system as follows:

Stage 1

– Abscess formation – single or multiple, recurrent abscesses with no sinus tracts or scarring
– One affected body region involved

Stage 2

– Recurrent abscesses with development of early sinus tracts and scarring
– Two or more body regions are involved

Stage 3

– Diffuse or near-diffuse involvement across a whole region
– Interconnected sinus tracts and extensive scarring
– Multiple body areas affected

Stage 2 falls in the middle severity, with more extensive involvement than stage 1 but less than stage 3. Most patients first seek medical care during stage 2 disease.


Doctors diagnose stage 2 HS based on:

– Characteristic location of lesions in flexural or intertriginous skin
– Clinical findings on exam as described above
– Patient history of recurrent, painful boils and draining lesions over months to years
– Presence of lesions in multiple bodily regions
– Exclusion of other potential causes or co-existing infections

There are no specific diagnostic blood tests or imaging studies. Bacterial culture of drainage may help identify superinfection. Biopsy can help confirm but is not required for diagnosis.

Clinical Evaluation

Thorough physical examination of all typically affected areas is key, looking for typical lesions and scarring. Medical history and onset of symptoms provides clues to diagnosis. No single lesion is specific for HS, but characteristic location in flexures and bilaterality is typical.

Differential Diagnosis

Other conditions like boils, carbuncles, pilonidal cysts, and fungal infections can mimic early stages of HS. Later stage HS with sinus tract formation is quite distinctive. Co-existing infections should also be excluded.

Role of Testing

While not required, bacterial culture of drainage can identify superinfection. Biopsy may be done to rule out HS mimics but is not needed for diagnosis except in atypical cases. Blood tests are not useful.

Hurley Staging

Hurley staging helps classify severity and guide treatment. Location in multiple bodily regions and early scarring places patients in Hurley stage 2 disease.


Treatment options for stage 2 HS aim to:

– Reduce inflammation and pain from active lesions
– Prevent new lesions from forming
– Minimize scarring
– Address any superimposed infection
– Improve quality of life

Treatment is tailored to symptoms and typically progresses in a step-wise approach, getting more aggressive if lower levels are ineffective.

General Measures

General measures that are always recommended include:

– Warm compresses to promote drainage
– Gentle skin care and hygiene
– Weight loss if overweight
– Smoking cessation
– Avoiding skin trauma


Topical or oral antibiotics are first line to control infection and inflammation. Other medications include:

– Topical antiseptic washes
– Intralesional steroid injections
– Oral retinoids like acitretin
– Anti-inflammatory drugs
– Pain relievers
– Hormonal therapies

Procedural Treatments

If medication fails, procedures can be considered such as:

– Incision and drainage of abscesses
– Excision of individual lesions
– Deroofing of sinus tracts
– Laser or photodynamic therapy
– Radiation therapy


Extensive surgery may be required including:

– Wide excision of entire affected areas
– Skin grafts or flaps for wound closure
– Removal of apocrine glands


Without adequate treatment, stage 2 HS can progress and lead to complications such as:

– Persistent drainage, pain, and odor
– Disorder of normal anatomy
– Joint mobility limitations due to scarring
– Squamous cell carcinoma – rare long term cancer risk
– Anemia from chronic inflammation and drainage
– Depression and social isolation

Early treatment can prevent complications of uncontrolled disease progression. Close follow up is key.

Progression of Scarring

Scarring worsens over time, leading to contractures, sinus tracts, and cosmetic disfigurement. Scars may limit use of arms, legs or normal movement.


Bacterial superinfection of lesions can cause worsening pain, fevers, and drainage. Repeated infections may produce antibiotic resistance.

Joint Problems

Scarring limits skin extension, causing restricted mobility of affected joints like shoulders, elbows, knees or wrists. This can impair range of motion.


Chronic suppuration and blood loss from lesions may lead to iron deficiency anemia. Patients require monitoring of hemoglobin levels.


Long standing HS is associated with a slightly increased risk of squamous cell carcinoma in affected areas. Early detection is important.

Psychological Toll

Depression, anxiety, embarrassment and social withdrawal are common due to pain, scarring and deformity. Supportive counseling and understanding helps.

Prognosis and Outlook

With appropriate treatment, the prognosis for stage 2 HS is generally good. However, HS tends to be a chronic relapsing disease. Recurrences are common when treatment is stopped. With proper care and follow up, patients can expect:

– Reduction in number and severity of flare ups
– Healing of active lesions
– Prevention of new lesions
– Slowing of scarring process
– Decreased drainage, pain and odor
– Improved joint mobility and function
– Enhanced overall wellbeing and quality of life

While HS cannot be cured, long term remission is possible in up to 50% of patients with early diagnosis and attentive treatment. Close follow up care with a dermatologist knowledgeable in HS is essential. An optimistic outlook and healthy lifestyle also aid healing.

Achieving Remission

The goal of treatment is inducing remission, where patients are free of inflammatory lesions for prolonged periods. Maintenance therapy is required to sustain remission without flare ups. Remission is more likely when treatment is started in early stages before severe scarring occurs.

Role of Patient Self-Care

Daily warm compresses, gentle skin care, and avoidance of trauma or friction to lesions promotes healing. Keeping follow up appointments and adhering to prescribed treatments is key. Tracking symptoms helps identify triggers.

Importance of Follow Up

Lifelong monitoring every 3-6 months is crucial to assess treatment efficacy and catch recurrences early. Patients should have low threshold to follow up sooner if symptoms recur. Ongoing care prevents complications.

Expect Some Recurrence

Patients and doctors should be prepared for occasional flares even with proper treatment. Early intervention at signs of recurrence prevents progression. Maintenance therapy may be adjusted to reduce frequency or severity of flare ups.


In summary, stage 2 HS presents with recurrent, painful inflammatory lesions in multiple bodily regions, with early scarring. Abscesses and nodules with purulent drainage predominate, along with moderate pain and itching. Sinus tract formation is just beginning. Diagnosis is made clinically based on characteristic appearance and locations. Treatment aims to reduce symptoms, prevent new lesions, and stop progression. A combination approach is used starting with antibiotics, followed by procedures or surgery if needed. Lifelong monitoring and care is crucial to manage this chronic condition. While HS is not curable, early diagnosis and treatment in stage 2 can achieve sustained remission in many patients with proper follow up care.