Hidradenitis suppurativa (HS) is a long-term skin condition characterized by small, painful lumps under the skin. The early signs of HS can be subtle and many people mistake them for acne or boils at first. Detecting HS in the early stages is important for getting proper treatment and managing symptoms. Here is an overview of what to look for with early hidradenitis suppurativa.
Where Are Early HS Lesions Located?
HS lesions most commonly occur in areas of the body with apocrine sweat glands. These include:
- Armpits (axillae)
- Groin and genital region
- Under the breasts
- Around the anus
- Under the abdomen
The early lesions of HS form as nodules, pimple-like bumps, pus-filled abscesses, or swollen tissue under the skin. They often start out as small, red, tender lumps in the hair follicles or sweat glands of the affected regions.
Early Stage Symptoms
Some of the earliest symptoms of HS include:
- Single or multiple nodules – These are firm, tender lumps under the skin, ranging from pea-sized to a few centimeters across.
- Mild discomfort or pain – The lumps may feel sore or tender to the touch, especially when pressure is applied.
- Mild swelling – Some swelling and inflammation develops around the lesions.
- Dark marks – Dark spots or discoloration can appear on the overlying skin as the lumps heal.
- Foul odor – A bad smell may arise as the lumps start to drain fluid or pus.
- Itching – Itching and irritation is common around the lesions.
At first, a person may notice only one or two lesions. But over time, more nodules tend to gradually develop and form interconnected tunnels under the skin. The lesions are not necessarily painful at this stage, but cause discomfort when pressure is applied.
How Early HS Differs from Acne
HS is often mistaken for acne in the beginning stages because it also causes bumps and pimple-like lesions. However, there are some key differences between early HS and acne:
| Early HS | Acne |
|---|---|
| Deep, painful nodules under skin | Pimples on surface of skin |
| Located in armpits, groin, under breasts | Mostly affects face, shoulders, back |
| Lesions recur in same locations | Acne can occur anywhere with pores |
| Lesions drain pus or blood | Pimples may drain white/yellow pus |
| Heals with scarring or dark marks | Usually resolves without scarring |
| Lesions progressively worsen over time | Acne may improve or worsen with hormonal changes |
Paying attention to where the lesions are occurring and how they behave over time can help distinguish early HS from regular acne. HS also does not respond as well to typical acne treatments like over-the-counter creams or oral antibiotics.
When to See a Doctor
It’s important to make an appointment with your doctor or dermatologist if you notice any persistent, painful lumps or boils in the typical HS-prone regions. The earlier HS is diagnosed, the better the treatment outcomes tend to be.
See a doctor promptly if you have any of the following symptoms:
- Tender, swollen lumps under the arms, groin, breasts or other HS-prone areas
- Bumps that are swollen, red and painful
- Pus or blood draining from lesions in HS regions
- Dark scarring or skin discoloration where lumps have healed
- Foul odor coming from lesions
- Itching and irritation around the lumps
Your doctor can examine the lesions and determine if they are likely to be early signs of HS based on the appearance and location. They may take a small sample to analyze under a microscope to confirm it is HS.
HS Stages
Doctors use a staging system to classify HS based on the extent of lesions and scarring. The earliest stage is considered stage 1:
Stage 1
- Single or few scattered abscesses, nodules or lesions
- Mild discomfort and pain
- No scarring or sinus tract formation
Stage 2
- Multiple recurrent abscesses, lesions and nodules
- More discomfort and inflammation
- Some minor scarring may be present
- No sinus tract formation
Stage 3
- Multiple interconnected lesions and abscesses
- Development of sinus tracts and tunnels
- Scarring is present
- Drainage of pus and blood
Catching HS in stage 1 gives the best chance to treat lesions before they progress and do permanent damage under the skin. People with stage 1 HS may only have one or two bumps at a time that flare up occasionally before healing.
Early HS Treatment
Treatment for early stage HS aims to prevent the condition from getting worse. Options may include:
- Warm compresses – Applying warm, wet compresses to lesions can help soothe pain and inflammation.
- Antibacterial soaps – Washing with antibacterial cleansers can help prevent infection in lesions.
- OTC pain medications – Over-the-counter drugs like ibuprofen can temporarily reduce discomfort.
- Topical antibiotics – Creams with clindamycin, erythromycin or dapsone may be prescribed to apply on early lesions.
- Oral antibiotics – Antibiotics by mouth such as doxycycline, clindamycin or rifampin may be used short-term.
- Steroid injections – Direct steroid injections into small, localized lesions can reduce inflammation.
- Laser or light therapy – Laser or intense pulsed light therapy can help reduce HS lesions and inflammation.
- Surgery – Minor surgery may be done to drain larger cysts or close tracts between lesions.
The specific treatment will depend on the number and extent of lesions present. Mild cases can often be controlled with conservative treatments, while more severe cases may need stronger prescription medications or minor surgical procedures. Catching HS early provides more options for nonsurgical management.
Preventing Early HS from Progressing
It can be very challenging to completely cure HS once it reaches an advanced stage. That’s why the priority is stopping it from getting worse if it’s identified early. Some tips for preventing progression of early stage HS include:
- Using medicated body washes containing benzoyl peroxide, chlorhexidine or triclosan.
- Avoiding tight clothing or garments that rub on affected areas.
- Applying antibiotic creams after hair removal to prevent infection.
- Taking antibiotics as prescribed to treat flare ups.
- Keeping lesions clean and covered with bandages.
- Losing weight if overweight or obese.
- Stopping smoking due to the association with HS severity.
- Managing stress levels which may trigger flares.
While early HS cannot always be cured, people can keep it under control and prevent extensive scarring or complications with vigilant skin care and treatment. Tracking flare ups, identifying triggers, and contacting the doctor at the first sign of lesions recurring can all help control HS progression.
Outlook for Early Stage HS
The outlook for early stage HS is generally better than more advanced cases. When treated quickly, some people with stage 1 HS find their lesions clear up entirely between flare ups. The lesions tend to be smaller and less painful than in later stages as well.
However, HS is still considered a chronic, lifelong condition. Most patients will have periodic flare ups to manage even with proper treatment. But starting treatment as early as possible provides the best chance of controlling symptoms and avoiding extensive scarring.
Around 1 in 3 people with stage 1 HS find their condition resolves after a first flare up, while 2 in 3 have recurrent flare ups. With consistent care and tracking of symptoms, people with early HS can keep outbreaks localized and mild. The overall prognosis is better when HS is diagnosed before it has a chance to progress.
When to See a Dermatologist
It’s advisable see a dermatologist if you are experiencing potential early signs of HS. A dermatologist has specialized training in identifying and treating skin conditions like HS.
See a dermatologist promptly if you notice any of the following:
- Painful lumps or bumps under the arms, groin, breasts or other HS-prone regions
- Lesions that drain pus or blood when squeezed
- Foul odor coming from lesions in the underarm, groin or breast regions
- HS symptoms that do not improve with over-the-counter acne medications
- Signs of infection around lesions, like worsening pain, swelling and redness
A dermatologist can examine your skin and determine whether suspicious lesions may be related to HS. They may perform tests to look for skin infections that need treatment as well. Dermatologists also have specific medications and therapies they can offer to treat HS in the earliest stages.
Diagnosing Early Stage HS
To diagnose early HS, a dermatologist will:
- Ask about your symptoms and when they started
- Examine the locations where you are having lesions
- Evaluate for signs of HS like nodules, draining lesions, and tunnels under the skin
- Rule out other potential causes like acne, infections, or ingrown hairs
- Consider a skin biopsy if the diagnosis is uncertain
- Assess the extent of lesions and scarring to classify the HS stage
Blood tests are not usually needed unless there are signs of infection. Cultures may be taken from draining lesions to identify any bacteria present. A skin biopsy can confirm HS, but is not always required if the clinical examination is highly indicative.
Based on the presenting symptoms and exam findings, a dermatologist can often make an accurate early diagnosis of HS. This then allows for timely treatment to keep the condition from getting worse.
Risk Factors for Early Onset HS
HS can begin at any age, but often starts between puberty and age 40. Factors that increase risk of developing HS at a younger age include:
- Being overweight or obese
- Going through puberty and hormonal changes
- Having a family history of HS
- Smoking tobacco products
- Friction from shaving, tight clothing, etc.
- Use of certain medications like lithium, corticosteroids
- Metabolic conditions like PCOS (in women)
Younger onset HS may be more genetic in nature, while cases developing later in life are more often associated with modifiable risks like smoking and obesity. Having one or more risk factors does not mean HS is inevitable, but it does warrant closer monitoring of the skin for early signs.
Early Signs of HS in Men vs. Women
The early symptoms of HS are similar in both men and women, but the locations involved may differ:
Early HS in Women
- Armpits (axillae)
- Groin and genital region
- Under the breasts (mammary/breast folds)
- Around the anus
Early HS in Men
- Armpits (axillae)
- Groin and genital region
- Around the anus
- Under abdominal folds
Women tend to get early HS lesions under the breasts as well as the groin, while men are more likely to be affected under abdominal folds. But both genders can experience lesions in the armpits, groin and anal regions in early HS.
Early Signs of HS in Dark Skin
HS has traditionally been considered a disease primarily affecting white patients. But more recent research found prevalence is also significant in those with dark skin tones.
Some unique aspects of early HS in people with dark skin include:
- Lesions may present as skin darkening, rather than redness/swelling
- Scarring canappear as light patches, not dark scars
- HS is often misdiagnosed as regular folliculitis or keloids
- Bumps are often less conspicuous and harder to detect visually
Paying attention to skin texture changes, pain, itching, and odd smells from lesions can help identify early HS in those with darker skin when visibility is poor. Seeking treatment at first symptoms is important, as HS may be caught later in dark-skinned patients.
Will Early Stage HS Go Away?
For some patients diagnosed and treated very early, HS may seemingly go away for a period of time after a first flare. But HS is considered a chronic condition, and most people will experience recurrence of symptoms over time.
In one study, 35% of people had their HS resolve after initial treatment, while 65% had recurring flares. Even if lesions clear up entirely with early treatment, that does not mean the HS has been cured.
It is possible for HS to go into remission for months or even years before flaring back up. Going into remission is more likely if it is caught in stage 1. But you should remain vigilant for symptoms recurring and follow up regularly with your dermatologist.
Conclusion
Catching hidradenitis suppurativa early is critical for getting the condition under control before it can progress. Be on the lookout for symptoms like painful bumps, drainage, and odor in the armpits, groin and other typical HS regions. See a doctor promptly at the first signs of possible HS lesions for proper diagnosis and treatment. With early detection and management, it may be possible to achieve longer remission periods and prevent extensive scarring from HS.