Synopsis
Diagnose hidradenitis suppurativa from recurrent lesions in typical flexures, stage structural damage, identify emergencies and comorbidity, and coordinate medical, wound, pain, lifestyle and surgical care without blame.
- Diagnosis rests on typical lesions, typical flexural sites and chronic recurrence: painful nodules, abscesses, tunnels and scars in axillae, groins, inframammary, abdominal-fold, genital, perianal or buttock skin.
- Ask whether there have been at least two episodes in six months, but do not let an arbitrary frequency erase a convincing longer recurrent history.
- Hurley I has nodules or abscesses without tunnels and permanent scars; Hurley II has recurrent lesions with separated tunnels or scars; Hurley III has diffuse interconnected disease.
- Hurley stage records structural damage, not today’s inflammatory activity, pain or quality of life; include active lesion counts and patient priorities separately.
- Hidradenitis is not caused by poor hygiene and is not contagious; use non-stigmatising language when discussing smoking, weight and friction as modifiable associations.
- Routine swabbing is unnecessary for a typical inflammatory flare; culture fresh pus when secondary infection, unusual organisms or repeated antibiotic failure is suspected.
- Medical treatment can suppress new inflammation, but persistent tunnels and scarred fields often need deroofing or excision for durable local control.
- Screen for depression, pain, metabolic and cardiovascular risk, inflammatory bowel symptoms and inflammatory joint disease, and ask about sexual and work impact.
Key red flags
Sepsis physiology, rapidly progressive perineal pain, crepitus, urinary obstruction, uncontrolled bleeding, a chronic ulcer or mass suggesting squamous-cell carcinoma, severe depression or suicidal thoughts requires urgent escalation.
Rapid perineal progression, disproportionate pain, crepitus, dusky necrosis, confusion or hypotension requires immediate surgical and sepsis management.
A new hard mass, persistent ulcer, bleeding or altered pain in long-standing anogenital disease needs urgent biopsy and specialist review.
Investigation priorities
Document structural extent and identify areas needing medical or procedural treatment.
Management branches
Hurley I or limited Hurley II disease has active nodules without an emergency or extensive tunnel field.
- Explain the diagnosis without hygiene blame, reduce friction and traumatic hair removal, offer absorbent non-adherent dressings and create a proportionate pain plan.
- Consider off-label topical clindamycin for localised disease or a twelve-week oral tetracycline for more widespread activity, using an explicit response and stop assessment.
- Review recurrence, adverse effects, tunnels and scars; escalate early if new structural damage develops rather than repeating acute abscess prescriptions.