FFinalistSouthampton · 2027
Dermatology
AKT · Dermatology/Inflammatory & papulosquamous

Hidradenitis suppurativa

Chronic follicular occlusion + inflammation of apocrine-bearing skin

Overview

A chronic, relapsing inflammatory disease of follicular occlusion in apocrine-gland-bearing flexures (axillae, groin, inframammary, perianal). Recurrent painful nodules and abscesses that rupture, discharge and form sinus tracts and scars. Strongly associated with smoking and obesity.

Recognise

  • Recurrent painful inflammatory nodules and abscesses in the AXILLAE, groin, inframammary and perianal regions
  • Discharging sinus tracts, "double-ended" (tombstone) comedones, and rope-like scarring with chronicity
  • Hurley staging (I nodules/abscesses → II recurrent with sinus tracts → III diffuse interconnected tracts); links to smoking, obesity, metabolic syndrome

Red flags

  • Severe scarring/contractures, fistulae, and rarely SCC in long-standing perianal disease; major psychological impact

Differentials & how to tell them apart

Recurrent furunculosis/boilsStaph folliculitis without the sinus tracts and flexural chronicity
Crohn disease (cutaneous/perianal)perianal fistulae + GI symptoms — can coexist with HS
Epidermoid cystsisolated cysts with a punctum, not the recurrent flexural inflammatory disease
Pilonidal sinusnatal cleft, hair-containing sinus

Clinical image

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Hidradenitis suppurativa — clinical imagesDermNet

Investigations

Clinical (recurrent lesions in typical sites, Hurley stage). Swab only to guide antibiotics in flares.

Management

Smoking cessation + weight loss + topical clindamycin (mild) / oral antibiotics (moderate)

  1. 1General measures for all — smoking cessation, weight loss, loose clothing, antiseptic washes, analgesia. Mild (Hurley I) → topical clindamycin.Gate: Hidradenitis is NOT simple recurrent boils — it is follicular occlusion in ap/ocrine flexures; lifestyle modification (especially STOPPING SMOKING and weight loss) is genuinely disease-modifying and is part of first-line treatment, not an afterthought
  2. 2Moderate → oral tetracycline, or clindamycin + rifampicin. Severe/refractory (Hurley II–III) → adalimumab; surgery (de-roofing/wide excision of sinus tracts) for established tracts.
Topical clindamycin — mild localised (Hurley I)
Oral tetracycline; clindamycin + rifampicin — moderate disease
Adalimumab (anti-TNF) — moderate-to-severe disease refractory to antibiotics
Lifestyle: smoking cessation + weight loss — disease-modifying — strongly advised

Key points

Often misdiagnosed as recurrent abscesses for years. The flexural distribution + sinus tracts + scarring is the pattern. Smoking and obesity drive it.

Monitor & prognosis

Hurley stage, flare frequency, psychological impact.

Chronic; early treatment and lifestyle change limit scarring.

Source: NICE CKS Hidradenitis suppurativa; BAD guideline