Hidradenitis suppurativa (HS), also known as acne inversa, progresses through three stages. In stage 2, painful, pus-filled lumps called abscesses recur (disappear and reappear) at sites of previously healed skin lesions. This recurrent inflammation often leads to scarring and the development of tunnels under the skin, known as sinus tracts.

HS affects up to 4 percent of the global population, though estimates vary. HS is considered a rare dermatological (skin-related) disease, and it can greatly impact a person’s quality of life, both physically and emotionally.

What Is Stage 2 Hidradenitis Suppurativa?

HS is categorized into three stages based on its severity and how it progresses, following the Hurley staging system.

• Stage 1 HS — In this early stage, there is typically one or a few abscesses or lesions, but no scarring or sinus tract formation (narrow channels that develop beneath the skin).
• Stage 2 HS — This stage involves one or more recurring lesions. Sinus tracts and scarring are common, and the lesions may appear either close together or in separate areas.
• Stage 3 HS — This is the most severe stage, characterized by multiple interconnected sinus tracts, extensive scarring, and lesions that frequently recur.

Around 28 percent of HS cases progress to stage 2. During this stage, abscesses that heal can reappear in the same locations or form in new areas. As abscesses resolve, they often leave scars. Over time, scar tissue accumulates beneath the skin, leading to sinus tract formation.

HS commonly first develops after puberty and is typically diagnosed between the ages of 20 and 24. Diagnosing HS in its early stages can be challenging, and it can take an average of around seven years to be diagnosed. This delay can allow the condition to progress to stage 2.

HS is three times more common in women than in men, according to the Journal of Clinical and Aesthetic Dermatology. In the United States, Black people have a higher prevalence of HS compared to other racial and ethnic groups — likely due to genetic factors, according to Mayo Clinic.

What Causes HS?

The exact cause of hidradenitis suppurativa (HS) is not fully understood. However, health experts have identified several risk factors that may increase the likelihood of developing the condition:

• Having a family history of HS
• Smoking tobacco
• Being clinically overweight or obese, which is diagnosed based on a person’s body mass index (BMI), calculated using a person’s weight and height.
• Having co-occurring diseases, such as severe acne, arthritis, inflammatory bowel disease (IBD), diabetes, or metabolic syndrome

It’s important to note that HS is not sexually transmitted, is not contagious, and is not caused by poor hygiene.

Certain triggers can provoke HS flare-ups (periods of increased or worsened symptoms). These triggers may include:

• Excessive sweat
• Wearing of tight clothing
• Heat exposure
• Stress
• Fatigue
• Hormonal changes during menstrual cycles

Does Hidradenitis Suppurativa Always Progress to Stage 3?

HS doesn’t always progress to stage 3. In fact, only about 4 percent to 7 percent of people with the condition eventually develop stage 3 hidradenitis suppurativa.

Symptoms of Stage 2 Hidradenitis Suppurativa

Stage 2 HS lesions can develop in new areas or reappear near or on the same spot as a previous lesion. These lesions tend to form in areas where skin rubs together or in regions rich in apocrine sweat glands, such as the armpits, groin, buttocks, and breasts.

Stage 2 HS lesions are large, inflamed lumps or abscesses filled with pus and fluid. They may be widely spaced apart. Lesions often break open, releasing foul-smelling pus and fluid. Over time, scarring and sinus tracts (tunnels beneath the skin) form in the affected areas.

Stage 2 HS symptoms are more noticeable and painful compared to those in stage 1 HS. Some people experience about two abscesses per month, but this can vary from person to person. While symptoms can differ based on the area affected, the most common ones in stage 2 HS include:

• Single or multiple recurring painful lesions filled with fluid or pus
• Moderate discomfort, burning, or itching on the affected area of skin
• Draining sinus tracts under the skin
• Scarring

If stage 2 HS is left untreated, symptoms can become more severe and spread to larger areas of skin. At that point, it may progress to stage 3. It is crucial to speak with your doctor if you begin to experience recurring abscesses, scarring, draining sinus tracts, or any new symptoms.

Treatments for Stage 2 Hidradenitis Suppurativa

There is no cure for HS, but many treatment options are available to help manage symptoms. Dermatologists recommend treatments based on the stage of HS. The doctor will consider factors, such as the severity of your symptoms, the number of lesions, and your general health and medical history.

Stage 2 HS is treated with a combination of medications that may include:

• Oral antibiotics, such as tetracycline or rifampin (Rifadin) with clindamycin — These antibiotics help reduce inflammation and bacterial growth, which can lower the chance of infection and calm active lesions.
• Oral retinoids, such as acitretin (Soriatane) and isotretinoin (include Accutane, Absorica, Amnesteem, and Claravis) — Retinoids regulate skin cell turnover and reduce the formation of new lesions by preventing clogged hair follicles and inflammation.
• Hormonal therapy, such as oral contraceptive pills, finasteride (Propecia, Proscar), or spironolactone (Aldactone, CaroSpir) — These therapies help regulate hormones that may trigger HS flares and can reduce inflammation and the severity of lesions.
• Corticosteroids (steroids), such as prednisone — Steroids reduce inflammation and swelling in affected areas, providing relief from pain and slowing down flare-ups.
• Biologics, such as adalimumab (Humira) — Biologics target specific parts of the immune system responsible for inflammation, helping to reduce the number of lesions and prevent future flare-ups.
• Metformin — Primarily used to manage insulin levels in people with diabetes, metformin can also promote weight loss and reduce inflammation, which may benefit people with HS.
• Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen or over-the-counter pain relievers — NSAIDs help reduce pain and inflammation associated with HS lesions.

Some surgical treatments may also be used to manage stage 2 HS, including:

• Deroofing — Deroofing removes the surface layer of skin over abscesses or sinus tracts, enabling the area to heal.
• Wide excision — This surgery removes larger areas of affected skin, including abscesses and sinus tracts, to prevent the lesions from returning.
• Laser hair removal — By targeting and reducing hair follicles , laser therapy can help prevent new lesions from forming in commonly affected areas.

Incision and drainage is another procedure that your dermatology team may recommend. While this was a more common HS treatment in the past, it’s no longer the preferred option due to the risk of lesions returning. However, it may still provide temporary relief for individuals experiencing severe pain. It’s essential to discuss the risks and benefits with your dermatologist before considering this procedure.

Skin Care Tips

Doctors may sometimes recommend topical antiseptic washes, such as 4-percent chlorhexidine or benzoyl peroxide, to keep the skin clean and reduce the risk of a bacterial infection.

Other ways to help treat and manage the affected skin at home including:

• Applying a warm compress to the affected area for a few minutes to relieve discomfort
• Wearing loose-fitted undergarments and clothing to minimize friction
• Using antibacterial soap on the affected skin to help prevent infection
• Avoiding skincare products that may irritate the skin or cause flare-ups
• Refraining from shaving areas prone to HS, such as the underarms, groin, genital area, or buttocks
• Minimizing heat exposure and sweating, which can trigger symptoms
• Keeping the skin dry and cool to reduce irritation and flare-ups

Managing Stage 2 Hidradenitis Suppurativa

Living with stage 2 HS can be challenging. However, certain lifestyle changes may help manage or reduce symptoms and improve the quality of life for some people.

Quit Smoking

The link between smoking and HS is well-established through research. Smoking increases inflammation throughout the body, which can worsen HS symptoms. Studies show that most people with HS actively smoke. By quitting smoking, you may reduce your risk of HS flare-ups and improve your overall health.

Adjust Your Diet

Certain foods and stress can trigger a flare-up in some people. The Mayo Clinic recommends:

• Eliminating dairy products
• Reducing sugar
• Avoid brewer’s yeast

Adjusting your diet may also help with weight loss, which can benefit HS management.

However, it's important to note that changing your diet may not significantly improve your symptoms unless specific food triggers are identified. Talk to your dermatologist or health care provider before making major dietary changes or starting a new exercise routine.

Lose Excess Weight

Obesity contributes to inflammation throughout the body. There’s a strong association between increasing body mass index and the increasing severity of HS. Achieving and maintaining a healthy weight for your body type may help reduce the recurrence of lesions (flare-ups) and slow disease progression.

Talk With Others Who Understand

Living with HS can be difficult, but you are not alone. On myHSteam, the social network for people with hidradenitis suppurativa and their loved ones, more than 44,000 members come together to ask questions, give advice, and share their experiences with others who understand life with hidradenitis suppurativa.

Do you have stage 2 hidradenitis suppurativa? What advice do you have for others? Share your thoughts in the comments below or by posting on myHSteam.