Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that causes painful bumps to form, often in areas where skin rubs together. In stage 3 HS, recurring nodules and abscesses spread over large areas and may form interconnected tunnels under the skin. These tunnels can lead to severe scarring and skin changes. This advanced stage of HS is challenging to treat and can significantly impact quality of life.

“I have stage 3 HS — it’s very difficult at times and very depressing not being able to work outside the home due to the flares,” one myHSteam member shared. Another wrote, “I have stage 3 HS. I’ve had major surgery on both sides of my groin, both armpits, and my butt. I have flare-ups all the time on my waist where my pants rub.”

Read on to learn more about stage 3 HS, including its symptoms and available treatment options.

What Is Stage 3 Hidradenitis Suppurativa?

HS, also called acne inversa, begins at the hair follicle. This inflammation leads to painful, discolored nodules, boils, or abscesses in areas where hair grows. The condition most often affects the armpits, groin or genital area, thighs, and buttocks. Symptoms may also develop on the face, neck, area behind the ears, folds of the stomach, and skin under the breasts. HS isn’t contagious, sexually transmitted, or caused by poor hygiene.

The severity of HS is classified into three stages using the Hurley staging system. Stages are sometimes referred to using Roman numerals (e.g., stage II instead of stage 2).

• Stage 1 HS — This stage is characterized by one or a few isolated abscesses or nodules with no sinus tracts (narrow, tunnel-like openings under the skin) or scarring.
• Stage 2 HS — This stage involves abscesses or nodules that form and heal repeatedly, with some scarring and sinus tract formation. Lesions may be clustered or spread apart.
• Stage 3 HS — The most advanced stage of HS involves multiple recurrent abscesses or nodules, interconnected draining sinus tracts, and severe scarring.

Only about 4 percent to 7 percent of people with HS develop stage 3. In stage 3, new nodules and abscesses form as soon as older ones have healed. These may form in the same or new areas of the skin. Over time, this causes significant scarring, interconnected tunnel formation, and widespread inflammation.

What Causes HS?

The exact cause of HS remains unknown, but several risk factors are linked to its development. These include:

• Genetics — Up to 40 percent of people with HS have a family member with HS.
• Smoking — Tobacco use is known to worsen inflammation and may increase the risk of HS.
• Body mass index (BMI) — BMI is a measure of body fat based on height and weight. People with a BMI of 25 or higher (classified as overweight or obese) are at greater risk for HS.
• Other health conditions — HS often occurs with conditions like severe acne, diabetes, arthritis, metabolic syndrome, and inflammatory bowel disease (IBD).

HS triggers include excessive sweat, stress, heat, fatigue, tight clothing, certain lifestyle and environmental factors, and hormonal changes during the menstrual cycle.

According to Mayo Clinic, Black people are more likely to develop HS compared to people of other racial groups. Additionally, Mayo Clinic notes that women are three times more likely to develop HS than men.

Symptoms of Stage 3 Hidradenitis Suppurativa

In stage 3 HS, lesions can form at new sites on the skin or reappear near or on the original site. Stage 3 lesions typically affect areas of the body where there are many lymph nodes and apocrine sweat glands, such as the armpits, groin, buttocks, and below the breasts. As HS progresses to stage 3, areas of the body where the skin repeatedly rubs together are affected, such as the:

• Nape of the neck
• Torso
• Abdominal folds (waistline)
• Perianal area (around the anus)
• Thighs

In rare cases, HS lesions can also appear on the face.

Stage 3 HS lesions are large, inflamed lumps resembling boils and are filled with foul-smelling pus. These lesions often connect under the skin through sinus tracts, which can cause widespread inflammation. The sinus tracts may then break through to the surface and leak pus and fluid. Stage 3 is marked by severe scarring and persistent draining of wounds. This drainage may damage the lymphatic system, the network of tissues and organs that helps the body remove waste, toxins, and unwanted materials. Damage to the lymphatic system can lead to swelling in the legs, arms, or genitals. Additionally, some HS lesions may become infected with bacteria, leading to further complications.

Stage 3 HS symptoms are more severe than those of stage 2 HS. While specific symptoms may vary depending on the affected area, the most commonly reported symptoms of stage 3 HS include:

• Inflammatory lesions affecting multiple body areas
• Multiple interconnected sinus tracts
• Leaking cysts, bumps, or sores
• Extensive and deep scarring
• Tenderness, burning, or itching on the affected area of skin
• Anxiety or depression

Other Symptoms

One study found that people with stage 3 HS experienced challenges during work or school activities. Severe scarring and chronic inflammation from stage 3 HS lesions can lead to:

• Restricted movement, especially in the thighs or armpits
• The development of an anal fistula (an infected tunnel between the skin and the anus)
• Anal stenosis (narrowing of the anal canal)
• Urethral stricture (narrowing of the urethra, the tube that carries urine out of the body)

Stage 3 HS can also lead to frequent bacterial infections in affected skin areas​​.

Studies have also found that the negative stigma associated with HS has a substantial emotional impact on individuals and may increase the risk of depression, social isolation, and poor self-esteem. Research indicates that people living with HS have a significantly higher risk of depression, with estimates ranging from 6 percent to over 40 percent.

Treatment of Stage 3 Hidradenitis Suppurativa

There’s no cure for HS, but many treatment options can help you manage your symptoms. Dermatologists recommend treatments based on the stage of HS. Other factors, including the severity of symptoms, the number of lesions, and the person’s general health and medical history, are also considered.

Stage 3 HS is treated with a combination of medications and therapies, including:

• Oral antibiotics, such as tetracycline or a combination of rifampin and clindamycin
• Oral retinoids, like acitretin and isotretinoin
• Hormonal therapy, such as birth control pills, finasteride, or spironolactone
• Biologic medications, such as adalimumab (Humira) and secukinumab (Cosentyx)
• Over-the-counter and prescribed pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids
• Metformin, which can help with insulin levels and promote weight loss

Surgical treatments may be considered for severe cases or if multiple medical therapies have not been effective. Options include:

• Deroofing — Removes the skin covering an abscess or sinus tract
• Wide excision — Removes lesions or tunneling wounds extensively

Your dermatology team may also recommend incision and drainage. Though less common today due to the risk of lesions returning, it can provide temporary relief for those experiencing intense pain. If you’re considering this procedure, discuss the potential risks and benefits with a dermatologist.

Skin Care Techniques

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

Here are some other ways to take care of your skin at home and while undergoing treatment:

• Apply a warm compress on the affected area of the skin.
• Wear loose-fitting undergarments and clothing to reduce friction.
• Use antibacterial soap on the affected skin.
• Avoid skin care products that can irritate the skin.
• Refrain from shaving affected areas.
• Minimize sweating and avoid exposure to heat.
• Keep the affected skin dry and cool.

Managing Stage 3 Hidradenitis Suppurativa

Living with stage 3 HS is challenging. This inflammatory skin disease can profoundly affect quality of life and take a toll on a person’s mental and social health. However, some lifestyle changes may help manage or relieve symptoms for some individuals.

Quit Smoking

The link between smoking and HS has been well studied. Smoking tobacco is known to increase inflammation throughout the body, which can worsen HS symptoms. Studies indicate that most people with HS smoke and experience higher disease severity. By quitting smoking, you may reduce the frequency and intensity of HS flare-ups.

Adjust Your Diet

Certain foods and stress can trigger a flare-up in some people. Some studies have suggested that eliminating dairy products, reducing sugar, and avoiding brewer’s yeast helped improve HS symptoms for some people.

However, dietary changes may only benefit your HS if you identify specific food triggers that contribute to flare-ups. Consult a dermatologist or other health care provider before making major changes to your diet or starting an exercise program.

Reduce Your BMI

There’s a strong association between higher BMI and the increasing severity of HS. Achieving weight loss or maintaining a healthy weight may lower the risk of recurrent lesions and slow the progression of HS.

Work With Your Doctor

Living with stage 3 HS can be challenging, but effective treatments are available. Working closely with your health care team is essential to finding the right approach for your symptoms and lifestyle. Keeping your doctor regularly updated on what works and what doesn’t, along with any changes in your symptoms, helps ensure that your treatment plan meets your needs and goals. Open communication can make a significant difference in managing HS effectively.

Talk With Others Who Understand

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 3 hidradenitis suppurativa? What advice do you have for others? Share your thoughts in the comments below or by posting to your Activities page.