Doctors classify hidradenitis suppurativa as mild, moderate, and severe based on the presence and severity of boils, abscesses, and tracts.

Hidradenitis suppurativa (HS), previously known as acne inversa and Verneuil’s disease, is characterized by painful acne-like boils under your skin.

It develops when hairs become trapped in hair follicles, leading to inflammation deep in the skin. Bacteria may also get trapped in the follicles, leading to mild infections. As the lesions grow, they can become painful and eventually rupture.

HS is diagnosed based on examination and the presence of these lesions.

The Hurley staging system was introduced by dermatologist HJ Hurley in 1989 as an instrument to help doctors quickly identify appropriate treatments for HS based on the severity of the boils in affected areas.

A study from 2019 asked dermatologists, plastic surgeons, and general surgeons to select Hurley stages using photos alone. They found that the staging was most reliable for Hurley stage 3 and required very little time to assess — around 14 seconds.

The researchers suggested that this indicates that Hurley staging can be useful even during telemedicine appointments where healthcare professionals are unable to complete a more thorough examination.

The simplicity of this assessment is part of what makes it one of the most used instruments for assessing HS. Other staging instruments include the Sartorius Hidradenitis Suppurativa Score and the HS Physician Global Assessment (PGA).

Read on to learn more about the Hurley stages of HS.

Hurley stage 1 is the mildest clinical form of this condition. It’s marked by isolated abscesses or boils. These include bumps under the skin and pus-filled bumps on the skin, usually in skin folds such as the armpits or groin. They can become painful and inflamed.

While stage 1 HS can cause multiple abscesses, they’re typically not as widespread as in later stages. They also don’t have the connecting tunnels or scarring common with more severe HS.

Treatment for milder cases can include home remedies, such as:

  • washing with antibacterial soaps
  • applying warm compresses
  • avoiding shaving
  • staying dry
  • using antiseptics

A doctor may also recommend medication to decrease inflammation. This may help the boils decrease in size or severity and can include:

  • an over-the-counter (OTC) anti-inflammatory medication, such as ibuprofen (Advil)
  • topic steroid cream
  • corticosteroid injections
  • antibiotics
  • hormonal therapy, if needed
  • biologics, which modify the activity of your immune system

Left untreated, stage 1 HS will likely develop into stage 2.

hidradenitis suppurativa, Hurley stage 1Share on Pinterest
Seen here are multiple abscesses without sinus tracts and scarring, which is still considered stage 1.

Hurley stage 2 can cause more moderate abscesses that may appear alone or be more separated. The boils that originally developed under your skin can become further irritated and break open, producing pus.

You may have some tracts, or narrow tunnels, under the skin where abscesses are connected. You may also experience scarring.

Treatment for stage 2 HS can include:

  • an OTC anti-inflammatory medication, such as ibuprofen (Advil)
  • topic steroid cream
  • corticosteroid injections
  • oral steroids, to decrease inflammation
  • antibiotics, to decrease the buildup of bacteria
  • biologics, which modify the activity of your immune system
  • hormone therapy, if needed
Share on Pinterest
Shown are multiple abscesses with sinus tract formation and scarring.

Hurley stage 3 is the most severe form of HS. It’s characterized by a more broad and widespread development of HS lesions, including tract formations. Pain and scarring are also expected in this stage.

Due to this widespread and recurring nature, stage 3 can be difficult to treat.

Doctors typically recommend the treatments listed above for stage 3 HS. Immunosuppressant drugs like adalimumab (Humira), which limit the activity of your immune system, may be used for severe cases, too.

If HS is starting to interfere with your quality of life, doctors may suggest surgery to remove:

  • boils
  • tracts
  • scars

Laser therapies and hair removal may also help.

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This is diffuse or nearly diffuse involvement of the affected region, with multiple interconnected tracts and abscesses across the entire area.

Many people with HS may not seek medical help right away. This is sometimes due to a previous misdiagnosis of cystic acne or other chronic skin conditions. Unlike traditional acne, HS tends to recur in the same areas, and it doesn’t typically respond to OTC treatment.

Talk with a doctor about your skin condition if you experience one or more of the following:

  • boil-like lesions that develop in the folds of your skin, such as the groin, breast, or neck area
  • lesions that recur in the same areas
  • symmetrical boils that affect both sides of your body equally
  • areas of skin that are extremely painful and interfere with your daily activities

While HS can be difficult to treat, leaving the condition untreated can increase your risk for complications. These can include:

  • significant pain, especially when walking or moving around in Hurley stage 3 HS
  • bacterial infections
  • social isolation
  • missed days of work
  • anxiety and depression

What are the three clinical stages of HS?

The three stages of HS include Hurley stage 1, 2, and 3. They’re characterized by mild, moderate, and severe HS, respectively.

What does stage 3 of HS look like?

Hurley stage 3 HS typically involves the broad, widespread development of HS lesions with tract formation and scarring. A person in stage 3 may also experience severe pain.

Does HS always progress to stage 3?

Early treatment in stage 1 or 2 HS can help prevent progression to stage 3. Treatment may include anti-inflammatories, medications that modify or suppress the immune system, antibiotics, pain relievers, and other therapies, such as laser hair removal.

What is the progression of HS disease?

HS can progress to cause the development of more abscesses. Tracts may also form beneath the skin, connecting abscesses. The condition can become severely painful in later stages.

There’s currently no cure for HS, but early treatment can help prevent complications and worsening of the condition. Treatment can help decrease the lesions and the underlying inflammation and bacteria that can worsen HS.

Treatments can reduce pain and scarring, which can improve your overall quality of life. The more severe your HS, the more aggressive the treatment measures may be.

If you find that your current HS treatment isn’t improving your skin lesions, you may need to see a specialist like a dermatologist or even a surgeon to explore other options.