Hidradenitis Suppurativa: More Than Recurrent Boils

Being told for the fourth time that the painful lump in your armpit is just a boil, handed another course of antibiotics, and sent on your way is a familiar sequence. So is the moment six weeks later when it returns in almost exactly the same spot.

Recurrence in the same place is the detail that should redirect the whole conversation. A boil that keeps coming back to one site, particularly in the armpit, groin, buttocks or under the breast, is often not a boil at all, and the condition behind it is one a dermatologist in S ingapore can recognise from the pattern alone.

What is happening in the skin

Hidradenitis suppurativa is a chronic inflammatory skin condition. It begins with subclinical inflammation around the terminal hair follicles together with hyperkeratosis inside the follicular opening, which plugs the follicle until it ruptures into the surrounding tissue¹. What the body then mounts against that spilled follicular material is the painful inflammatory lump a patient feels.

Two misconceptions follow the condition around, and both deserve dismantling. It is not primarily an infection. Bacteria are present and contribute through immune stimulation, but the review evidence describes the process as immunologically mediated rather than a straightforward infection¹, which explains why repeated antibiotic courses give only temporary relief. It is also not caused by poor hygiene, and telling a patient to wash more is both useless and unkind.

The condition favours hair-bearing flexural skin where surfaces rub together, which is why the armpits, groin, inner thighs, buttocks and inframammary folds are the usual sites.

Why it gets missed for years

Diagnostic delay is the defining feature of this condition. A study spanning 24 countries found the delay from first symptom to diagnosis was 7.2 years for hidradenitis suppurativa against 1.6 years for psoriasis, with 73.3% of patients experiencing a delay of more than two years².

Singapore data tells the same story locally. Among 45 patients at a Singapore centre, mean age at symptom onset was 21.8 years while mean age at diagnosis was 27.9 years³, a gap of roughly six years spent treating individual lumps instead of the disease producing them.

That gap is not a small administrative delay. Scarring and tunnelling accumulate during it, and damage already established in the skin does not reverse once the correct diagnosis is finally made.

The reasons are understandable. Early lesions genuinely look like boils, they occur in areas people are reluctant to show anyone, and each one does eventually settle, which makes the next one feel like a fresh event. Hidradenitis suppurativa belongs on any list of skin conditions that are often misdiagnosed, and it is among the most consequential to miss.

How severity gets described

Severity is recorded in more than one way. Hurley staging is a static description of how much irreversible damage is present, running from isolated lesions without tunnels or scarring, through recurrent lesions with tunnel formation and scarring in separated areas, to widespread involvement with interconnected tunnels across an entire region⁴. It is useful for planning surgery because it describes structural change.

Dynamic scores complement it by counting active nodules, abscesses and draining tunnels so that response to treatment can be tracked over time⁴. A patient may sit at an advanced Hurley stage structurally while having relatively little active inflammation, and the two measures answer different questions.

What the local picture looks like

Presentation in Asian populations differs from Western cohorts in at least one consistent respect. Among 58 patients at a Singapore institution, 34 of them, or 58.6%, were male, which reverses the female predominance usually reported in Europe and North America, and the axilla was the commonest site followed by the groin and buttocks⁵.

The parts that go beyond the skin

Hidradenitis suppurativa travels with other conditions, and current consensus recommendations set out evidence-based screening across 19 comorbidities, including depression, generalised anxiety disorder, smoking, obesity, dyslipidaemia, diabetes, metabolic syndrome, cardiovascular disease, polycystic ovary syndrome, inflammatory bowel disease and spondyloarthritis⁶. A first consultation that only looks at the lumps is an incomplete consultation.

The psychological load is measurable rather than anecdotal. In the Singapore cohort, 28.9% screened positive for depression and 15.6% for anxiety, and greater objective severity correlated with poorer quality of life and lost productivity at work³. Pain, unpredictable flares and drainage in areas that are difficult to dress around account for a great deal of that.

How it is managed

There is no single treatment, and the range is wider than most patients expect. Published North American guidelines cover topical and systemic medical therapy, intralesional corticosteroid injection, laser hair removal and Nd:YAG laser treatment of affected areas, deroofing of established tunnels, wide local excision, and biologic therapy for more severe disease⁴. Which combination suits a given patient depends on stage, sites involved, how much structural damage is already present, and their own priorities.

Prescription treatment is a decision for a doctor after assessment, and this article deliberately gives no doses or regimens. Two general points hold across plans. Established tunnels and scars do not resolve with medication, so procedural treatment has a real role once damage is fixed. And smoking cessation and weight management are consistently part of the conversation, offered as clinical measures and not as blame.

Expectations should be set honestly. Treatment aims to reduce flare frequency, pain and progression, and no approach reliably cures the condition.

Conclusion

Recurrence in the same place is information, and acting on it early protects tissue that cannot be recovered later. At Angeline Yong Dermatology, Dr Angeline Yong assesses the pattern, stage and extent of disease before recommending a plan, with medical and surgical options available at the clinic. Book a consultation if painful lumps keep returning to the same areas, however many times you have been told they are nothing.

References

Wolk, K., Join-Lambert, O., & Sabat, R. (2020). Aetiology and pathogenesis of hidradenitis suppurativa. British Journal of Dermatology, 183(6), 999–1010. https://doi.org/10.1111/bjd.19556

Saunte, D. M., Boer, J., Stratigos, A., Szepietowski, J. C., Hamzavi, I., Kim, K. H., Zarchi, K., Antoniou, C., Matusiak, L., Lim, H. W., Williams, M., Kwon, H. H., Gürer, M. A., Mammadova, F., Kaminsky, A., Prens, E., van der Zee, H. H., Bettoli, V., Zauli, S., … Jemec, G. B. E. (2015). Diagnostic delay in hidradenitis suppurativa is a global problem. British Journal of Dermatology, 173(6), 1546–1549. https://doi.org/10.1111/bjd.14038

Ooi, X. T., Choi, E., Han, H., Ahmad, H., Patwardhan, K. R., & Chandran, N. S. (2023). The psychosocial burden of hidradenitis suppurativa in Singapore. JAAD International, 10, 89–94. https://doi.org/10.1016/j.jdin.2022.10.010

Alikhan, A., Sayed, C., Alavi, A., Alhusayen, R., Brassard, A., Burkhart, C., Crowell, K., Eisen, D. B., Gottlieb, A. B., Hamzavi, I., Hazen, P. G., Jaleel, T., Kimball, A. B., Kirby, J., Lowes, M. A., Micheletti, R., Miller, A., Naik, H. B., Orgill, D., & Poulin, Y. (2019). North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management. Journal of the American Academy of Dermatology, 81(1), 76–90. https://doi.org/10.1016/j.jaad.2019.02.067

Choi, E., Cook, A. R., & Chandran, N. S. (2018). Hidradenitis suppurativa: An Asian perspective from a Singaporean institute. Skin Appendage Disorders, 4(4), 281–285. https://doi.org/10.1159/000481836

Garg, A., Malviya, N., Strunk, A., Wright, S., Alavi, A., Alhusayen, R., Alikhan, A., Daveluy, S. D., Delorme, I., Goldfarb, N., Gulliver, W., Hamzavi, I., Jaleel, T., Kimball, A. B., Kirby, J. S., Kirchhof, M. G., Lester, J., Lev-Tov, H., Lowes, M. A., … Naik, H. B. (2022). Comorbidity screening in hidradenitis suppurativa: Evidence-based recommendations from the US and Canadian Hidradenitis Suppurativa Foundations. Journal of the American Academy of Dermatology, 86(5), 1092–1101. https://doi.org/10.1016/j.jaad.2021.01.059

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Hidradenitis Suppurativa: More Than Recurrent Boils