There are three stages of hidradenitis suppurativa (HS), also known as acne inversa. In stage 2 hidradenitis suppurativa, abscesses (pus-filled lumps) reappear on previously healed skin wounds, causing scarring and leading to tunnel formation (or sinus tracts) under the skin. Researchers estimate HS affects up to 4 percent of the global population. HS is considered a rare dermatological disease, and its impact on a person’s quality of life can be profound.

What Is Stage 2 Hidradenitis Suppurativa?

HS is classified into three stages based on severity and how it develops, according to the Hurley staging system.

• Stage 1 involves one lesion or isolated abscesses without sinus tract formation (narrow openings underneath the skin) or scarring.
• Stage 2 involves recurrent abscesses with widely separated lesions, sinus tract formation, and scarring.
• Stage 3 involves multiple interconnected sinus tracts, abscesses, and extensive scarring.

Stage 2 HS affects about 28 percent of people living with HS. During this stage, single or multiple abscesses that have healed will reappear in previous places on the skin or develop new areas. The abscesses can leave behind scars. Over time, scar tissue forms under the skin and leads to sinus tracts.

The most common areas of skin affected by stage 2 HS are the:

• Armpits
• Groin
• Genital area
• Thighs
• Buttocks
• Perianal area (around the anus)
• Under the breast

Stage 2 HS can also affect the face, neck, area behind the ears, and abdominal folds.

Similar to stage 1 HS, the onset of stage 2 HS commonly occurs after puberty and is often diagnosed between the ages of 20 and 24. HS is seen in women three times more frequently than in men. In the United States, Black people have a higher prevalence of HS than people of other races.

Although the cause of HS is poorly understood, experts have found that certain risk factors are associated with HS development. These factors include:

• Having a family history of HS
• Smoking tobacco
• Being overweight or obese
• Having co-occurring diseases such as severe acne, arthritis, diabetes, metabolic syndrome, and inflammatory bowel disease

HS is not sexually transmitted, is not contagious, and is not caused by poor hygiene.

For people who have HS, triggers can include:

• Excessive sweat
• Heat
• Stress
• Fatigue
• Tight clothing
• Hormonal changes during the menstrual cycle in some women

Symptoms of Stage 2 Hidradenitis Suppurativa

Stage 2 HS lesions can appear at new sites or reappear near or on the same spot as the initial lesion. Lesions occur in areas of the body where the skin rubs together or in regions with many glands called apocrine sweat glands. These regions include the armpits, groin, buttocks, and breasts.

Stage 2 HS lesions are widely spread apart and present as large lumps or abscesses that are inflamed and filled with pus and fluid. Lesions may break open and leak out strong-smelling pus and fluid. Over time, scarring and draining sinus tracts form on the affected areas of the skin.

Stage 2 HS symptoms are more noticeable and painful compared to those in stage 1 HS. Abscesses commonly reappear two to three times every six months. Signs and symptoms of stage 2 HS may vary from person to person depending on the area of skin affected. The most common symptoms 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
• Anxiety or depression

If stage 2 HS is left untreated, symptoms can become more severe and affect more significant areas of the skin, progressing to stage 3 HS. It is essential to speak with your doctor if you begin to experience recurrent abscesses, scarring, draining sinus tracts, or new symptoms.

Treatments for Stage 2 Hidradenitis Suppurativa

There currently is no cure for HS, but many treatments can help you manage your symptoms. Dermatologists recommend treatments based on the stage of HS. The doctor will likely consider other factors, including 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, like metronidazole or Rifadin (rifampin) with clindamycin
• Oral retinoids, like Soriatane (acitretin) and isotretinoin
• Hormonal therapy, such as oral contraceptive pills, Propecia (finasteride), or Aldactone (spironolactone)
• Corticosteroids (steroids), such as prednisolone
• Anti-TNF medicines, such as Humira (adalimumab)
• Anti-inflammatory drugs, such as metformin
• Botulinum toxin to treat excessive sweating
• Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen or over-the-counter pain relievers, to treat pain and inflammation

Some surgical treatments may also help treat stage 2 HS, including:

• Incision and drainage, to drain the abscess and relieve pain
• Deroofing, to remove the area of skin with an abscess or sinus tract
• Wide excision, to remove a lesion or tunnel wound
• Laser hair removal, to reduce hair follicles and prevent recurrent lesions

Skin Care Tips

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

Other ways to treat stage 2 HS lesions at home include:

• Applying a warm compress to the affected area for a few minutes
• Wearing loose-fitted undergarments and clothing to minimize friction
• Using antibacterial soap on the affected skin
• Avoiding skin care products that irritate the skin
• Avoiding shaving affected areas, such as the underarms, groin, genital area, or buttocks
• Minimizing heat exposure and sweating
• Keeping the skin dry and cool

Managing Stage 2 Hidradenitis Suppurativa

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

Losing Weight

Obesity contributes to inflammation throughout the body. There is a strong association between increasing body mass index (BMI) and the increasing severity of HS. Weight loss or managing a healthy weight may reduce your risk of recurrent lesions (or flare-ups) or worsened progression of HS.

Quitting Smoking

The link between smoking and HS has been well studied. Smoking tobacco can increase inflammation throughout the body, worsening HS symptoms. Studies have found that most people with HS actively smoke. By quitting smoking, you may reduce your risk of HS flare-ups.

Read more about hidradenitis suppurativa and smoking.

Watching Your Diet

Certain foods and stress can trigger a flare-up in some people. The Mayo Clinic recommends eliminating dairy products, reducing sugar, and avoiding brewer’s yeast for people with HS. Changing your diet may also be a helpful and healthy way to lose weight.

Read more about diet and hidradenitis suppurativa.

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 23,000 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.