HS Diagnosis: Recognizing Typical Lesions, Locations, and Chronicity

"HS Diagnosis: Recognizing Typical Lesions, Locations, and Chronicity" takes up the question of how clinicians can recognize HS reliably.

Dr. Lev-Tov says HS is often misdiagnosed early as folliculitis or an infectious abscess. He argues that the real problem is not the diagnosis itself but awareness. The more clinicians think about HS, the more they will make the diagnosis and arrange either treatment or an appropriate referral.

He offers a mnemonic, the three T's: typical lesions, typical locations, and typical story. Few other skin conditions look like HS, so these features make recognition straightforward.

Typical lesions begin as papules and pustules, which are red or pus-filled bumps around hair follicles. Nodules are larger, deeper, and painful, and abscesses are fluctuant and filled with pus. Abscesses are highly detrimental to quality of life. They can progress to ulcers or to tunnels that drain substantial exudate. At the final stage, rope-like scars form over tunnels and can restrict movement and cause disfigurement.

Typical locations are skin folds where skin rubs against skin. These include the armpits, the area under the breasts, the groin, and the buttocks, and lesions can also appear behind the ears.

The typical story is chronicity. Lesions come and go, and sometimes only a scar or post-inflammatory darkening remains. Dr. Lev-Tov urges clinicians to ask about prior painful bumps, since patients almost invariably recall earlier episodes in the same area.

He cites data showing that one simple question can diagnose HS with over 90 percent confidence: did you have boils in skin folds more than two times in the last six months? The diagnosis is relatively simple, he says, once clinicians look for it.

Our next episode, "Delayed HS Diagnosis: Misconceptions, Stigma, and Suicide Risk," turns to what happens when patients go years without a diagnosis.