Conditions Often Mistaken for Hidradenitis Suppurativa
Many people with HS spend years being misdiagnosed with other skin conditions. Understanding the differences can help patients seek proper medical care sooner.
Medical Disclaimer
This page is for educational purposes only and should not replace evaluation by a qualified healthcare professional. If you suspect you have HS or any skin condition, please consult a board-certified dermatologist.
About the illustrations: The images on this page are AI-generated educational diagrams, not clinical photographs. They are designed to convey anatomical concepts and visual characteristics for learning purposes only. Individual presentations of each condition vary widely. Always seek evaluation from a qualified healthcare professional for any skin concern.
Why HS Is So Often Misdiagnosed
Hidradenitis Suppurativa is one of the most frequently misdiagnosed skin conditions in dermatology. Many patients are initially told they have recurring boils, infections, or cysts. On average, it takes 7 to 10 years from the first symptom to a correct HS diagnosis.
The conditions below share visual similarities with HS but have distinct causes, patterns, and treatments. Understanding these differences can help you have more informed conversations with your doctor and advocate for the correct diagnosis.
10 Conditions Commonly Mistaken for HS
Each condition below can look like HS at first glance. The key difference is almost always in the pattern, location, and recurrence of the lesions.
Carbuncles
Bacterial InfectionA carbuncle is a cluster of infected hair follicles caused by bacteria, most commonly Staphylococcus aureus. It appears as a swollen red lump with multiple draining openings and is often accompanied by fever and fatigue.
Key Difference from HS
Carbuncles are typically single bacterial infections that heal once treated with antibiotics or drainage. HS is a chronic inflammatory condition driven by immune dysfunction, not infection, and repeatedly returns in the same areas.
Furuncles (Boils)
Bacterial InfectionA furuncle is a painful pus-filled infection of a single hair follicle, most commonly caused by Staphylococcus aureus. It begins as a tender red bump and gradually develops a white or yellow center as pus accumulates.
Key Difference from HS
Boils usually resolve completely once the infection clears, either on their own or with treatment. HS lesions recur repeatedly in the same locations and are not caused by bacterial infection alone.
Epidermoid Cysts
Structural CystAn epidermoid cyst forms when skin cells become trapped beneath the surface of the skin and multiply, creating a slow-growing, smooth lump. They are usually painless unless they become inflamed or infected.
Key Difference from HS
Epidermoid cysts often have a small central opening called a punctum through which cheesy material can be expressed. HS lesions do not have a punctum and occur in characteristic body fold locations rather than anywhere on the body.
Pilonidal Disease
Structural CystPilonidal disease involves a cyst or infection that occurs near the tailbone at the top of the buttocks. It is thought to be caused by loose hairs penetrating the skin and triggering an inflammatory reaction.
Key Difference from HS
Pilonidal disease occurs almost exclusively in the natal cleft (tailbone region) and is closely associated with hair ingrowth. HS affects multiple body fold areas simultaneously and is not caused by ingrown hairs.
Folliculitis
Follicle InflammationFolliculitis is inflammation or infection of hair follicles, causing small red bumps or white-headed pimples around the follicle openings. It can be caused by bacteria, fungi, viruses, or physical irritation.
Key Difference from HS
Folliculitis affects the surface of the skin, resolves with treatment, and rarely forms deep tunnels or significant scarring. HS involves deep inflammation below the skin surface and characteristically forms interconnected tunnels.
Acne Conglobata
Severe AcneAcne conglobata is a severe form of acne characterised by large, deep inflammatory nodules, cysts, and comedones that can connect beneath the skin. It is most common in young men and can cause significant scarring.
Key Difference from HS
Acne conglobata typically appears on the face, chest, back, and upper arms rather than the body fold areas affected by HS. It is also associated with comedones (blackheads and whiteheads), which are not a feature of HS.
Crohn's Disease Skin Lesions
Systemic ConditionCrohn's disease, an inflammatory bowel condition, can cause skin manifestations including perianal fistulas, skin tags, and inflammatory lesions that closely resemble HS lesions in the groin and perianal area.
Key Difference from HS
Crohn's skin lesions typically occur alongside digestive symptoms such as chronic diarrhoea, abdominal pain, and weight loss. Importantly, HS and Crohn's disease can also co-exist in the same patient, making accurate diagnosis critical.
Lymph Node Infections
Lymph SystemLymphadenitis is an infection of the lymph nodes that causes swelling, tenderness, and warmth in the affected area. In the armpits and groin, enlarged lymph nodes can be mistaken for HS nodules.
Key Difference from HS
Lymph node infections are usually deeper beneath the skin and do not create the characteristic skin tunnels or surface scarring seen in HS. They also typically resolve with antibiotic treatment.
Infected Sweat Glands
Gland InfectionLocalised infections of the apocrine sweat glands can cause swelling, redness, and tenderness in the armpits, groin, and other areas where these glands are concentrated. This presentation closely mimics early HS.
Key Difference from HS
Isolated sweat gland infections do not typically cause the recurring sinus tracts, chronic inflammation, or progressive scarring that characterise HS. HS involves a complex immune-mediated inflammatory process, not simple gland infection.
Cutaneous Abscess
AbscessA cutaneous abscess is a localised collection of pus within the skin caused by a bacterial infection. It presents as a painful, fluctuant swelling that may spontaneously drain.
Key Difference from HS
Cutaneous abscesses usually occur as isolated events and resolve with incision, drainage, and antibiotics. HS abscesses recur repeatedly in the same locations and are part of a chronic inflammatory disease process that cannot be cured with antibiotics alone.
How Doctors Diagnose Hidradenitis Suppurativa
There is no blood test or biopsy that definitively diagnoses HS. Dermatologists use three clinical criteria to make the diagnosis.
Typical Lesions
Dermatologists look for the characteristic lesion types of HS: deep painful nodules, abscesses, interconnected tunnels (sinus tracts), and rope-like scarring. The presence of tunnels is particularly diagnostic.
Typical Locations
HS occurs in specific body fold areas where apocrine sweat glands are concentrated: armpits, groin, buttocks, under the breasts, and inner thighs. Lesions in these characteristic locations are a key diagnostic indicator.
Recurrence Over Time
HS is defined by its chronic, recurring nature. Lesions return repeatedly in the same areas over months and years. A single episode of a boil-like lesion does not meet the diagnostic threshold for HS.
All three criteria must be present for an HS diagnosis
A single boil in the armpit does not constitute HS. The diagnosis requires typical lesions, in typical locations, with a pattern of recurrence. This is why a board-certified dermatologist with HS experience is essential for accurate diagnosis.
Think You May Have HS?
If you recognise your symptoms in this guide, the next step is getting an accurate diagnosis from a dermatologist. In the meantime, these resources can help you understand what to expect.
Continue Your HS Education
Medical References
- [1]Kokolakis G, et al. Delayed diagnosis of hidradenitis suppurativa and its effect on patients and healthcare system. Dermatology. 2020;236(5):421-430. PubMed
- [2]Goldburg SR, Strober BE, Payette MJ. Hidradenitis suppurativa: epidemiology, clinical presentation, and pathogenesis. J Am Acad Dermatol. 2020;82(5):1045-1058. PubMed
- [3]Jemec GBE. Hidradenitis suppurativa. N Engl J Med. 2012;366(2):158-164. PubMed
- [4]Alikhan A, et al. North American clinical management guidelines for hidradenitis suppurativa. J Am Acad Dermatol. 2019;81(1):76-90. PubMed