Hidradenitis suppurativa rarely shows up first in a dermatology office. It shows up in urgent care with a painful lump in the axilla, in the emergency department for an incision and drainage, or in primary care as "another boil." The diagnosis is usually there to be made long before it is made.
How long does an HS diagnosis take?
Years, in most published cohorts. An international study of 517 patients across 24 countries found a mean diagnostic delay of 7.2 years (Saunte et al., British Journal of Dermatology, 2015).
The Global VOICE survey, published in JAAD in 2020, put the mean delay at 10.2 years. In that same survey, 63.7% of patients saw a physician five or more times before they were diagnosed, and 18.3% went to an emergency department five or more times for their symptoms.
A newer single-center cohort from Portugal reported a mean delay of 10.1 years, with no improvement over the study period. The numbers vary by setting and method. The direction does not.
The patient with the third abscess this year is not having bad luck.
Where does HS first present?
Mostly outside dermatology. Patients bring recurrent, painful nodules and abscesses to the clinicians they can reach quickly: urgent care, emergency medicine, primary care, gynecology and general surgery.
Each visit looks reasonable on its own. Drain the abscess, prescribe a short course of antibiotics, send the patient home. The problem is that each visit is treated as a single event. Nobody is counting. The patient with the third abscess this year is not having bad luck. They may have HS.
The American Academy of Dermatology notes that HS can look like acne, boils or herpes, and that it tends to develop in the armpits, groin, buttocks and under the breasts. Shame and stigma add to the delay. Many patients do not volunteer that the lesions keep coming back, and many are not asked.
What does earlier recognition look like?
It looks like pattern recognition at the first or second visit, not the tenth. Diagnosis of HS is clinical. Three questions do most of the work:
- Are these lesions typical (deep, painful nodules, abscesses, draining tunnels, scarring)?
- Are they in typical places (axillae, inframammary folds, groin, perineal and gluteal skin)?
- Do they recur (more than once, in the same regions, over months)?
If the answer to all three is yes, HS belongs on the differential. A clinician in urgent care does not need to stage disease or start a biologic. They need to name the possibility, document it, and make sure the next clinician sees it.
Small changes at the front door
- Ask "Has this happened before, here or anywhere else?" at every abscess visit.
- Look at the other axilla and the groin, not just the lesion in front of you.
- Use the words "possible hidradenitis suppurativa" in the note so the pattern travels with the patient.
- Treat the pain. HS is a painful disease, and patients remember who took it seriously.
Why does HS need a team?
Because the disease is more than skin. HS is a chronic inflammatory condition, and the North American clinical management guidelines (Alikhan et al., JAAD, 2019) include comorbidity screening as part of evaluation, alongside diagnostic testing and procedural care.
That means more than one clinician has a role. Primary care tracks the whole patient and the comorbidities. Dermatology confirms the diagnosis, stages disease and manages medical therapy. Surgery handles procedures when indicated. Mental health and pain management often belong in the plan too.
None of this works without clean handoffs. A referral that says "recurrent abscesses, rule out HS, three episodes in the right axilla since spring" moves faster than one that says "skin lesion." A dermatology note that goes back to primary care with a clear plan keeps the patient from starting over at the next urgent care visit.
This is the thinking behind a phrase DermIQ uses often: "Know when to treat. Know when to refer." It is not about drawing lines between specialties. It is about making sure the patient does not fall between them.
The clinicians most likely to catch HS early are often the least likely to have been trained to look for it. That is a system problem, not a patient problem, and it is why HS was part of the medical dermatology program at the DermIQ Summit 2026. For the PAs and NPs who carry much of this work, read PAs and NPs in dermatology. For another condition that crosses specialty lines, see chronic urticaria and the mast cell.
What's next
The DermIQ Summit returns to Miami in June 2027, with medical dermatology back on the agenda. Join the Summit 2027 waitlist to hear first when dates and registration open, or sign up for the DermIQ newsletter for case-based education between meetings.
Education for every clinician who touches skin. Written for clinicians, not as advice for patients. Questions or a case to share? Write to us.
