HS almost always starts as a single painful lump that gets called a boil. What sets it apart is not the lump itself — it is that it comes back, and it comes back in the same few places.
On brown and Black skin the early inflamed lumps may look purple, dark brown or almost the same colour as surrounding skin rather than red, so early HS is easy to miss and easy to dismiss. Healed areas often leave dark patches, and the raised scarring can build into thick keloid-like ridges that are more prominent on darker skin. HS is both more common and often more severe in Black patients, and it is diagnosed later — worth knowing if you are trying to be taken seriously.
HS is mistaken for several other things, and one of them is treated completely differently. See Lookalikes near the bottom of this page.
HS is a disease of the hair follicle, not of the sweat glands, and not of dirt. The follicle becomes blocked, swells, and ruptures under the skin. The contents spill into the surrounding tissue, and the immune system reacts hard to something that should never have been there. That reaction is the pain, the swelling and the drainage. Bacteria can move into the damaged tissue afterwards, which is why antibiotics sometimes help for a while, but the bacteria are a passenger rather than the driver. This is why an antibiotic clears things for a few weeks and then it all comes back.
Genetics matter a great deal. About one in three people with HS has a close relative with it, and having a family history often means it starts earlier. On top of that, the immune system in HS is set to overreact, which is why the drugs that work best are the ones that dial down specific parts of it. Hormones play a part too — flares around periods are common, and it usually starts after puberty. Smoking and carrying extra weight are both genuinely linked to more severe HS, and changing either can make a measurable difference. Neither one caused this. Plenty of people with HS have never smoked and are not overweight, and no one develops HS because of something they did wrong.
None of this treats the underlying inflammation, but it makes daily life with HS considerably easier and can reduce how often mild disease flares. Nothing here is a substitute for getting on prescription treatment.
If you have had more than one painful lump in the same fold, book an appointment. Do not wait for it to get worse, and do not accept "a boil" as an answer for the third time.
What the visit gets you: a name, which is the part most people have been waiting years for. Then a stage, which decides what is worth trying. Then an actual plan — a wash and a topical for mild disease, a longer antibiotic course or a hormonal option for moderate disease, and a biologic for anything more than that. A dermatologist can also drain a lump properly under local anaesthetic, inject a steroid into a painful one for fast relief, and refer for surgery on tunnels that will never settle.
Go the same day, or to urgent care, if an area is spreading fast, hot and hard with a fever. That suggests infection spreading in the skin, which is different from an HS flare and needs treating quickly.
HS is diagnosed by looking and by history. There is no blood test or scan for it, and no test is needed to make the diagnosis.
Swabs are the test you will most likely be offered, and they are usually not helpful. A swab of draining fluid often grows normal skin bacteria, or grows nothing at all. Neither result changes the diagnosis. HS is not an infection, so a swab that comes back clear does not mean nothing is wrong with you, and a swab that grows something does not mean you simply have a skin infection. A swab is genuinely useful in one situation: when an area looks infected on top of the HS and your doctor needs to know which antibiotic will work.
A few other tests come up:
If you are asked to keep coming back for repeat swabs and repeat antibiotics with no plan beyond that, it is fair to ask what the result would change.
What you are offered depends on your stage. Mild disease starts with a topical and a wash, moderate disease usually means a longer antibiotic course or a hormonal option, and anything beyond that is where the biologics come in. Two are FDA-approved specifically for HS.
Procedures do the job medication cannot: emptying a painful lump now, and removing tunnels and scarring that will never close on their own. Surgery is a normal part of HS care, not a last resort or a failure.
Pain and new lumps usually settle before anything looks better. Judge a treatment by how often you are flaring, not by whether the old scarring has changed.
Most people who respond notice fewer new lumps within 12 weeks. If nothing has moved by then, it is reasonable to switch rather than wait it out. Around half of people get a meaningful response, which means this is worth trying and also worth having a second option ready.
Deroofing and excision heal slowly and are often left open to heal from the base up, which can take weeks. The area that was operated on usually stays clear. New spots can still appear elsewhere, because the surgery treated the damage, not the disease.
HS is a lifelong condition that runs in flares. Nothing available now cures it. Treatment aims at fewer and shorter flares, less pain, and no new tunnels. Existing tunnels and scars will not close on their own no matter how good the medication is — that is a separate job. Many people find it quietens down over the years, and some women find it settles after menopause.
HS is not dangerous in the short term, but it is a condition where waiting costs something real, because the damage is what does not reverse.
HS is misdiagnosed constantly, usually as one of these. The detail that separates them is almost always whether it comes back in the same place.