TL;DR
Doctors stage hidradenitis suppurativa with the Hurley system. Stage I is isolated lumps without tunnels, stage II has recurring lumps with some tunnels and scarring, and stage III is widespread tunnels and scarring. Topicals suit stage I and some stage II, while stage III usually needs a biologic or surgery.
Hidradenitis suppurativa stages are usually described with the Hurley system, and knowing yours is the fastest way to work out which treatment is worth your money. A cream that makes sense at stage I will not do much at stage III, and the reverse can mean over-treating a mild case.
What are the Hurley stages of HS?
The Hurley staging system was created in the 1980s and is still the most widely used. It sorts HS into three stages based on lumps, tunnels (sinus tracts), and scarring in a given area.
| Stage | What you see | Typical feel |
|---|---|---|
| Hurley I | One or more abscesses or nodules. No tunnels, little or no scarring. | Painful lumps that come and go |
| Hurley II | Recurrent abscesses with one or more tunnels and scarring. Lesions are spaced apart. | Frequent flares, drainage, visible scars |
| Hurley III | Widespread or multiple interconnected tunnels and abscesses across a whole area. | Constant drainage, severe pain, limited movement |
You can have different stages in different areas. For example, stage I in the groin and stage II in one armpit.
What does Hurley stage I look like?
Stage I is the mild end. You may have a few tender bumps a year or a few a month, and they heal without tunnels. Most of the roughly 1 in 100 people estimated to have HS (figures vary by study) start here.
This is also the stage where early treatment can matter the most, because stopping new lumps from forming is easier than undoing scars later.
What does stage II look like?
At stage II, lumps return in the same area, some connect under the skin, and you see scars or drainage. Pain is higher and flares may affect sleep or work.
This stage is a broad range. Some people sit at the mild edge and still respond to topicals and antibiotics. Others at the severe edge are clearly candidates for a biologic.
What does stage III look like?
At stage III, tunnels and scarring are widespread. Drainage is constant, skin can feel rope-like, and daily movement can be restricted. This is the stage where disease can affect quality of life the most.
What should you use at each stage?
Stage I
- Friction control, no shaving, gentle skin care. See how to stop flare-ups.
- A prescription topical such as resorcinol plus clindamycin. Vuret's HS Flare Control Cream is built for this range.
- OTC antiseptic washes as an add-on.
Stage II
- Topical plus oral antibiotics (doxycycline, or clindamycin with rifampin).
- Steroid injections for single painful nodules.
- Deroofing for tunnels.
- Consider a biologic if disease is widespread or antibiotics are not holding. Read treatment without biologics for the options before that point.
Stage III
- A biologic (adalimumab, secukinumab, bimekizumab), often with antibiotics or other drugs.
- Surgical excision of heavily scarred areas.
- Pain and wound care support. A topical may still help as an add-on for new spots.
Honest note: the Hurley system is a rough guide. A doctor may also use scoring tools like IHS4 or HiSCR (a measure used in trials) to track how treatment is working. Staging yourself at home is a starting point, not a diagnosis.
Can HS move from one stage to another?
It can progress, particularly if left untreated, but many people stay in the same stage for years. Smoking and higher body weight are linked with more severe disease. Early, consistent treatment gives you the best chance of staying where you are.
How can you tell your stage at home?
Ask yourself:
- Do any lumps connect, or do I see small openings that drain repeatedly in one spot?
- Do I have raised, rope-like scars?
- Are lumps in more than one area at once?
If you answered no to all three, you are probably stage I. If yes to the first two in one area, stage II is likely. If your lesions cover a whole region, stage III is likely. Either way, see a doctor to confirm.
How do stages affect what insurance and specialists do?
Staging often shapes what happens next. Many insurers require documented moderate to severe disease (often Hurley II or III) before approving a biologic, and specialists use stage to choose between topicals, antibiotics, procedures, and surgery. That is another reason to get the diagnosis and stage written down in your records.
What should you track between visits?
Keep a log with these points, and bring it with you:
- Number of active nodules and abscesses in each area.
- How often lumps drain, and how long they take to heal.
- Pain on a 0 to 10 scale.
- Days of missed work or school.
- Photos taken monthly under the same lighting.
A short record like this makes it easier to see whether a treatment is helping, and it gives your doctor something concrete to work with rather than trying to remember the last six months.
Does early treatment really change the outcome?
Researchers and dermatologists widely believe that treating HS early reduces the risk of tunnels and scarring, though not every study agrees on how much. Even so, controlling inflammation sooner means fewer painful weeks and fewer lesions that go on to scar. If you are at stage I and wondering whether a cream is worth trying, the downside is small and the potential upside is a quieter few years.
What if your stage doesn't match your pain?
Hurley staging looks at structure, not how much it hurts. A person with stage I disease can have severe pain from a single large abscess, and someone with stage II can be relatively comfortable between flares. Pain, drainage, and the effect on your life matter just as much as stage when deciding how aggressively to treat.
If your symptoms feel worse than your stage suggests, say so. Doctors can adjust treatment based on how you actually live with HS, not just on a three-stage label.
If you think you are in the mild to moderate range, an online visit through Vuret's HS page is a quick way to get a physician's opinion and, if appropriate, a prescription. Not sure what else is on the menu? See the best HS treatments, or topicals compared.
HS Flare Control Cream: Resorcinol 15% + Clindamycin 1%
A prescription cream that pairs resorcinol 15% with clindamycin 1%, applied right where flares start. Prescribed online by a U.S.-licensed physician only if it is right for you. Compounded medications are not FDA-approved.
See HS Flare Control CreamFrequently asked questions
What is Hurley stage 1 hidradenitis suppurativa?
It is the mildest stage: single or multiple abscesses or nodules without tunnels and with little scarring. Treatment often starts with topicals and lifestyle changes.
Can you go from stage 2 back to stage 1?
Scars and tunnels do not usually reverse, but good treatment can reduce flares and drainage so that disease behaves more like a milder stage. Surgery can remove tunnels in an area.
Does everyone with HS need a biologic?
No. Many people with stage I and mild stage II do well without one. Stage III and more severe stage II disease are the most common reasons for a biologic.
How is HS severity measured besides Hurley stage?
Doctors may use IHS4 or Hurley staging with pain scores. Clinical trials often use a measure called HiSCR to see how many lumps improve.
How quickly does HS progress?
It varies widely. Some people stay mild for decades, while others progress over a few years, especially if they smoke or have uncontrolled inflammation.