The Hurley staging system, developed in 1989, classifies HS severity into three stages based on the presence of abscesses, sinus tracts (tunnels under the skin), and scarring. Research estimates that approximately 68% of people with HS are at Stage 1, around 28% at Stage 2, and roughly 4% at Stage 3. Your stage shapes your treatment options.
What is the Hurley staging system?
The Hurley system is the most widely used clinical framework for classifying HS severity. It is a structural classification based on what's physically present in the skin: lesions, tunnels, and scars.
Your dermatologist uses Hurley staging to determine the appropriate treatment approach. The system has three stages, and you can be at different stages in different parts of your body simultaneously.
Clinicians and researchers also use more detailed scoring tools such as the Sartorius score and the IHS4, which track treatment response with more granularity. But the Hurley system is what most patients encounter in clinic.
Hurley Stage 1: what it means practically
Stage 1 is defined by one or more abscesses without sinus tract formation or scarring. There are no tunnels connecting lesions. Nodules may recur in the same location, but they remain isolated and do not connect.
This is the mildest form of the condition. But mild does not mean painless. Stage 1 HS can cause significant pain and disruption. Lesions may be mistaken for acne, boils, or ingrown hairs at this stage, which is part of why the average time to diagnosis is estimated at 7 to 10 years.
Treatment at Stage 1 typically involves topical therapies, oral antibiotics where needed, lifestyle modifications including trigger identification, and nutritional support. Surgery is generally not required at this stage.
The zinc-HS clinical trials, including the Brocard 2007 study and the Molinelli 2020 controlled study, primarily recruited patients at Hurley Stage 1-2. This is the patient population where the supplement evidence base has been tested.
Hurley Stage 2: what changes
Stage 2 is marked by recurring abscesses with sinus tract formation and some degree of scarring. The tunnels are present but isolated. Nodules recur more frequently and leave more significant scarring as they resolve.
This is where many patients experience the most disruption to daily life. Drainage becomes more consistent. Wound care becomes a daily consideration. The risk of secondary infection increases.
Treatment at Stage 2 expands to include biologic medications (such as adalimumab, secukinumab, or bimekizumab), more aggressive antibiotic regimens, and hormonal therapies in women where relevant. Local surgical procedures, including deroofing, may also be appropriate.
Hurley Stage 3: what it means for treatment
Stage 3 is the most severe classification. It involves diffuse involvement across an entire body area, multiple interconnected sinus tracts, extensive scarring, and often persistent drainage.
Estimates suggest Stage 3 accounts for approximately 4% of HS cases. Treatment at Stage 3 requires aggressive medical management. Biologics are the primary pharmacological intervention. Wide-field surgical excision is often the only intervention that produces lasting improvement.
At Stage 3, nutritional support and lifestyle modifications remain appropriate as part of a comprehensive approach. They do not replace biologic therapy or surgery.
Can HS progress between stages?
Yes. The factors most consistently associated with progression are smoking, uncontrolled inflammation over time, delayed treatment, and metabolic factors. HS progression is not inevitable.
For more on what determines disease trajectory, see our overview of what causes hidradenitis suppurativa (add URL when Post #18 publishes)
Limitations of the Hurley system
The Hurley system captures structure rather than experience. Two people at the same Hurley stage can have dramatically different pain levels and quality-of-life impacts. It is not dynamic — it classifies severity at a point in time, not change over treatment. And it doesn't capture location-specific variation.
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Frequently asked questions
How does a dermatologist determine my HS stage?
Staging is based on clinical examination: the dermatologist assesses the number of lesions, whether sinus tracts are present, whether lesions are interconnected, and the extent of scarring. No blood test or imaging is required for Hurley staging.
Can you move from Stage 3 back to Stage 2?
Hurley staging captures structural changes including scarring and tunnels, which do not reverse. However, active disease burden can improve significantly with treatment. Effective biologic therapy or surgery can dramatically reduce active symptoms even when the underlying Hurley classification remains Stage 3.
Is Stage 1 HS serious?
Stage 1 is classified as mild, but that refers to structural severity, not to how much the condition impacts daily life. Stage 1 HS can cause significant pain, embarrassment, and disruption. It should be taken seriously and managed with appropriate dermatological care even if surgery is not indicated.
Does everyone with HS eventually reach Stage 3?
No. Many people with HS remain at Stage 1 throughout their lives, particularly with early and appropriate management. Progression is not universal.
What treatments are used at each stage?
Stage 1: topical therapies, oral antibiotics, trigger management, lifestyle and nutritional support. Stage 2: adds biologics, more aggressive antibiotic regimens, hormonal therapy, and local surgical procedures. Stage 3: biologics, wide-field surgical excision, and specialist-led comprehensive care.
This article is for educational purposes only. It is not a substitute for medical advice. If you have hidradenitis suppurativa, work with a board-certified dermatologist to build a treatment plan.
References
- Hurley HJ. Axillary hyperhidrosis, apocrine bromhidrosis, hidradenitis suppurativa. In: Dermatologic Surgery. Marcel Dekker; 1989.
- MyHSTeam. Hidradenitis suppurativa stages. https://www.myhsteam.com/resources/hidradenitis-suppurativa-hs-stages
- Best Practice for HS Lesions Consensus. Journal of Wound Care. July 2025.
Published by HS Daily.
