Mind the Gap atlas
Hidradenitis suppurativa on Black skin
Key cue: Recurring painful deep bumps in armpits, groin, buttocks, or under breasts — not just 'boils' or 'acne'. Black women have 2-3× the severity and average 7-10 years to diagnosis.
Hidradenitis suppurativa (HS) is a chronic recurrent inflammatory disease of the apocrine-gland-bearing skin — axillae, groin, inframammary folds, buttocks, perianal area. It affects Black patients at roughly 2-3 times the rate of white patients, with higher severity and a mean diagnostic delay of 7-10 years. Early diagnosis + biologic therapy (adalimumab, secukinumab) change the trajectory dramatically.
What it actually looks like
Textbook says
Textbook: painful nodules, abscesses, sinus tracts, and scarring in intertriginous areas. Three Hurley stages: I (single nodules), II (recurrent with tracts), III (multiple interconnected tracts with extensive scarring).
On Black skin
On Black skin, HS is under-diagnosed and under-treated:
- Early lesions are often dismissed as 'boils' or 'ingrown hairs' or 'acne' by both patients and clinicians, delaying effective treatment.
- Post-inflammatory hyperpigmentation and scarring are especially prominent, producing dark tram-tracks and bridge-like scars that can be socially stigmatising.
- HS is strongly associated with obesity, metabolic syndrome, smoking, and PCOS — all of which are disproportionately present in Black women. Workup should include fasting glucose, lipids, and (for women) PCOS screening.
- HS is not an infection — antibiotic monotherapy (topical clindamycin, oral tetracyclines) is a supportive early step, but the disease is inflammatory. Biologics — adalimumab, secukinumab — are FDA-approved and change the trajectory.
- Painful disease flares affect mental health; depression and anxiety are common.
What to look for
- Painful nodules or abscesses in armpits, groin, under breasts, on buttocks, or in the perianal area — recurring at the same sites.
- Sinus tracts (tunnels under the skin) that drain pus or fluid.
- Double or triple-headed blackheads (open comedones) in intertriginous skin.
- Thick scarring with dark pigmentation in affected areas.
- Flares worse with heat, friction, tight clothing, or sweating.
When to seek care
Schedule a dermatology visit — ask for a clinician experienced in HS. Ask directly: 'Could this be hidradenitis suppurativa?' If so, request a discussion of biologic therapy (adalimumab or secukinumab). Supportive measures: loose breathable clothing, weight management if indicated, smoking cessation, appropriate wound care. Go to the ER for severe infected abscess with fever or systemic illness.
Common misdiagnosis
HS is most often initially diagnosed as recurrent folliculitis, recurrent abscesses, 'carbuncles', MRSA infection, or pilonidal disease. The key distinguishing features are: recurrence at the same sites, presence of sinus tracts, double-headed comedones, family history (often positive), and absence of response to antibiotic-only regimens.
See it for yourself — curated external imagery
We don't host clinical photos here. The links below go to peer-reviewed or open-access sources (Mind the Gap, DermNet NZ, PubMed Central, and similar). Each opens in a new tab.
- DermNet NZ — Hidradenitis suppurativa — image set across skin tones and Hurley stages.
- HS Foundation — patient education.
- Skin of Color Society — HS.
References
- Goldburg SR, Strober BE, Payette MJ. Hidradenitis suppurativa: epidemiology, clinical presentation, and pathogenesis. J Am Acad Dermatol. 2020;82(5):1045-1058. PMID: 31604104.
- Garg A, Kirby JS, Lavian J, Lin G, Strunk A. Sex- and age-adjusted population analysis of prevalence estimates for hidradenitis suppurativa in the United States. JAMA Dermatol. 2017;153(8):760-764. PMID: 28614533.
- Kimball AB, Kerdel F, Adams D, et al. Adalimumab for the treatment of moderate to severe hidradenitis suppurativa. Ann Intern Med. 2012;157(12):846-55. PMID: 23247938.
Medical disclaimer
Educational content only. This is not a substitute for in-person evaluation. If you are worried about yourself or someone you love, see a clinician — and if you are concerned about an emergency sign described here, call 911 or your local emergency number. We do not host clinical imagery; the external references are for reader self-education and are not owned by or affiliated with Black Health.