Is Hidradenitis Suppurativa Always Painful?
No, hidradenitis suppurativa (HS) is not always painful, though pain is the most common and impactful symptom when present. The defining diagnostic criteria for HS require typical lesions in typical sites with chronic recurrence, but pain is not an absolute requirement for diagnosis 1.
Clinical Presentation and Pain Characteristics
HS is formally defined as presenting with "painful deep-seated, inflamed lesions," but the reality in clinical practice shows variability in pain presentation 1. The condition can manifest with:
- Comedones (characteristically paired), papules, pustules, nodules, cysts, abscesses, sinus tracts and fistulae 1
- Pain severity ranging from absent to severe (rated 4/10 to 10/10 on numerical rating scales when present) 2
- Additional symptoms including pruritus, chronic discharge, and persistent malodor that may occur independently of pain 1
Pain Patterns and Mechanisms
When pain occurs in HS, it demonstrates distinct patterns 3:
- Chronic baseline discomfort that may be tolerable or minimal in some patients 3
- Acute, unpredictable disease flares that cause more distress and quality-of-life burden than chronic pain 3
- Mixed pain mechanisms including nociceptive pain (inflammatory), neuropathic pain, and itch components 2, 3
The pain is described variably as hot, burning, pressure, stretching, cutting, sharp, taut, splitting, gnawing, pressing, sore, throbbing, and aching 2.
Diagnostic Implications
The consensus diagnostic criteria do not mandate pain as an absolute requirement 1. Diagnosis requires:
- Typical lesions (nodules, abscesses, sinus tracts, bridged scars, or open comedones) 1
- Typical anatomic sites (axillae, groin, perineal, perianal, inframammary folds, or buttocks) 1
- Chronic and recurrent presentation 1
Clinical Pitfalls
Do not exclude HS diagnosis based solely on absence of pain 1. Some patients may present with:
- Primarily draining lesions without significant pain 1
- Burnout phase disease with scarring and minimal active inflammation 4
- Early-stage disease (Hurley I) with less painful manifestations 5
Pain assessment using Visual Analog Scale (VAS) or numeric rating scale (0-10) should be performed at baseline and follow-up, even when patients do not spontaneously report pain 1, 5. This proactive approach identifies unmet needs and facilitates better pain control 3.