Patients with hidradenitis suppurativa routinely present with one site and have three. The groin gets reported because it interferes with walking; the inframammary fold, the perianal skin and the buttocks often do not get reported at all, and a consultation that examines only the complaint will stage the disease a full Hurley grade too low.
The practical habit is to examine every flexural site at the first visit and at any visit where treatment is being escalated, and to say out loud that you are going to, because patients who have been dismissed before will not volunteer a perianal lesion to a clinician who has not asked. Record the sites, not just a stage — sinus tracts in one region and isolated nodules in another need different answers, and a patient with tracts is a surgical conversation as well as a medical one.
The second half of the same habit is the delay. Ask when the first lesion appeared. A median diagnostic delay of years is well described, and knowing that this has been going on since the patient was nineteen reframes both the urgency and the conversation about scarring.
- Examine axillae, inframammary folds, groin, perianal skin and buttocks — every visit that changes treatment.
- Record sites and lesion types separately from the Hurley stage.
- Ask when the first lesion appeared, not when it became a problem.
- Flag sinus tracts for surgical opinion rather than another antibiotic course.
- Ask about the effect on work, sex and clothing — it is what the patient came about.
Why it matters
Most under-staging in HS comes from examining only where the patient pointed.
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