Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by painful nodules, abscesses, sinus tracts, and scarring. HS disproportionately affects Black Americans — particularly Black women — yet their diagnoses often occur years after symptom onset.
Despite growing awareness of HS among clinicians, diagnostic disparities persist. Why are Black patients still being missed?
Keep reading to learn why many Black patients face a delayed HS diagnosis.
Although Black Americans make up about 13 percent of the U.S. population, they account for 30 percent of patients diagnosed with HS. They also account for about 60 percent of hospitalizations for the chronic skin condition. Black women, in particular, face a higher risk, greater disease severity, and longer diagnostic delays.
Compared with other populations, Black patients with HS are more likely to experience:
Aside from the physical effects, HS can impact a patient’s quality of life. The chronic pain, draining lesions, and odor can make everyday functioning difficult. Many patients also experience depression, anxiety, work limitations, and social isolation, underscoring the substantial psychosocial burden of HS.
A higher prevalence of HS among Black patients should raise — not lower — the index of suspicion.
Several reasons contribute to delayed diagnosis in Black patients, such as:
HS lesions can mimic other skin infections, including:
When HS symptoms are misdiagnosed, it can lead to repeated courses of antibiotics or incision and drainage (I&D), which may provide some relief for acute lesions, but fail to address the chronic inflammatory nature of the disease.
Many patients normalize their symptoms because they believe recurrent boils are simply something they have to live with. Others may delay seeking care because of embarrassment, particularly when lesions occur in intimate areas or are associated with drainage or odor.
There’s also significant stigma surrounding HS. Patients frequently report feeling judged or being told that poor hygiene or weight alone is responsible for their condition. In reality, HS is caused by blocked follicles and immune system dysfunction. Ultimately, this stigma can make it more difficult for patients to get properly assessed and start treatment, contributing to the physiological and psychological effects of living with HS.
For clinicians, it’s critical to engage in self-education to avoid victim-blaming, validate the patient’s experience, conduct mental health screenings, and ensure treatment advice goes beyond hygiene.
HS inflammation can appear differently on darker skin, making diagnosis more challenging. Erythema (skin redness) is often an early warning sign of active inflammation. On light skin, the spots can appear pink or red. On darker skin tones, the spots may appear darker, purplish, or like a bruise.
Additionally, hyperpigmentation and post-inflammatory pigment changes may complicate assessment. When HS lesions heal, they can leave behind post-inflammatory hyperpigmentation (PIH), which occurs when inflammation triggers melanocytes to dump excess melanin into surrounding tissue. Increased skin pigmentation can make erythema less visually apparent, making palpation, lesion history, and morphology even more important during assessment. Because of this, providers may misdiagnose HS early on.
Diagnosing HS in darker-skinned individuals often relies on feeling for deep bumps where skin rubs together.
Here are some practical approaches clinicians can implement during a skin assessment:
Systemic bias within healthcare can also contribute to delayed diagnosis. For many HS patients, pain and skin complaints are often underestimated by providers, leading to fragmented care and delays in dermatology referral. Many patients often cycle through urgent care, primary care, surgery, and emergency departments before receiving an HS diagnosis.
For clinicians, it’s critical to understand that delayed diagnosis and treatment of HS are not the patient’s fault — they’re a larger systemic issue that needs to be addressed.
Improving outcomes for Black patients with HS must start at their initial visit with a primary care provider. These patients are likely to experience significant physical and emotional distress, and may be uncomfortable about the physical appearance and odor of their skin disease. It’s on providers to not only deliver a thorough assessment, but foster an environment where patients feel comfortable discussing symptoms that may feel embarrassing.
Below are some practical recommendations clinicians can adopt to identify HS symptoms better:
An earlier HS diagnosis can reduce irreversible scarring. Ensuring timely diagnosis, referral, and treatment may improve patients’ pain, mobility, mental health, and overall quality of life. Providers who can recognize how HS can present differently in Black patients — and who maintain a higher level of suspicion for recurrent lesions — can help reduce longstanding disparities in diagnosis and treatment.
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