HS in Children and Adolescents: What Parents Should Know

Most adults with HS did not develop it as adults. Ask when it started and the answer is usually adolescence — a lump in the armpit or groin at thirteen or fourteen that was treated as a boil, then another one, then years of the same before anyone used the word hidradenitis.

This article is written for parents. If your child has recurring lumps in the folds of the body, it is worth reading before the next appointment.

It starts younger than most people realise

HS characteristically begins around puberty. Patients often notice afterwards that it started as the hormonal environment changed, and in those who menstruate it frequently tracks the cycle from early on.

What that means practically is that recurring lumps in the armpit, groin, under the breast or between the buttocks in a teenager should not be dismissed as ordinary adolescent skin. Recurrence in the same site is the signal. One boil is a boil; the same boil in the same fold, repeatedly, is a pattern that deserves a proper look.

What it gets called first

Almost always something else. Acne. Boils. An infection. A hygiene problem. Adolescents in particular get told to wash more, which is both untrue and corrosive to hear at that age.

The average delay between first symptoms and a correct diagnosis runs to years, and a good part of that delay is accumulated in adolescence — when the lesions are in places a teenager will not readily show anyone, and when they are most likely to be attributed to puberty and left.

If you take one thing from this: it is not caused by poor hygiene, and washing more will not resolve it. Scrubbing an inflamed fold makes it worse.

What parents most often get wrong

Not out of neglect — these are reasonable assumptions that happen to be wrong.

Assuming they will grow out of it. HS beginning at puberty does not typically resolve with age. Waiting is the main way early disease becomes established disease.

Treating it as a hygiene or diet failure. Both land as blame on a child already hiding something they find humiliating.

Underestimating the social weight. The lesions are painful; the part that tends to do lasting damage at this age is concealment — avoiding sport, changing rooms, swimming, friendships. Children rarely volunteer this. It is worth asking gently and directly.

Waiting for them to raise it. Given the sites involved, most will not.

Treating a growing body

The principle we work to is straightforward: a child or adolescent needs a more conservative, family-centred approach than an adult with the same disease.

That means avoiding aggressive or prolonged therapies unless they are clearly necessary, and weighing every intervention against its impact on a body that is still developing. The calculation is not only "will this control the disease" but "what does this cost a fifteen-year-old over the next decade" — and those two answers are not always the same.

It also means parents or guardians are part of treatment planning rather than recipients of a plan. For anyone under 18 that is not a courtesy; it is how the decision gets made.

None of this is a claim to a special paediatric protocol. It is ordinary clinical caution, applied properly.

Growth, nutrition and the things we watch

Three things get closer attention in a young patient than they would in an adult:

• Growth and development. Anything sustained enough to affect them needs justifying, not assuming.
• Nutrition. Adolescents with a painful chronic condition frequently eat badly around it, and dietary advice given without supervision at this age can do more harm than the disease.
• Emotional wellbeing. This is not a soft add-on. A visible, painful, private condition arriving in the middle of adolescence carries a real burden, and it should be asked about at every review rather than waited for.

If any of these is moving in the wrong direction, that changes the plan — regardless of what the skin is doing.

School, and what is worth asking for

Most of what helps does not require the school to know the diagnosis:

• Permission to use a private bathroom, and to change a dressing during the day.
• Flexibility around PE and shared changing rooms during a flare — participation where possible, an alternative where not.
• Being allowed to stand or move during long lessons, if the disease is at a site affected by sitting.
• A discreet route to leave a lesson without an explanation each time.

As with adults, disclosing the requirement rather than the condition is usually enough, and it keeps the information with your child rather than with a staffroom.

What we will and will not do

We do not treat a child as a smaller adult with the same protocol at a lower dose. The threshold for anything aggressive or long-running is higher, and where the honest answer is that a conservative approach may take longer, we say so rather than escalate.

We will not proceed with a young patient without a parent or guardian involved in the plan, and we will not give dietary or lifestyle instructions to an adolescent without a parent present.

We would also say plainly that a child with suspected HS should be assessed properly and in person by a clinician who can examine them. Nothing on this page substitutes for that, and if what you are describing turns out to be something other than HS, that matters more than anything written here.

What does not change with age is the underlying position: this is an inflammatory disease expressed in the skin, recurrence means the driver has not been addressed, and scarring that has already formed is structural. Reaching it earlier is the single thing that most changes what treatment can achieve — which is the reason to look properly at a teenager's third boil rather than the tenth.