Confusable diagnoses · PANCE / PANRE

Hidradenitis Suppurativa vs Folliculitis

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

Hidradenitis Suppurativa and Folliculitis are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.

Hidradenitis Suppurativa vs Folliculitis at a glance

  • Hidradenitis Suppurativa: Chronic recurrent follicular occlusive disease of intertriginous areas with painful nodules, abscesses, sinus tracts, and scarring.
  • Folliculitis: Inflammation of the hair follicle from infection, irritation, or ingrown hairs; presents as follicular pustules and papules.

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Question 1DermatologyMedium
A 27-year-old woman presents with a 4-year history of painful, recurrent boils in both axillae and the groin. Exam shows tender deep-seated nodules, several draining sinus tracts, double-headed open comedones, and bridged hypertrophic scars in the axillae and inguinal folds, separated by areas of normal skin. She has smoked one pack daily for 10 years and has a BMI of 34. A diagnosis of hidradenitis suppurativa is made. Which of the following best explains these findings?
  • ACutibacterium acnes overgrowth within hyperplastic sebaceous glands
  • BGranulomatous inflammation centered on the eccrine sweat ducts
  • CApocrine duct keratin plugging with sweat retention in the dermis
  • DFollicular occlusion with rupture of the follicle into the dermis
Reveal answer & full explanation
Correct answer: D — Follicular occlusion with rupture of the follicle into the dermis
  • ACutibacterium acnes overgrowth within hyperplastic sebaceous glands
  • BGranulomatous inflammation centered on the eccrine sweat ducts
  • CApocrine duct keratin plugging with sweat retention in the dermis
  • DFollicular occlusion with rupture of the follicle into the dermis✓

Why Follicular occlusion with rupture of the follicle into the dermis is correct

  • Hidradenitis suppurativa begins with hyperkeratinization and dilatation of the terminal follicle in apocrine gland-bearing skin, leading to follicular occlusion.
  • The occluded, distended follicle ruptures into the dermis, releasing keratin and bacteria that trigger a robust neutrophilic inflammatory response, sinus tract formation, and bridged scarring.
  • TNF-alpha, IL-17, and IL-1beta drive the inflammation, and the gamma-secretase/Notch pathway is implicated in familial forms. The double-headed comedones, sinus tracts, and intertriginous distribution all follow from this follicular occlusive process.

Why the others are wrong

  • Cutibacterium acnes overgrowth within hyperplastic sebaceous glands — C. acnes proliferation in sebum-rich follicles is part of the acne vulgaris model on the face and upper trunk; in HS, bacteria are secondary colonizers of the ruptured follicle rather than the initiating event, and the disease centers on intertriginous apocrine gland-bearing skin rather than sebaceous-rich sites.
  • Granulomatous inflammation centered on the eccrine sweat ducts — HS involves apocrine gland-bearing skin via follicular occlusion, not granulomatous eccrine duct disease; eccrine pathology underlies conditions such as miliaria, not HS.
  • Apocrine duct keratin plugging with sweat retention in the dermis — This reflects the outdated apocrine-centered view of HS and resembles Fox-Fordyce disease, in which keratin plugging of the follicular infundibulum traps apocrine sweat and causes itchy axillary papules; in HS the primary event is occlusion and rupture of the terminal hair follicle, with apocrine glands involved only secondarily.
Question 2DermatologyMedium
A 24-year-old previously healthy man presents with an itchy rash that appeared about 36 hours ago. He used a friend's hot tub two evenings before the rash began. On exam he has scattered 2-5 mm erythematous follicular papules and pustules concentrated over the trunk, buttocks, and upper thighs in a swimsuit distribution, sparing the face, palms, and soles. He is afebrile with normal vital signs and feels otherwise well. Which of the following is the most appropriate initial management?
  • AOral cephalexin for 7 days
  • BObservation and reassurance
  • COral ciprofloxacin for 7 days
  • DPustule incision and drainage
Reveal answer & full explanation
Correct answer: B — Observation and reassurance
  • AOral cephalexin for 7 days
  • BObservation and reassurance✓
  • COral ciprofloxacin for 7 days
  • DPustule incision and drainage

Why Observation and reassurance is correct

  • Pruritic follicular papules and pustules in a swimsuit distribution appearing 8-48 hours after hot tub use are classic for Pseudomonas aeruginosa (hot tub) folliculitis.
  • In an immunocompetent, afebrile, well-appearing patient this is self-limited and resolves over 7-14 days, so initial management is reassurance and supportive care (cool compresses, topical antipruritics) plus remediating the contaminated water source.
  • Systemic antibiotics are generally reserved for severe, persistent, or immunocompromised cases.

Why the others are wrong

  • Oral cephalexin for 7 days - cephalexin is first-line for extensive S. aureus folliculitis, but as a first-generation cephalosporin it has no activity against Pseudomonas, and this self-limited eruption needs no systemic antibiotic.
  • Oral ciprofloxacin for 7 days - ciprofloxacin is the correct oral anti-Pseudomonal agent but is reserved for severe, persistent, or immunocompromised disease, not a self-limited course in a healthy host.
  • Pustule incision and drainage - incision and drainage treats fluctuant abscesses and large furuncles; these are superficial 2-5 mm follicular pustules that resolve on their own, so incising them adds pain and scarring risk without benefit.
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Side-by-side comparison

FeatureHidradenitis SuppurativaFolliculitis
At a glanceChronic recurrent follicular occlusive disease of intertriginous areas with painful nodules, abscesses, sinus tracts, and scarring.Inflammation of the hair follicle from infection, irritation, or ingrown hairs; presents as follicular pustules and papules.
Classic presentationRecurrent abscesses + sinus tracts + bridged scarring in axillae and groin; double-comedones.; Painful recurrent nodules and abscesses, often draining purulent foul-smelling discharge; Pruritus, burning, stinging; Sleep disturbance, dyspareunia, gait disturbance, work absences; Significant pain — worst-rated chronic dermatologic disease…Pruritic follicular papules and pustules in a swimsuit distribution 1-2 days after hot tub use (Pseudomonas); persistent shaving bumps with ingrown hair tips at the beard line (PFB).; Itchy or mildly painful follicular papules and pustules; Bacterial: scattered pustules with central hair on the beard, scalp, thighs, buttocks, axillae;…
Workup / key labsAll three required (Dessau criteria): (1) typical lesions (nodules, abscesses, sinus tracts, scars), (2) typical locations (intertriginous), (3) chronic relapsing course.; Clinical diagnosis — no required labs; CBC, CRP, ESR (elevated during flares); Bacterial culture if secondary infection or atypical presentation (cultures often…Clinical diagnosis based on morphology and exposure history. Culture and Gram stain confirm bacterial etiology; KOH confirms fungal causes.; Usually clinical diagnosis; Bacterial culture and Gram stain of pustule contents when atypical, recurrent, severe, or suspected MRSA; KOH preparation and fungal culture if Pityrosporum, tinea, or…
ImagingUltrasound (high-frequency) — assesses sinus tract extent, often used to plan surgery; MRI for complex perineal/perianal disease and Crohn overlap; Sinography in selected presurgical casesNot routinely required; Ultrasound or imaging if abscess or deeper soft tissue involvement suspected (furuncle, carbuncle)
First-line treatmentLifestyle: smoking cessation (most impactful intervention), weight reduction, loose breathable clothing, avoid friction/shaving; Daily antiseptic wash: chlorhexidine 4%, dilute bleach baths, benzoyl peroxide 5-10%; Topical clindamycin 1% solution BID for mild Hurley I disease; Hurley I-II: oral tetracycline antibiotic — doxycycline 100…Bacterial folliculitis: warm compresses; topical antibacterial wash (chlorhexidine 4%, benzoyl peroxide 5-10%); topical antibiotics (mupirocin 2%, clindamycin 1%) for limited disease; Add oral antibiotics for extensive or recurrent disease: cephalexin 500 mg QID, dicloxacillin 500 mg QID; MRSA suspected → TMP-SMX DS BID, doxycycline 100…

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Full outlines

Hidradenitis Suppurativa Folliculitis (Bacterial, Hot Tub, Pseudofolliculitis Barbae) All 514 diagnoses

Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.