Key takeaways

• HS can look different on Black and brown skin. Inflammation may appear purple, gray, dark brown, or close to your natural skin tone rather than bright red.

• Dark marks after an HS flare are not always scars. Many are flat areas of discoloration that can fade over time, while raised scars and keloids may need treatment.

• Controlling active HS comes first. Preventing new flares helps limit new dark marks, tunnels, and scars.

• Experience with skin of color matters. A dermatologist familiar with how HS appears and heals across different skin tones can help identify it earlier and choose appropriate treatments.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that causes painful, recurring lumps, often in areas like the underarms, groin, inner thighs, buttocks, and under the breasts.

On Black and brown skin, those symptoms do not always look the way HS is traditionally described. Inflammation may appear purple, gray, brown, or only slightly darker than the surrounding skin rather than bright pink or red.

That can make early HS easier to miss. And after a flare heals, people with darker skin may be more likely to notice persistent dark marks or certain types of raised scars.

Knowing what to look for, and finding a dermatologist experienced in treating HS across different skin tones, can make it easier to recognize the condition and start the right treatment.

This guide covers how HS looks on darker skin, why it is often recognized later, what dark marks and scars mean, and the order treatment usually follows.

How HS looks on darker skin

HS lumps have the same shape and behavior on every skin tone. They form deep under the skin, swell, and can open and drain.

What changes is color, as the review above describes, and how easy the redness is to see. On brown and Black skin, inflammation can blend into the surrounding skin or look darker than it.

Lumps, boils, and color changes

The underlying signs of HS are similar across skin tones: deep, painful lumps form beneath the skin, may open and drain, and often return in the same areas.

What can look different is the color of the inflammation.

On lighter skin, an inflamed HS lesion may appear pink or red. On Black and brown skin, it may look purple, gray, dark red, brown, or close to the surrounding skin tone.

The table below shows the main visual differences our dermatologists look for.

The pattern that points to HS

A single lump can have many causes. HS shows itself through a pattern that repeats over months or years. These signs are part of that pattern:

• Lumps that return to the same places, such as the underarms, groin, inner thighs, buttocks, or under the breasts

• Bumps that open, drain fluid, and heal slowly

• Blackheads that appear in pairs, often in pitted skin

• Tunnels under the skin that connect one lump to another

• Flares that last for weeks at a time

This pattern over time is what separates HS from a single boil or an ingrown hair. It is also why many people with HS notice scars building up in the same places over time, such as the underarms and inner thighs.

Photos help. Take pictures when a flare starts and again as it heals, and write down the dates. Notes on pain, drainage, and what seems to trigger a flare give your dermatologist a clear record of how your HS behaves between visits.

Why HS is often recognized later in Black patients

A 2025 review of Black Americans with HS in Dermatology and Therapy found HS more than three times as common in Black than White individuals. The same Dermatology and Therapy review found that Black patients face longer diagnostic delays and have less access to specialized dermatologic care.

The reasons are often practical. On darker skin, redness is harder to see, so early lumps can look mild. Each early flare can also look like a single boil or infection, and it is treated that way.

In our dermatologists' experience, many patients have seen more than one clinician before reaching a dermatologist. Each visit may capture only one flare, so the pattern can stay hidden.

The pattern becomes clear when a dermatologist who regularly treats HS in skin of color looks at the whole history. That is often the point where a diagnosis is reached and a long-term plan begins. Your photos and notes can help make that moment come sooner.

Dark marks and scars after HS

Each flare can leave a mark as it heals. Repeated healing and reopening is how HS tunnels and scars form, according to the American Academy of Dermatology.

Over time, that cycle can create sinus tracts, which are tunnels under the skin, and permanent scars. Not every dark area is a scar, though, and knowing which kind you have shapes treatment.

Flat dark marks

Many dark areas after a flare are post-inflammatory hyperpigmentation, which means flat brown, gray, or purple marks left when inflammation triggers extra pigment. The skin surface stays smooth. These marks are common on melanin-rich skin.

When people describe dark scars from old HS boils, this is usually what they mean.

Dermatology guidance on fading dark spots in darker skin says a spot a few shades darker usually fades within 6 to 12 months. This general advice from the American Academy of Dermatology applies once the cause is stopped. Color that sits deeper in the skin can take years.

For HS, the cause is active inflammation. That is why calming flares comes before any effort to fade marks.

Raised scars and keloids

Some HS scars rise above the skin. A hypertrophic scar is a raised scar that stays within the edges of the original wound. A keloid is a raised scar that keeps growing beyond those edges.

A 2024 American Family Physician review of keloid risk in darker skin found that darker skin tones carry a 15 to 20 times higher risk.

In our dermatologists' clinical experience, raised scars and keloids respond better to early treatment. That makes an early evaluation worthwhile. Tono dermatologists have particular experience treating keloids in skin of color.

Tunnels and rope-like scars

Long-standing HS can leave tunnels under the skin and thick, rope-like scars. In the underarms or groin, these scars can pull and limit movement.

Tunnels and rope-like scars usually need in-person procedures or surgery. Your dermatologist plans this care and coordinates it with you.

Treating HS on darker skin, in the right order

Dermatologists usually plan HS treatment in an order: calm active disease, fade marks, then treat scars. Treating scars while flares continue means new marks can keep forming.

Calm active HS first

Controlling flares is the most important step for limiting new dark marks and scars. Your dermatologist tailors HS treatment to you and to how severe your HS is.

Options may include topical and oral antibiotics, hormonal therapy, and steroid injections given in the office to calm a painful lump.

For moderate to severe HS, a dermatologist may recommend a biologic approved by the U.S. Food and Drug Administration (FDA). A biologic is a medicine that targets specific immune signals that drive inflammation. The FDA-approved biologic treatments for HS listed by the American Academy of Dermatology are adalimumab, bimekizumab, and secukinumab.

HS is a long-term condition, so treatment often changes over time. Tono's dedicated hidradenitis suppurativa program covers diagnosis, biologic management, treatment escalation, and long-term care. Escalation means stepping up treatment when flares are not yet under control.

Fade dark marks with care

Once flares are calmer, dark marks can begin to fade. Your dermatologist builds a routine suited to your skin, and improvement is gradual. A typical plan includes:

• Daily broad-spectrum sunscreen, ideally tinted, because sun and visible light can deepen dark marks

• Prescription topicals such as hydroquinone, azelaic acid, tretinoin, or tranexamic acid, chosen by your dermatologist

• Chemical peels and lasers, used selectively and carefully, because overly aggressive treatment can worsen pigment on darker skin

• Gentle care of healing skin, with no picking and no harsh scrubs

Dermatologists choose pigment treatments with skin tone in mind. Tono's page on treating dark marks after inflammation explains these options in more detail.

Treat raised scars and tunnels in person

Steroid injections can help flatten raised scars and keloids. Tunnels may need an in-office procedure or surgery to open or remove them.

These treatments happen in person, at a Tono center or coordinated with a specialist near you. Planning and follow-up can happen by video.

Dermatologists usually begin this step once active HS is under control. Tono's approach to scar and keloid care brings these treatments together with your HS plan.

Care from dermatologists who know your skin

Living with HS on darker skin can mean years of explaining symptoms that are hard to see. Care feels different when your dermatologist already understands how the condition looks on your skin.

A dermatologist who regularly treats HS on darker skin reads color changes accurately and recognizes the pattern across flares. They choose pigment and scar treatments with your skin tone in mind.

Tono's Skin of Color Center brings together dermatologists with deep expertise in how conditions present, progress, scar, and respond to treatment across diverse skin tones. Our HS specialists work alongside that team.

Dr. Mondana Ghias, Tono's co-founder and Chief Medical Officer, is a board-certified dermatologist and HS researcher with more than two dozen peer-reviewed publications. HS specialists such as Dr. Brianna Olamiju focus on both HS and skin of color.

Tono has cared for more than 20,000 patients across a 33-state clinical footprint. HS appointments are available in 2 days or less. Most insurance is accepted, no referral is needed, and every visit is led by a specialist.

Your Tono dermatologist stays with you over time, through flares, dark marks, and scar treatment, so your care builds on what has already worked.

Questions to ask your dermatologist

Bring your photos and notes to your visit. These questions can help guide the conversation:

• Is this HS, and how severe is it?

• Which treatment will calm my flares, and how will we know it is working?

• How can we limit new dark marks?

• Which products or procedures are right for my skin tone?

• Are these marks flat, or are they true scars?

• When should we treat scars or keloids?

• Which parts of my care can happen by video, and which need an in-person visit?

The right diagnosis changes what comes next

HS on darker skin has a recognizable pattern, and it responds to treatment. Many dark marks fade with time, and raised scars can be treated once flares are under control.

Care works best when a specialist who knows your skin leads it from the first flare onward.

Frequently asked questions

Is HS contagious or a sexually transmitted infection?

No. The American Academy of Dermatology overview states that HS is not sexually transmitted, not contagious, and not caused by unclean skin. It is a chronic inflammatory condition.

Can I prevent new dark marks from HS?

Often, yes, to a large degree. In our dermatologists' experience, early flare control, daily sun protection, and not picking at healing skin all reduce new marks. Results vary from person to person.

Can HS be treated with virtual visits?

Much of HS care can happen by video. Diagnosis, staging (rating how severe your HS is), medication and biologic management, and follow-up visits work well virtually.

Injections, procedures, and surgery happen in person, and your dermatologist coordinates them. Our article on virtual-first HS care explains how the two settings fit together.

Do I need a referral to see an HS specialist at Tono?

No. You can book directly without a referral, and most insurance is accepted. Appointments for HS are available in 2 days or less.

Schedule an in-person or virtual appointment with a Tono Health specialist. Find a Tono HS specialist