Patients with HS are at increased risk of developing several comorbidities (Table 2).2  The mechanisms underlying these associations are unclear. Given that HS most commonly occurs in early adulthood, screening for these underlying comorbidities is essential for early detection and management in this younger population. Research suggests that early detection and management of coexisting comorbidities (eg, weight loss, diabetes treatment, and smoking cessation) are associated with improved disease control and decreased disease severity.6

Table 2. Comorbidities of Hidradenitis Suppurativa2

Acne
Arthropathy
Anxiety/depression
Follicular occlusion tetrad
Inflammatory bowel disease
Metabolic syndrome
Polycystic ovarian syndrome
Pyoderma gangrenosum and autoinflammatory syndromes
Smoking
Squamous cell carcinoma (of HS-affected skin)
Type 2 diabetes

Cardiovascular Disease Risk Factors

Several independent risk factors for cardiovascular disease are observed increasingly in patients with HS, including type 2 diabetes, metabolic syndrome, and tobacco smoking. Studies suggest that patients with HS are at increased risk of developing cardiovascular disease and death due to cardiovascular events, demonstrating the importance of screening for these underlying conditions.7

Type 2 Diabetes

Patients with HS have a 1.5- to 3-fold increased risk of developing type 2 diabetes, and the prevalence of type 2 diabetes in this population is approximately 30%.2 It is recommended that patients with signs or symptoms of diabetes mellitus (DM) should be screened with glycated hemoglobin type A1c (HbA1c) and/or fasting glucose levels.2 Patients with additional risk factors for diabetes such as obesity, hypertension, acanthosis nigricans, and hyperlipidemia should be referred for HbA1c and/or fasting glucose testing as well.2

Metabolic Syndrome

Metabolic syndrome and its components, including obesity, dyslipidemia, and diabetes, have been consistently associated with HS in controlled studies. Early detection and management of these components can lessen the severity of HS disease as well as increase the longevity of patients’ lives.7


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Research suggests an association between metabolic syndrome and HS even in younger and nonobese populations and in patients with a milder disease state, after controlling for potentially confounding variables including age, obesity, and disease severity.8 Therefore, it is important to screen for metabolic syndrome in patients presenting with HS regardless of age or symptoms.

A detailed evaluation for metabolic syndrome, including waist circumference, BMI, and blood pressure should be evaluated at baseline. Long-term monitoring of these parameters is also required.3

Smoking

Conflicting data exist regarding a direct association between smoking and HS.2,3 It is suspected that 70% to 75% of HS patients are current smokers, and 10% to 15% are former smokers.2 In 2 case studies, complete remission was achieved by women with HS following smoking cessation.9 Although studies suggest that smoking is associated with an increase in HS severity, duration, and failure of treatment, other studies have found no correlation between smoking and HS severity. 2,3

Although it is unclear whether or not smoking is a direct contributor to HS, it is clear that smoking is known to increase the inflammatory response, which can further exacerbate HS symptoms. Regardless of this conflicting data, it is important to take a thorough smoking history and counsel patients on smoking cessation for improvement of HS and overall health.1-3

Anxiety and Depression

Psychiatric conditions are observed at higher rates in patients with HS than in the general population. Dufour et al found that the impairment in quality of life, rates of depression, and social isolation were significantly higher in patients with HS vs those with other skin conditions, including psoriasis, atopic dermatitis, acne, and alopecia.3 Furthermore, patients with HS have an increased incidence of suicide.10 Thus, HS guidelines recommend regular screening for anxiety and depression in this population and referral for a psychological consult if warranted.1-3

Polycystic Ovarian Syndrome

One of the most common endocrinopathies affecting young women, PCOS is characterized by hyperandrogenism, irregular menses, and polycystic ovaries.11 The condition is associated with several comorbidities including premature adrenarche and infertility.11 There is considerable overlap between HS comorbidities and PCOS risk factors, including obesity, diabetes, and metabolic syndrome.11

Patients with HS have a more than a 3-fold increased risk of developing PCOS, with a prevalence of 9% in this population compared with 2.9% among patients without HS.2,11 Although women with HS without underlying PCOS can display signs of hyperandrogenism, screening for PCOS is recommended due to the burden associated with the disease. The HS guidelines recommended that patients with signs of androgen excess or irregular menses be referred for further workup for PCOS.2 

Squamous Cell Carcinoma

Squamous cell carcinoma developing on HS-affected skin is another comorbidity deemed essential for screening in HS patients, specifically in patients with long-standing severe disease.2,12 It is hypothesized that chronic inflammation of HS-affected skin may lead to proliferative changes in the epithelium resulting in nonmelanoma skin cancers.

Squamous cell carcinoma should be considered when weighing treatment options for HS patients since biologic agents also increase the risk of developing nonmelanoma skin cancer. Early detection and management of neoplasms in HS-affected skin are imperative because neoplasms originating from chronic wounds are prone to metastasize and are typically invasive.13

The HS guidelines recommend periodic skin examinations by a dermatologist with special attention paid to areas with chronic lesions, the perineum, and the buttocks, as these are areas where squamous cell carcinoma is most commonly seen in patients with HS.2

Conclusion

Hidradenitis suppurativa is a complex disorder with an unclear etiology primarily affecting patients in their 20s and 30s. Although research involving disease management is sparse, treatment recommendations suggest proper identification and management of underlying diseases in this younger population.2,14

Comorbidities including type 2 diabetes, metabolic syndrome, tobacco smoking, anxiety and depression, PCOS, and squamous cell carcinoma are common in patients with HS and should be screened for during clinical evaluation. Concomitant treatment of HS and these comorbidities is essential for achieving optimal outcomes and improving quality of life.2

Kathryn Shea, PA-C, graduated in the class of 2020 from Augusta University. Alicia Elam, PharmD, is an associate professor, Physician Assistant Department, Augusta University, Augusta, Georgia.

References

1. Okoye GA. Hidradenitis suppurativa. In: Kang S, Amagai M, Bruckner AL, et al.  Fitzpatrick’s Dermatology. 9th ed. McGraw-Hill Education; 2019.

2. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. 2019;81(1):76-90. doi:10.1016/j.jaad.2019.02.067

3. Dufour DN, Emtestam L, Jemec GB. Hidradenitis suppurativa: a common and burdensome, yet under-recognised, inflammatory skin disease. Postgrad Med J. 2014;90(1062):216-221. doi:10.1136/postgradmedj-2013-131994

4. Reddy S, Strunk A, Garg A. Comparative overall comorbidity burden among patients with hidradenitis suppurativa. JAMA Dermatol. 2019;155(7):797-802. doi:10.1001/jamadermatol.2019.0164

5. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009;60(4):539-561. doi:10.1016/j.jaad.2008.11.911

6. Kimball AB, Sundaram M, Gauthier G, Guérin A, Pivneva I, Singh R, Ganguli A. The comorbidity burden of hidradenitis suppurativa in the United States: a claims data analysis. Dermatol Ther (Heidelb). 2018;8(4):557-569. doi:10.1007/s13555-018-0264-z

7. Tzellos T, Zouboulis CC, Gulliver W, Cohen AD, Wolkenstein P, Jemec GB. Cardiovascular disease risk factors in patients with hidradenitis suppurativa: a systematic review and meta-analysis of observational studies. Br J Dermatol. 2015;173(5):1142-1155. doi:10.1111/bjd.14024

8. Ergun T. Hidradenitis suppurativa and the metabolic syndrome. Clin Dermatol. 2018;36(1):41-47. doi:10.1016/j.clindermatol.2017.09.007

9. Simonart T. Hidradenitis suppurativa and smoking. J Am Acad Dermatol. 2010;62(1):149-150. doi: 10.1016/j.jaad.2009.08.001

10 Patel KR, Lee HH, Rastogi S, Vakharia PP, Hua T, Chhiba K, Singam V, Silverberg JI. Association between hidradenitis suppurativa, depression, anxiety, and suicidality: A systematic review and meta-analysis. J Am Acad Dermatol. 2020;83(3):737-744. doi: 10.1016/j.jaad.2019.11.068

11. Garg A, Neuren E, Strunk A. Hidradenitis suppurativa is associated with polycystic ovary syndrome: a population-based analysis in the United States. J Invest Dermatol. 2018;138(6):1288-1292. doi: 10.1016/j.jid.2018.01.009

12. Fabbrocini G, Ruocco E, De Vita V, Monfrecola G. Squamous cell carcinoma arising in long-standing hidradenitis suppurativa: An overlooked facet of the immunocompromised district. Clin Dermatol. 2017;35(2):225-227. doi: 10.1016/j.clindermatol.2016.10.019

13. Juviler PG, Patel AP, Qi Y. Infiltrative squamous cell carcinoma in hidradenitis suppurativa: A case report for early surgical intervention. Int J Surg Case Rep. 2019;55:50-53. doi: 10.1016/j.ijscr.2019.01.006.

14. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part II: topical, intralesional, and systemic medical management. J Am Acad Dermatol. 2019;81(1):91-101. doi: 10.1016/j.jaad.2019.02.068