To the Editor: Hidradenitis suppurativa (HS) is a chronic painful inflammatory folliculitis which has been associated with numerous co-morbidities such as obesity, metabolic syndrome, smoking, and autoimmune diseases in the literature.1,2 These comorbidities contribute to systemic inflammation and immunologic dysfunction that worsen the pathogenesis of the disease.3 In cases of severe disease (Hurley Stage III), surgical intervention including wide local excision is required for treatment.1
Given the documented association of co-morbid conditions, our study sought to better understand the impact of medical comorbidities on postoperative outcomes for patients with severe HS. We conducted a retrospective review of 65 Hurley Stage III HS patients (Table I) at a multicenter academic institution in New Orleans, Louisiana, from 2013 to 2023. Patients were identified from a single-surgeon panel utilizing CPT codes that covered excision of HS from numerous areas of the body and associated codes (10060, 10061, 11450, 11451, 11462, 11463, 11470, 11471, 15002, 15003, 15004, 15040, 17110, 17111). Recurrence was defined as recurrence of disease anywhere on the body after surgical excision.
Table I.
Demographics and comorbidities
| Overall (n = 65) | Male (n = 15) | Female (n = 50) | P-value | |
|---|---|---|---|---|
| Demographics | ||||
| Age; mean [range] | 41.3 [16-70] | 49.7 [25-70] | 38.8 [16-67] | .023 |
| Race | ||||
| Black | 47 (72%) | 10 (67%) | 37 (74%) | .820 |
| White | 17 (26%) | 5 (33%) | 12 (24%) | .699 |
| Hispanic ethnicity | 3 (5%) | 1 (7%) | 2 (4%) | .999 |
| Insurance provider | ||||
| Private insurance | 47 (72%) | 11 (73%) | 36 (72%) | .260 |
| Medicaid | 7 (11%) | 0 (0%) | 7 (14%) | |
| Medicare | 10 (15%) | 4 (27%) | 6 (12%) | |
| Self-pay | 0 (0%) | 0 (0%) | 0 (0%) | |
| Unknown | 1 (2%) | 0 (0%) | 1 (2%) | |
| BMI | 34.9 (8.6) | 35.1 (9.6) | 8.3 (34.8) | .891 |
| Smoking status | ||||
| Never smoker | 41 (63%) | 5 (36%) | 36 (72%) | .044 |
| Former smoker | 10 (15%) | 4 (29%) | 6 (12%) | |
| Active smoker | 13 (20%) | 5 (36%) | 8 (16%) | |
| Comorbidities | ||||
| Depression | 35 (54%) | 7 (47%) | 28 (56%) | .733 |
| Anxiety | 30 (46%) | 4 (27%) | 26 (52%) | .153 |
| Metabolic syndromes | 14 (22%) | 3 (20%) | 11 (22%) | .999 |
| Sexual dysfunction | 23 (35%) | 7 (47%) | 16 (32%) | .463 |
| Obesity | 47 (72%) | 10 (67%) | 37 (74%) | .820 |
| HIV | 1 (2%) | 0 (0%) | 1 (2%) | .999 |
| Iron deficiency anemia | 12 (18%) | 3 (20%) | 9 (18%) | .999 |
| Anemia of chronic disease | 12 (18%) | 2 (13%) | 10 (20%) | .838 |
| Malnutrition | 4 (6%) | 2 (13%) | 2 (4%) | .480 |
| IBD | 15 (23%) | 4 (27%) | 11 (22%) | .979 |
| HTN | 43 (66%) | 12 (80%) | 31 (62%) | .327 |
| HLD | 30 (46%) | 10 (67%) | 20 (40%) | .128 |
| DM | 22 (34%) | 4 (27%) | 18 (36%) | .720 |
| Rheumatoid arthritis | 4 (6%) | 1 (7%) | 3 (6%) | .999 |
| Psoriasis | 4 (6%) | 1 (7%) | 3 (6%) | .999 |
| Psoriatic arthritis | 3 (5%) | 1 (7%) | 2 (4%) | .999 |
| No associated disease | 5 (8%) | 0 (0%) | 5 (10%) | .470 |
| Number of comorbidities mean [range] | 5.2 [0-12] | 5.5 [0-10] | 5.1 [1-12] | .645 |
BMI, Body mass index; DM, diabetes mellitus; HLD, hyperlipidemia; HTN, hypertension; IBD, inflammatory bowel disease.
The results of our study (Table II) indicate that patients with metabolic syndrome were 5.16 times more likely to have HS recurrence (P = .014), and patients with sexual dysfunction disorders were 5.84 times more likely to have HS recurrence (P = .002) relative to HS patients without these disorders. For each additional comorbidity, the odds of a recurrence increased by a factor of 1.48 (P = .029). Former smokers had an increased defect size by a factor of 3.62 compared to never smokers (P = .039), and for every additional medication, the defect size increased by a factor of 1.39 (P = .026).
Table II.
Recurrence and defect size
| Recurrence |
Defect size |
|||
|---|---|---|---|---|
| OR (95% CI) | P-value | Exponentiated coefficient (95% CI) | P-value | |
| Demographics | ||||
| Age | 1.01 (0.98, 1.04) | .538 | 1.01 (0.98, 1.04) | .625 |
| Race | ||||
| Black | 2.28 (0.72, 8.07) | .174 | 0.50 (0.20, 1.23) | .129 |
| White | 0.50 (0.14, 1.57) | .250 | 1.95 (0.77, 4.92) | .153 |
| Insurance provider | ||||
| Private insurance | [Reference] | [Reference] | ||
| Medicaid | 0.86 (0.15, 4.32) | .851 | 1.15 (0.29, 4.52) | .835 |
| Medicare | 0.29 (0.04, 1.30) | .138 | 1.27 (0.29, 5.55) | .749 |
| BMI | 1.03 (0.97, 1.09) | .378 | 1.05 (0.99, 1.10) | .056 |
| Smoking status | ||||
| Never smoker | [Reference] | [Reference] | ||
| Former smoker | 2.03 (0.50, 9.02) | .326 | 3.62 (1.07, 12.23) | .039 |
| Active smoker | 0.41 (0.08, 1.57) | .218 | 0.89 (0.31, 2.57) | .827 |
| Alcohol consumption >0 | 1.95 (0.60, 6.51) | .267 | 0.88 (0.33, 2.36) | .787 |
| Comorbidities | ||||
| PCOS | 0.94 (0.12, 6.12) | .952 | 2.60 (0.64, 10.58) | .177 |
| Depression | 1.29 (0.47, 3.60) | .619 | 0.72 (0.30, 1.72) | .448 |
| Anxiety | 1.71 (0.62, 3.79) | .299 | 0.46 (0.19, 1.09) | .076 |
| Metabolic syndromes | 5.16 (1.48, 21.23) | .014 | 1.92 (0.64, 5.80) | .239 |
| Sexual dysfunction | 5.84 (1.95, 19.15) | .002 | 1.26 (0.51, 3.12) | .610 |
| Obesity | 2.98 (0.90, 11.83) | .089 | 1.79 (0.64, 5.01) | .259 |
| Iron deficiency anemia | 0.66 (0.16, 2.38) | .537 | 1.88 (0.59, 5.98) | .280 |
| Anemia of chronic disease | 0.78 (0.19, 2.91) | .716 | 1.51 (0.31, 7.31) | .601 |
| Malnutrition | 1.46 (0.17, 12.84) | .715 | 6.55 (0.79, 54.16) | .080 |
| Inflammatory bowel disease | 2.30 (0.69, 8.01) | .177 | 1.86 (0.61, 5.61) | .266 |
| HTN | 0.51 (0.17, 1.46) | .208 | 0.64 (0.26, 1.61) | .338 |
| HLD | 1.31 (0.48, 3.63) | .597 | 0.93 (0.39, 2.26) | .878 |
| DM | 1.48 (0.51, 4.30) | .470 | 1.08 (0.39, 2.60) | .987 |
| Rheumatoid arthritis | 4.70 (0.56, 98.12) | .192 | 3.16 (0.54, 18.61) | .197 |
| Other comorbidities | 2.70 (0.60, 14.28) | .204 | 0.88 (0.37, 2.14) | .780 |
| Number of comorbidities | 1.48 (1.06, 2.17) | .029 | 1.10 (0.89, 1.35) | .360 |
| Number of medications | 1.38 (0.97, 2.02) | .081 | 1.39 (1.04, 1.85) | .026 |
BMI, Body mass index; DM, diabetes mellitus; HLD, hyperlipidemia; HTN, hypertension; PCOS, polycystic ovarian syndrome.
While prior studies have shown as association between metabolic syndrome and sexual dysfunction and HS, our study adds to the literature by characterizing the association of these comorbidities with disease recurrence in individuals with severe disease who have undergone wide-surgical excision.4,5 In addition, the association between HS and sexual dysfunction sheds light on the multifaceted nature of this debilitating condition and the impact on patients’ overall well-being and suggests that comorbid sexual dysfunction may exacerbate the underlying inflammatory process involved in HS pathogenesis leading to a higher likelihood disease recurrence.
It is critical to emphasize that while our findings highlight the challenges posed by comorbidities in HS, our data advocate for multidisciplinary preoperative assessment and management to optimize outcomes for patients with severe HS. We suggest patients with comorbid metabolic syndrome undergo medical optimization prior to surgery. We also suggest that disorder of sexual dysfunction be screened for during dermatologic and preoperative visits to further optimize patients prior to surgery to provide holistic care for HS patients.
In conclusion, metabolic syndrome and sexual dysfunction disorders were found to negatively impact postoperative healing in HS. An awareness of at-risk comorbidities and interprofessional management of these patients are essential for physicians caring for Hurley Stage III HS patients.
Conflicts of interest
None disclosed.
Footnotes
Funding sources: None.
This data have no other prior presentations.
Patient consent: Not applicable.
IRB approval status: Reviewed and approved by Tulane IRB; approval #2023-1277.
References
- 1.Taylor E.M., Hamaguchi R., Kramer K.M., Kimball A.B., Orgill D.P. Plastic surgical management of hidradenitis suppurativa. Plast Reconstr Surg. 2021;147(3):479–491. doi: 10.1097/prs.0000000000007677. [DOI] [PubMed] [Google Scholar]
- 2.Garg A., Malviya N., Strunk A., et al. Comorbidity screening in hidradenitis suppurativa: evidence-based recommendations from the US and Canadian hidradenitis suppurativa foundations. J Am Acad Dermatol. 2022;86(5):1092–1101. doi: 10.1016/j.jaad.2021.01.059. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Krueger J.G., Frew J., Jemec G.B.E., et al. Hidradenitis suppurativa: new insights to disease mechanisms and an evolving treatment landscape. Br J Dermatol. 2024;190(2):149–162. doi: 10.1093/bjd/ljad345. [DOI] [PubMed] [Google Scholar]
- 4.Cuenca-Barrales C., Molina-Leyva A. Risk factors of sexual dysfunction in patients with hidradenitis suppurativa: a cross-sectional study. Dermatology. 2020;236(1):37–45. doi: 10.1159/000501905. [DOI] [PubMed] [Google Scholar]
- 5.Seetan K., Al-Zubi M., Al-Omari R. Sexual dysfunction in patients with hidradenitis suppurativa: a systematic review and meta-analysis. J Clin Aesthet Dermatol. 2021;14(8):61–65. [PMC free article] [PubMed] [Google Scholar]