What is known about this subject in regard to women and their families?
Women are disproportionately affected by hidradenitis suppurativa (HS) and depression in the United States.
Patients with HS have a higher risk of depression.
What is new from this article as messages for women and their families?
The Patient Health Questionnaire-2 (PHQ-2) may be a quick, feasible, and useful method to screen for depression as part of routine dermatology clinic visits.
Dear Editor,
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder that disproportionately affects women in the United States.1 Patients with HS have demonstrated higher odds of having depression (1.3–4.8 times) compared with patients without HS.2 The Patient Health Questionnaire-2 (PHQ-2) is a two-question validated depression screening tool that is recommended in the North American HS comorbidity screening guidelines.2 The PHQ-2 has also been studied in other dermatologic conditions, such as psoriasis3 and atopic dermatitis.4 However, there is a paucity of studies evaluating its use in dermatology clinics for screening patients with HS.
A retrospective chart review was conducted of HS patients seen at the University of Southern California dermatology clinic from January 1, 2024 to June 30, 2024 (IRB # UP-24-00320). Patients with an established HS diagnosis who completed a PHQ-2 within the study window were included. Demographic data and HS disease characteristics were extracted. Differences in characteristics between the positive PHQ-2 cohort (score ≥ 3) versus the negative PHQ-2 cohort (score < 3) were determined using Fisher exact test for categorical variables and the unpaired t test for continuous variables.
A total of 156 patients met the inclusion criteria (Table 1). Of these, the majority (78.8%, 123/156) were female. Over a quarter (26.3%, 41/156) of patients had a positive PHQ-2 score, and of those, the majority (53.7%, 22/41) did not have a pre-existing depression diagnosis. Patients with a positive PHQ-2 score had statistically significant increased quality of life impact (Dermatology Life Quality Index; 17.8 vs 8.3, P < .0001), HS disease activity (Hidradenitis Suppurativa Physician Global Assessment, P = .037), and symptom burden (including pain [P < .0001], itch [P = .004], and drainage [P < .0001] scores) compared with patients with negative PHQ-2 scores (Table 2). There was no significant sex difference between the PHQ-2 positive and negative groups.
Table 1.
Demographics, disease characteristics, and outcome measures
| Demographics (N = 156a) | No. (%) |
|---|---|
| Age at time of collection (mean ± SD, range) | 37.5 ± 14.6, 14–77 |
| Age at symptom onset (mean ± SD, range) | 22.4 ± 12.4, 1–74 |
| Age at HS diagnosis (mean ± SD, range) | 30.8 ± 14.6, 10–74 |
| Sex | |
| Female male | 123 (78.8) 33 (21.2) |
| Race (n = 152) | |
| White | 57 (37.5) |
| Black | 32 (21.1) |
| Asian | 10 (6.6) |
| Multiracial | 3 (2.0) |
| Other | 50 (32.9) |
| Ethnicity (n = 144) | |
| Non-Hispanic Hispanic | 100 (69.4) 44 (30.6) |
| Smoking status (n = 155) | |
| Never Former Current | 117 (75.5) 30 (19.4) 8 (5.2) |
| Family history of HS (n = 131) | 33 (25.2) |
| BMI classification (n = 152) | |
| Obese (30+) | 84 (55.3) |
| Overweight (25 – <30) | 37 (24.3) |
| Normal weight (18.5 – <25) | 29 (19.1) |
| Underweight (<18.5) | 2 (1.3) |
| Hurley stage (n = 155) | |
| I / II / III | 20 (12.9) 84 (54.2) 51 (32.9) |
| Pain score (mean ± SD, range) | 3.3 ± 3.1, 0–10 |
| Itch score (mean ± SD, range) | 2.9 ± 3.1, 0–10 |
| Drainage (n = 155) | |
| None Mild Moderate Severe | 69 (44.5) 52 (33.5) 26 (16.8) 8 (5.2) |
| DLQI (mean ± SD, range) (n=152) | 10.8 ± 7.8, 0–30 |
BMI, body mass index; DLQI, Dermatology Life Quality Index; HS, hidradenitis suppurativa; SD, standard deviation.
Unless otherwise specified.
Table 2.
Characteristics of patients with positive versus negative Patient Health Questionnaire (PHQ)-2a scores
| PHQ-2 score ≥3 (N = 41b) n (%) |
PHQ-2 score <3 (N = 115b) n (%) |
P valuec | |
|---|---|---|---|
| Age at time of collection (mean ± SD, range) | 37.8 ± 15.1, 18–76 | 37.4 ± 14.5, 14–77 | .881 |
| Sex | >.999 | ||
| Male female | 9 (22.0) 32 (78.0) | 24 (20.9) 91 (79.1) | |
| Race | .171 | ||
| White | 9/38 (23.7) | 48/114 (42.1) | |
| Black | 12/38 (31.6) | 20/114 (17.5) | |
| Asian | 2/38 (5.3) | 8/114 (7.0) | |
| Multiracial | 1/38 (2.6) | 2/114 (1.8) | |
| Other | 14/38 (36.8) | 36/114 (31.6) | |
| Ethnicity | >.999 | ||
| Hispanic Non-Hispanic | 12/39 (30.8) 27/39 (69.2) | 32/105 (30.5) 73/105 (69.5) | |
| Smoking status | .833 | ||
| Never Current or Former | 32 (78.0) 9 (22.0) | 85/114 (74.6) 29/114 (25.4) | |
| Family history of HS | 12/32 (37.5) | 21/99 (21.2) | .099 |
| BMI classification | .078 | ||
| Underweight (<18.5) | 1/40 (2.5) | 1/112 (0.9) | |
| Normal weight (18.5–<25) | 4/40 (10.0) | 25/112 (22.3) | |
| Overweight (25–<30) | 7/40 (17.5) | 30/112 (26.8) | |
| Obese (30+) | 28/40 (70.0) | 56/112 (50.0) | |
| Anatomical regions involved | |||
| Face, Ears, and/or Neck | 6 (14.6) | 14 (12.2) | .786 |
| Chest/Inframammary | 9 (22.0) | 29 (25.2) | .833 |
| Axillae | 28 (68.3) | 62 (53.9) | .141 |
| Abdomen | 8 (19.5) | 11/113 (9.7) | .162 |
| Back | 2 (4.9) | 6/114 (5.3) | >.999 |
| Groin and/or Buttocks | 34 (82.9) | 90/112 (80.4) | .819 |
| Legs | 15/40 (37.5) | 40/112 (35.7) | .850 |
| Presence of sinus tracts/tunnels | 20/40 (50.0) | 49/113 (43.4) | .580 |
| Pain score (mean ± SD, range) | 5.1 ± 3.0, 0–10 | 2.7 ± 2.8, 0–10 | <.0001 |
| Itch score (mean ± SD, range) | 4.1 ± 3.5, 0–10 | 2.5 ± 2.8, 0–10 | .004 |
| Drainage | <.0001 | ||
| Any drainage No drainage | 34 (82.9) 7 (17.1) | 52/114 (45.6) 62/114 (54.4) | |
| Hurley stage | .612d | ||
| I | 5 (12.2) | 15/114 (13.2) | |
| II | 21 (51.2) | 63/114 (55.3) | |
| III | 15 (36.6) | 36/114 (31.6) | |
| HS-PGA | .037 | ||
| Clear (0) | 2/38 (5.3) | 21/108 (19.4) | |
| Minimal (1) | 3/38 (7.9) | 9/108 (8.3) | |
| Mild (2) | 17/38 (44.7) | 44/108 (40.7) | |
| Moderate (3) | 6/38 (15.8) | 25/108 (23.1) | |
| Severe (4) | 8/38 (21.1) | 7/108 (6.5) | |
| Very severe (5) | 2/38 (5.3) | 2/108 (1.9) | |
| DLQI (mean ± SD, range) | 17.8 ± 6.8, 2–30 | 8.3 ± 6.5, 0–28 | <.0001 |
| Returning patient at clinic | 18 (43.9) | 64 (55.7) | .208 |
| New patient at clinic | 23 (56.1) | 51 (44.3) | .208 |
| Biologic use at time of PHQ-2 visit | 11 (26.8) | 41 (35.7) | .340 |
BMI, body mass index; DLQI, Dermatology Life Quality Index; HS, hidradenitis suppurativa; HS-PGA, Hidradenitis Suppurativa Physician’s Global Assessment; PHQ-2, Patient Health Questionnaire-2; SD, standard deviation.
The PHQ-2 consists of two questions to assess for the frequency of depressed mood and anhedonia over the past 2 weeks: (1) little interest or pleasure in doing things and (2) feeling down, depressed, or hopeless. Each question is scored on a scale from 0 to 3, and a total score of 3 or higher is considered positive (range, 0–6).
Unless otherwise specified.
Fisher exact test was used for comparisons of categorical variables, and unpaired t tests were used for continuous variables, unless otherwise specified.
Cochran-Armitage Test for Trend utilized.
Our study found that over a quarter of patients with HS seen in our dermatology clinics had a positive PHQ-2 score, aligning with the estimated prevalence of depression in patients with HS of up to 26%.2 Our findings support the HS comorbidity screening guidelines2 recommending depression screening in all patients with HS, regardless of Hurley stage. A prior study that administered the PHQ-9 survey to HS patients found that 33% met criteria for major depression, and no significant relationship was found between PHQ-9 score and patient-reported disease severity.5 HS symptom burden, quality of life impact, and disease activity appeared significantly higher for patients with a positive PHQ-2 score. Future studies are needed to further explore the relationship between depression and HS disease activity, including whether greater disease control can improve mental health outcomes. In clinical practice, if a patient screens positive on the PHQ-2, dermatologists can evaluate for suicidal ideation, provide mental health resources, and facilitate referral to a primary care provider or mental health professional for comprehensive assessment, diagnosis, and management. Limitations of our study include its retrospective, single-center design, small sample size, and predominance of patients with moderate to severe disease, which may impact generalizability.
Our study supports administering the PHQ-2 to all HS patients and suggests that patients with more severe HS disease activity may be at higher risk of a positive PHQ-2 score. This brief two-item questionnaire can be used to identify at-risk patients who may not have been diagnosed with depression or patients with existing depression who may need additional intervention.
Conflicts of interest
The authors made the following disclosures: V.Y.S. is on the board of directors for the Hidradenitis Suppurativa (HS) Foundation, an advisor for the National Eczema Association, a stock shareholder of Learn Health, and has served as an advisory board member, investigator, speaker, and/or received research funding from Sanofi Genzyme, Regeneron, AbbVie, Genentech, Eli Lilly, Novartis, SUN Pharma, LEO Pharma, Pfizer, Incyte, Dermavant, Boehringer Ingelheim, Almirall, Alumis, Aristea Therapeutics, Menlo Therapeutics, Dermira, Burt’s Bees, Galderma, Kiniksa, UCB, Ceraclere, Bain Capital, Target-PharmaSolutions, Castle Bioscience, Altus Lab/cQuell, MYOR, Polyfins Technology, GpSkin, and Skin Actives Scientific. J.L.H. is on the board of directors for the HS Foundation and has served as an advisor, investigator, and/or speaker for AbbVie, Aclaris, AstraZeneca, Boehringer Ingelheim, Galderma, Incyte, Novartis, Pfizer, Regeneron, Sanofi, and UCB. K.H.L. has served as an investigator for Novartis. The other authors report no conflict of interest.
Funding
None.
Study approval
The author(s) confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies.
Author contributions
RG: Participated in data collection and analysis, writing, reviewing, and editing manuscript for this project. CM: Participated in data collection and reviewing and editing manuscript. AJ: Participated in data analysis and reviewing and editing manuscript. SEP: Participated in reviewing and editing manuscript. VYS: Participated in reviewing and editing this manuscript and the conceptualization and administration of this project. JLH and KHL: Participated in data analysis, writing, reviewing, and editing this manuscript, and the conceptualization and administration of this project.
Footnotes
Published online 20 August 2025
References
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