Abbreviations
- BMI
body mass index
- COST‐FACIT
Comprehensive Score for Financial Toxicity—Functional Assessment of Chronic Illness Therapy
- CRP
C‐reactive protein
- DLQI
Dermatology Life Quality Index
- ED
emergency department
- ESR
erythrocyte sedimentation rate
- FT
financial toxicity
- HS
hidradenitis suppurativa
- QOL
quality of life
- SD
standard deviation
Financial toxicity (FT) refers to the adverse impact of medical expenses on patients' quality of life (QOL) [1]. Hidradenitis suppurativa (HS) imposes a significant economic burden on patients due to its chronic nature, costly biological and surgical therapies, and frequent use of high‐cost healthcare settings [2]. Limited data exist on patient‐reported FT and its impact on QOL in HS [3]. Herein, we evaluate whether FT independently predicts QOL in patients with HS and identify demographic and clinical factors associated with FT.
Validated Comprehensive Score for Financial Toxicity–Functional Assessment of Chronic Illness Therapy (COST‐FACIT) and Dermatology Life Quality Index (DLQI) surveys were completed by 114/142 (80%) patients receiving care for HS at an academic specialty clinic within the United States healthcare system between April 2024 and January 2025. The COST‐FACIT is an 11‐item questionnaire scored from 0 to 44, with higher scores reflecting lower financial toxicity; a score ≤ 25 has been used to indicate significant financial toxicity in prior studies. Patients are subject to direct costs associated with specialty clinic visits, biologic therapies, surgical procedures, emergency department care, and inpatient admissions, varying by insurance coverage, prior authorization, and manufacturer assistance eligibility (Table S1, https://data.mendeley.com/datasets/dzh9w7d882/1) [4]. Multivariable linear regression assessed the association between COST‐FACIT and DLQI scores, adjusting for age, sex, race, marital status, and employment status. Stepwise regression identified independent predictors of FT based on demographic and clinical characteristics. Analyses were conducted in R version 4.4.3 (significance p < 0.05).
The cohort was predominantly female, with a mean age of 36.9 years and diverse racial representation (Table 1). Most had Hurley stage II (40.4%) or III (39.5%) HS with ≥ 3 anatomic lesion sites (64.0%), reflecting high disease burden. The mean COST‐FACIT score was 20.3 ± 10.1, indicating mild FT, and the mean DLQI score was 14.4 ± 7.82, indicating severe QOL impairment (DLQI> 10). Psychiatric disease, tobacco use, greater anatomic disease involvement, and biologic use were associated with lower COST scores (all p < 0.05, Tables 1 and 2). In contrast, family history of HS and antibiotic use were associated with higher COST scores (both p < 0.05, Table 2).
TABLE 1.
Mean COST‐FACIT scores across demographic and patient characteristics.
| Characteristic | Number (%) | COST‐FACIT Score (mean ± SD) | p value |
|---|---|---|---|
| Sex | |||
| Male | 31 (27.2%) | 17.9 ± 8.6 | 0.09 |
| Female | 83 (72.8%) | 21.2 ± 10.5 | |
| Age (mean ± SD; Pearson R) | 36.9 ± 14.1 | −0.151 | 0.11 |
| Race | |||
| White | 56 (49.1%) | 19.6 ± 10 | 0.45 |
| Black | 46 (40.4%) | 21.7 ± 10.7 | |
| Other | 12 (10.5%) | 18.3 ± 8.3 | |
| BMI, kg/m2 (mean ± SD; Pearson R) | 35.3 ± 10.1 | −0.091 | 0.35 |
| Marital Status | |||
| Single | 85 (74.6%) | 20.7 ± 10.5 | 0.41 |
| Married | 29 (25.4%) | 19 ± 9 | |
| Employment | |||
| Employed | 29 (25.4%) | 20.6 ± 9.3 | 0.23 |
| Student | 10 (8.8%) | 25.7 ± 11.3 | |
| Unemployed | 52 (45.6%) | 19 ± 10.5 | |
| Comorbidities | |||
| Cardiovascular disease | 33 (28.9%) | 17.8 ± 9.5 | 0.084 |
| Diabetes | 25 (21.9%) | 19.6 ± 10.6 | 0.70 |
| Obesity | 71 (62.3%) | 20.4 ± 10.2 | 0.96 |
| Psychiatric Disease | 75 (65.8%) | 17.6 ± 8.6 | 0.031 |
| Tobacco Use | 52 (45.6%) | 18 ± 8.8 | 0.029 |
Note: Bold represents values that are statistically significant (p < 0.05).
TABLE 2.
Mean COST‐FACIT scores across clinical characteristics of cohort.
| Characteristic | Number (%) | COST‐FACIT Score (mean ± SD) | p value |
|---|---|---|---|
| Family History of HS | 33 (28.9%) | 23.2 ± 9.7 | 0.045 |
| Disease Duration (mean ± SD; Pearson R) | 12.6 ± 10.3 | −0.102 | 0.29 |
| Number of Anatomic HS Locations | |||
| 1 | 9 (7.9%) | 30.4 ± 9.1 | 0.0023 |
| 2 | 32 (28.1%) | 22.5 ± 9 | |
| 3+ | 73 (64.0%) | 18.1 ± 9.8 | |
| Number of Treatments | |||
| ≤ 1 | 15 (13.2%) | 22.7 ± 10.8 | 0.53 |
| 2 | 35 (30.7%) | 19.3 ± 10.5 | |
| 3 | 33 (28.9%) | 18.9 ± 9.4 | |
| 4+ | 33 (28.9%) | 21.7 ± 10.2 | |
| Treatment Type | |||
| Biologics | 70 (61.4%) | 18.3 ± 8.9 | 0.0097 |
| Hormonal | 21 (18.4%) | 20.6 ± 10 | 0.89 |
| Antibiotics | 76 (66.7%) | 21.6 ± 9.9 | 0.045 |
| Steroids | 21 (18.4%) | 20.2 ± 10.3 | 0.96 |
| Topical | 51 (44.7%) | 20.8 ± 10.2 | 0.61 |
| Surgery | 35 (30.7%) | 21.5 ± 11.1 | 0.43 |
| Laser | 10 (8.8%) | 21.8 ± 8.2 | 0.56 |
| History of ED Visits | 29 (25.4%) | 18.4 ± 8.9 | 0.28 |
| History of Inpatient Admissions | 23 (20.2%) | 18.7 ± 9.3 | 0.39 |
| Hurley Stage | 0.25 | ||
| 1 | 22 (19.3%) | 22.7 ± 10.5 | |
| 2 | 46 (40.4%) | 21 ± 11 | |
| 3 | 45 (39.5%) | 18.6 ± 8.9 | |
| Pilonidal Sinus | 49 (43.0%) | 19.9 ± 10 | 0.71 |
| Elevated ESR | 26 (22.8%) | 19.1 ± 9.8 | 0.33 |
| Elevated CRP | 28 (24.6%) | 20 ± 9.9 | 0.31 |
Note: Bold represents values that are statistically significant (p < 0.05).
Higher COST‐FACIT scores were significantly associated with better QOL after adjusting for covariates. Each 1‐point increase in COST‐FACIT corresponded to a 0.448‐point decrease in DLQI score (95% confidence interval [CI]: [−0.573, −0.324]; r = −0.571; p < 0.001). Each additional HS site was independently associated with worse FT (. < 0.05), consistent with previous literature [3]. Psychiatric and cardiovascular comorbidities were also independently associated with worse FT (p = 0.025 and 0.031, respectively). Interestingly, patients with a family history of HS reported lower FT (p = 0.01), possibly due to earlier recognition, shared management and coping strategies. Limitations include the single‐center design, small cohort, reliance on patient‐reported data, and lack of a validated disease severity assessment (Hurley stage and lesion sites were used as surrogates). Our findings are specific to the US academic medical center context and may not generalize to other healthcare systems or community‐based practices. Notably, the association between biologic use and worse FT likely reflects the substantial out‐of‐pocket costs patients bear in the US healthcare system. In universal healthcare settings, where biologic costs are largely absorbed by the system, this relationship could be reversed, as improved disease control may reduce flares, healthcare visits, and overall financial burden.
FT is a robust, independent predictor of QOL in HS. Greater disease involvement and psychiatric and cardiovascular comorbidities may increase financial strain, while a family history of HS may reduce burden through earlier recognition and intervention. Integrating financial counseling and targeted support into multidisciplinary HS care may mitigate FT and improve patient‐centered outcomes.
Funding
The authors have nothing to report.
Ethics Statement
Reviewed and approved by UVA IRB; approval #301205.
Consent
Written patient consent for the participation in surveys and publication of results was obtained by authors and was available at the time of article submission to the journal stating that all patients gave consent with the understanding that this information may be publicly available.
Conflicts of Interest
Dr. Flowers has served as a principal investigator for Abbvie, Acelyrin, AstraZeneca, Clinuvel, Regeneron/Sanofi, and Sun Pharmaceuticals. He has served on advisory boards for Argenx, Bristol‐Myers Squibb, and Janssen. Shan, Lyons, Smith, Winfield, Soon, and Alsaadawi have no conflicts of interest to declare.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
- 1. Pisu M. and Martin M. Y., “Financial Toxicity: A Common Problem Affecting Patient Care and Health,” Nature Reviews. Disease Primers 8, no. 1 Published 2022 Feb 10 (2022): 7, 10.1038/s41572-022-00341-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Kirby J. S., Miller J. J., Adams D. R., and Leslie D., “Health Care Utilization Patterns and Costs for Patients With Hidradenitis Suppurativa,” JAMA Dermatology 150, no. 9 (2014): 937–944, 10.1001/jamadermatol.2014.691. [DOI] [PubMed] [Google Scholar]
- 3. Towfighi P., Huffman S. S., Bovill J. D., et al., “Financial Toxicity of Hidradenitis Suppurativa: A Single‐Center Experience at an Urban Wound‐Care Clinic,” Journal of Dermatology 50, no. 10 (2023): 1279–1286, 10.1111/1346-8138.16868. [DOI] [PubMed] [Google Scholar]
- 4. Rome B. N., Han J., Mooney H., and Kesselheim A. S., “Use and Cost of First‐Line Biologic Medications to Treat Plaque Psoriasis in the US,” JAMA Dermatology 161, no. 6 (2025): 622–628, 10.1001/jamadermatol.2025.0669. PMID: 40238112. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.