Hidradenitis Suppurativa in Older Adults

Abstract

This cohort study describes the clinical characteristics of patients aged 65 years or older with hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic inflammatory condition presenting as recurrent painful nodules, abscesses, and tunnels primarily in intertriginous cutaneous zones. Certain subgroups of patients, such as those living with HIV¹ and pediatric patients, have been characterized,² but reports on HS in adults 65 years or older are lacking. We describe the clinical presentation, disease severity, associated comorbidities, and management of HS in older adults.

Methods

This cohort study used a registry of prospectively collected data from patients with HS in a specialty clinic. Following University of North Carolina institutional review board approval, data were obtained for 26 adults 65 years or older and 1122 adults younger than 65 years at enrollment. All patients provided written informed consent. Retrospective electronic medical record review was completed to elicit additional data from those 65 years or older. The study followed the STROBE reporting guidelines.

The statistical analyses are described in the eMethods in Supplement 1 and were performed using Stata, version 14 (StataCorp LLC). Two-tailed P < .05 was considered significant.

Results

Age at disease onset was significantly higher in older adults vs those younger than 65 years (mean [SD], 41.8 [18.9] vs 20.1 [9.4] years; P < .001), as was age at HS diagnosis (mean [SD], 58.6 [12.8] vs 27.7 [11.5] years; P < .001). Older adults were more likely to be current (11 [42%] vs 215 [19%]) or former (8 [31%] vs 221 [20%]; P = .001) smokers and male (10 [39%] vs 236 [21%]; P = .03) (Table 1).

Table 1. Demographic Characteristics of Patients With Hidradenitis Suppurativa by Age Group.

Characteristic	No. (%)		P valuea
	<65 y (n = 1122)	≥65 y (n = 26)
Sex
Female	886 (79)	16 (62)	.03
Male	236 (21)	10 (39)
Age, mean (SD), y
At enrollment	34.7 (12.7)	69.7 (4.9)	<.001
At disease onset	20.1 (9.4)	41.8 (18.9)	<.001
No. of patients	1109	26	NA
At diagnosis	27.7 (11.5)	58.6 (12.8)	<.001
No. of patients	1094	25	NA
Delay in diagnosis, mean (SD), y	7.7 (8.9)	16.3 (19.2)	.03
No. of patients	1092	25	NA
Symptom duration, mean (SD), y	14.6 (10.8)	27.9 (19.6)	.002
No. of patients	1110	25	NA
BMI
No. of patients	1111	26	NA
Mean (SD)	34.5 (8.8)	31.4 (7.6)	.05
≥30	734 (66)	14 (54)	.19
Race and ethnicityb
Black or African American	581 (52)	14 (54)	.80
White	454 (41)	12 (46)
American Indian or Alaska Native	9 (<1)	0	NR
Asian (includes Indian)	16 (1)	0
Hispanic	34 (3)	0
Native Hawaiian or Pacific Islander	0	0
Mixed	22 (2)	0
Otherc	6 (<1)	0
Smoking status
No. of patients	1117	26	NA
Never	681 (61)	7 (27)	.001
Current	215 (19)	11 (42)
Former	221 (20)	8 (31)

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); NA, not applicable; NR, not reported.

^a P values calculated from χ² test or z score for categorical variables and t test for continuous variables.

^b Race and ethnicity were self-reported by the patient at enrollment. The P value is reported only for patients of Black vs White race.

^c The Other race and ethnicity category included Algerian, Egyptian, Middle Eastern, and Portuguese.

No significant phenotypic differences were noticed between groups. Logistic regression revealed that compared with White younger adults, White older adults (odds ratio [OR], 8.7; 95% CI, 2.5-29.8), Black older adults (OR, 3.27; 95% CI, 1.1-9.7), and Black younger adults (OR, 3.6; 95% CI, 2.6-4.8) were more likely to be diagnosed at Hurley stage 3.

Older adults had a high prevalence of comorbidities previously associated with HS (Table 2). The most common medical treatments included systemic antibiotics (23 [88%]) and biologics (20 [77%]). Among older adults, surgical excision and deroofing were used in 12 patients (46%), and 2 deaths (8%), 2 cancer diagnoses (8%), 1 wound infection (4%), and 1 shingles diagnosis (4%) occurred (Table 2).

Table 2. Comorbidities, Adverse Outcomes, and Treatments in 26 Patients Aged 65 Years or Older With Hidradenitis Suppurativa.

Variable	No. (%)
Comorbidity
Hypertension	18 (69)
Dyslipidemia	16 (62)
Type 2 diabetes	14 (54)
Obesity	13 (50)
Allergic rhinitis	7 (27)
Anxiety/depressive disorder	7 (27)
Chronic kidney disease	7 (27)
Congestive heart failure	7 (27)
Gastroesophageal reflux disease	7 (27)
Anemia	6 (23)
Coronary artery disease	5 (19)
Chronic obstructive pulmonary disease	3 (12)
Stroke	3 (12)
Hypothyroidism	2 (8)
Latent tuberculosisa	2 (8)
Rheumatoid arthritis	2 (8)
Asthma	1 (4)
Pyoderma gangrenosum	1 (4)
Adverse outcome
Cancerb	2 (8)
Deathc	2 (8)
Psoriasis, medication-inducedd	2 (8)
Anti-adalimumab antibody developed	1 (4)
Cutaneous MRSA infectione	1 (4)
Delayed surgical wound healinge	1 (4)
Diarrhea, severef	1 (4)
Shingles infectiong	1 (4)
Treatment
Topical	9 (35)
Chlorhexidine, antiseptic wash	6 (23)
Triamcinolone	4 (15)
Clobetasol	3 (12)
Clindamycin	2 (7)
Neosporin	1 (4)
Systemic antibiotics	23 (88)
Clindamycin	12 (46)
Rifampin	10 (38)
Cefdinir	9 (35)
Doxycycline	9 (35)
Metronidazole	4 (15)
Cephalexin	3 (12)
Trimethoprim/sulfamethoxazole	3 (12)
Levofloxacin	2 (8)
Minocycline	2 (8)
Ertapenem	1 (4)
Biologics	20 (77)
Adalimumab	18 (69)
Infliximab	5 (19)
Secukinumab	2 (8)
Golimumab	1 (4)
Unroofing procedure	11 (42)
Single	5 (19)
Multiple	6 (23)
Surgical excision	2 (8)
Other treatment	13 (50)
Intralesional Kenalog	6 (23)
Incision and drainage, punch	4 (15)
Finasteride	4 (15)
Systemic steroids	4 (15)
Apremilast	1 (4)

Abbreviation: MRSA, methicillin-resistant Staphylococcus aureus.

^a Discovered before Humira (AbbVie) initiation.

^b Breast cancer and myelodysplastic syndrome.

^c One as a result of myelodysplastic syndrome and 1 while waiting for liver and kidney transplant.

^d Adalimumab and golimumab.

^e Following hidradenitis suppurativa unroofing procedure, not on immunosuppressive medication.

^f Patient misread medication label and took adalimumab every day for 1 to 2 weeks.

^g Developed and treated before adalimumab or other biologics initiation.

Discussion

Relatively uncommon in older adults, HS has been reported to decrease after menopause.³ Mean age at disease onset in older adults was significantly later than in younger adults. This finding is consistent with a study showing a bimodal distribution of age of HS onset⁴ and suggests that HS onset around the fourth decade may be associated with disease persisting into older adulthood. Reasons for increased rates of Hurley 3 disease may include health care access barriers, natural differences in disease progression in older adults, and lack of clinician awareness leading to delayed diagnosis. Although CIs are wide, Hurley 3 disease was particularly prevalent in older adults, which may reflect extensive tunnels and scars persisting into older age. Higher Hurley 3 rates in Black patients of all ages may reflect underdiagnosis and undertreatment, though these patients could be predisposed to advanced disease for reasons currently unclear.

Limitations include a relatively small cohort evaluated by a single dermatologist specializing in HS at an academic center. Most of the data were prospectively collected, but limited additional follow-up data were retrospective with few missing data points.

Because older adult patients commonly present with Hurley 2/3 disease, aggressive management is often required. Increased infection risk with biologics⁵ and delayed wound healing in older adults are concerning. Low infection rates were observed in this cohort despite prevalent biologics use, with only 1 shingles occurrence and 1 wound infection (patient nonimmunosuppressed). Two cancer diagnoses occurred before initiation of immunomodulatory therapy. One death was secondary to myelodysplastic syndrome, and 1 occurred while awaiting liver and kidney transplant. Together, these findings should reassure clinicians when escalating care for older patients with HS.

Supplement 1.

eMethods

Supplement 2.

Data Sharing Statement