Depression and anxiety are common across all disease severity levels, underscoring need for routine screening, say researchers.
Patients with hidradenitis suppurativa face a significantly higher risk of developing depression and anxiety compared with the general population, regardless of how severe their disease is, according to a large Danish cohort study.
Researchers analysed data from 10,206 patients with HS and 40,125 matched controls between 1997 and 2022.
They found a 69% higher risk of new-onset depression and a 48% higher risk of new-onset anxiety among HS patients.
However, markers of disease severity – including treatments received (topicals, systemic agents, or biologics) and hospitalisations for HS-related surgical procedures – did not independently affect these risks.
Full results from the study were published in JAMA Dermatology.
“These findings suggest that patients with HS had an elevated risk of new-onset depression and anxiety,” the researchers wrote.
“Using treatment- and HS-related surgical procedures as severity markers, no consistent differences in mental health risk across severity levels were observed, emphasising the need for psychiatric assessment and intervention across all patients with HS regardless of disease severity.”
Australian HS expert Associate Professor Erin McMeniman welcomed the findings.
The Queensland-based specialist dermatologist practises at Central Brisbane Dermatology and the Princess Alexandra Hospital where she conducts medical clinics and is involved with multi-disciplinary teams treating HS and cutaneous lymphoma.
She told Rheumatology Republic the link between HS and anxiety and depression was well-established, but it was good to see the research quantifying it and confirming it – particularly when it comes to disease severity.
“I’d say particularly, we found that with respect to sexual distress and dysfunction caused by the disease, it was also not correlated to severity,” she said.
“Even small areas, or even only having two or three painful draining nodules or tracks in the groin area, for example, can make an enormous impact on a young person’s sexual confidence and ability to engage in sexual relationships.
“I absolutely agree with the importance of awareness of the diagnosis, and that GPs and emergency doctors and dermatologists are aware and diagnose it early so that person can get treatment.
“I’ve had young women in their late 20s who’ve never been in a sexual relationship, because they’re terrified that someone will see their groin area.”
The prevalence of HS is estimated to be about 1-2% and is predominant among female patients. Disease onset is usually in late adolescence, but patients affected by the disease have an average diagnostic delay of approximately seven years, causing severe psychological stress and unmet needs, the researchers wrote.
HS has been associated with numerous somatic comorbidities, including cardiovascular disease, inflammatory bowel disease (IBD), metabolic syndrome, polycystic ovarian syndrome and spondylarthritis.
The substantial comorbid burden within the HS population has been attributed to several factors, including a high prevalence of obesity, smoking, genetic and environmental factors, and aspects associated with systemic inflammation.
“Apart from somatic comorbidities, patients with HS have also been shown to have an increased prevalence of mental disorders, particularly depression and anxiety, compared with the background population,” the researchers wrote.
“A particularly high risk of mental disorders has been identified among female patients and among patients with alcohol use disorders and a history of tobacco smoking. Several reasons for an increased risk of psychiatric disorders have been suggested, including impaired body image and sexual dysfunction.
“Additionally, studies have shown a higher prevalence of drug use disorder and unemployment among patients with HS, which are factors that may further elevate the risk of mental disorders.”
Previous national cohort studies of patients with HS have presented estimates of the overall risk of depression and anxiety in the US population, but the researchers said that, to their knowledge, no studies from a European population currently existed.
Overall, the risk of depression and anxiety did not differ notably between treatment or surgery groups.
This could be for several reasons, one being that these variables are proxies for disease severity and not actual clinical measurements, which could either overestimate or underestimate actual severity, the authors wrote.
Another could be that disease severity was not the driving factor for risk of depression and anxiety among patients with HS and that the increased risk in this group of patients was associated with other factors, such as increased mental burden, pain, occurrence of flares, or body image impairment.
“Nevertheless, these findings emphasise the fact that clinicians should be aware of mental health disorders across all severity groups of patients with HS and not solely those with severe disease,” the authors wrote.
Patients treated with biologics had a risk of depression, which was not significantly different from controls, despite being considered the group with the most severe disease and a high prevalence of smoking and alcohol and drug use disorders.
However, small sample sizes in this group introduced substantial uncertainties, and the actual risk might be identical to the other treatment groups, the authors said.
A similar pattern of low risk among patients treated with biologics has been observed among patients with psoriasis, for whom biologic therapy was associated with a lower risk of depression compared with conventional therapies.
“A reason for the attenuated risk could be that patients treated with biologics within the Danish health care system are regularly monitored at dermatologic outpatient clinics, allowing for early detection and management of mental health conditions,” the researchers wrote.
“Additionally, the lower risk of depression among patients treated with biologics may be associated with the role of inflammatory cytokines in mental disorders.”
Professor McMeniman said awareness of HS and the treatments available had improved dramatically in recent years, but there was still a lot of shame and humiliation attached to the disease.
“When they have presented early for medical help, they often are embarrassed even to show their family and friends, which is a particularly sad for me; they don’t want to show their parents, they feel embarrassed about the look of it, as opposed to diseases like external psoriasis, where at least often they’ll show friends and family the areas of skin,” she told RR.
“So it feels particularly isolating when people don’t even want their mother in the room because they think it’s disgusting, it smells. We try to do a lot of work in explaining it’s an immune disease. It’s not your fault. It’s nothing for you to be ashamed of. You have a severe immune inflammatory disease.”
Professor McMeniman said the tide was definitely turning in the right direction however, and interestingly the internet had proved a positive influence.
“I’ve heard of people even seeing it on TikTok and platforms like that, and they’ll realise that’s what they have, and then find a support group of peers that they can ask questions of,” she said.
“A lot of patients tell me anecdotes that they read about or learnt about in their online support groups.”
She said GPs were playing an important role in ensuring patients were being diagnosed earlier – which made a huge difference to outcomes.
“I have been thrilled,” Professor McMeniman said.
“Especially in the last year, I’ve had a number of teenage patients referred to me within 12 months of symptoms. That’s awesome, I am so excited when that happens.
“Then we can discuss with them all the preventative lifestyle measures. We can say to them, don’t ever start smoking, which is much easier than trying to quit if you’ve been smoking for 10 years.
“They’ll come in with only two or three lesions, say age 14 or 15, and it’s a really great place to also not have all those shame mantras instilled in their psyche about their disease.
“You can really educate the family and the patient: you have an immune disease. Whereas we know the heartbreaking stories of people who are now in their 40s and 50s, who at that time in life were told: wash more, you’re infectious, it’s germs – which, of course, made them feel awful.”
