Comorbidities in Hidradenitis Suppurativa

8 Conditions to Look Out for if You Have Hidradenitis SuppurativaQuick Summary

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by deep, painful lumps under the skin. HS often occurs in areas of the body with skin-to-skin contact, such as the underarms, the groin, under the breasts, and between the buttocks. These skin lesions can be extremely painful and sometimes itchy. Lesions in HS often open at the surface and leak pus that can have a foul smell, leaving patients feeling embarrassed and self-conscious.

HS can be extremely difficult to treat and can have a powerful negative impact on the quality of life of affected individuals. Aside from the skin manifestations of this disease, HS is known to be associated with many other medical problems, also known as comorbidities, that can contribute to the already immense burden for patients.

Individuals with HS are at an increased risk of having metabolic syndrome, a cluster of conditions that increase the risk of heart disease, stroke, and diabetes. It has been found that HS is associated with high cholesterol levels, high blood pressure, high blood sugar, and obesity.^[1] It is estimated that up to 50.6% patients with HS also have metabolic syndrome.^[2]

Abnormal Cholesterol and Fat Levels

HS is associated with dyslipidemia, a term used to describe abnormal levels of cholesterol and fats in the blood. Individuals with HS are at an increased risk of having high levels of triglycerides, a type of fat in our blood.^[3] High levels of low density lipoprotein (LDL), also known as the “bad cholesterol,” can also be seen in these patients.^[3] Additionally, these individuals may have lower levels high density lipoprotein (HDL), known as the “good cholesterol,” since it can protect against heart disease.^[3]

Collectively, these findings of dyslipidemia can increase the risk of disease in the heart and blood vessels, which can predispose HS patients to having a heart attack or a stroke.

High Blood Pressure

An association between HS and high blood pressure has also been found in many studies. Both the systolic blood pressure (the top number in a blood pressure reading) and the diastolic blood pressure (the bottom number in a blood pressure reading) have been shown to be elevated in patients with HS.^[1] A normal blood pressure reading is generally regarded to be at or under 120/80.  

Recent guidelines now recommend that blood pressure levels above 130/80 be considered high blood pressure.^[4] This definition of blood pressure places many more Americans in the high blood pressure category and the risk of being in this category is even higher in patients with HS. Higher than normal levels of both systolic blood pressure and diastolic blood pressure are known to increase the risk of heart disease.

Obesity

Rates of obesity in individuals with HS may range from 12% to 88%.^[5] Some studies have shown that increasing severity of HS is associated with increasing body mass index (BMI), a measure of body fat in adults.^[6] 

Rubbing of the skin folds in obese patients may contribute to development of HS.^[5] Additionally, increased levels of inflammation in obesity, as well as the imbalance of hormones found in obese patients may also contribute to HS development.^[7] Interestingly, non-obese patients with HS seem to have more time periods where they are disease-free than obese patients with HS.^[5]

Glucose Intolerance

Glucose intolerance refers to a condition that results in higher than normal blood sugar levels. Glucose intolerance may predispose individuals to developing diabetes or heart disease in the future. In one study, patients with HS were twice as likely to have glucose intolerance than healthy individuals.^[2] 

Individuals with HS are at an increased risk of having high blood sugar levels while fasting.^[1] Fasting blood sugar levels between 100 and 125 mg/dL are considered abnormal and classified as impaired glucose tolerance. Fasting blood sugar levels above 126 mg/dL are seen in diabetes.

Diabetes Mellitus

The risk of having Type 2 Diabetes Mellitus has been shown to be 3 times greater in individuals with HS than in the general population.^[8] A large study estimated that about 10.6% of patients with HS will also have diabetes mellitus.^[8] It is thought that the higher rates of obesity and metabolic syndrome seen in HS contribute to the higher rates of diabetes seen in these individuals. Because of this high risk, it is recommended that patients with HS be screened early and aggressively managed if found to have diabetes.

Depression and Anxiety

HS has been associated with depression and anxiety in several studies.^[9,10] The embarrassment of the appearance of the skin lesions along with their odor can lead to symptoms of depression and anxiety in individuals with HS. Constantly feeling self-conscious can lead individuals suffering from HS to avoid others and become isolated due to their low self-esteem and fear of rejection.^[11]

Additionally, patients with HS may miss days from work due to fear of stigmatization, embarrassment from the smell, and fear of the leaked fluids seeping through their clothes.^[9] Avoiding the workplace may further contribute to the isolation experienced by these individuals and contribute to the symptoms of depression and anxiety.

It has been suggested that certain inflammatory chemicals (tumor necrosis factor alpha, interleukin-1, and interleukin-10) that become elevated in the skin and brain of HS patients can also contribute to the depression and anxiety seen in these individuals.^[9] Therefore, several different factors can be responsible for the symptoms of anxiety and depression seen in HS. 

Suicide Risk

Individuals with HS are at a significantly increased risk of having suicidal thoughts and completing suicide when compared to the general population.^[12] This is an especially alarming finding that should be screened for in these individuals. It is very important for people with HS to seek care for their depression and anxiety to prevent it from escalating to suicide.

Intimacy

Issues with intimacy are also commonly experienced by individuals living with HS. One study found that patients with HS, especially females, had high levels of sexual distress and sexual dysfunction, which greatly impacted their quality of life.^[13] Issues with intimacy are likely due to pain and discomfort in the groin area as well as the embarrassment from the appearance and smell of the lesions. Problems with sexual function may further contribute to the symptoms of anxiety and depression seen in individuals with HS.

Other Conditions Associated with Hidradenitis Suppurativa

As HS is an inflammatory disease, it may also be associated with certain autoimmune diseases. HS has been shown to have an association with inflammatory bowel disease and arthritis.^[5] Some studies have also described a possible association between HS and non-melanoma skin cancer.^[14] It is unclear whether it is HS itself that is associated with the development of skin cancer or if the relationship is the result of the increased inflammation seen in HS.  

What To Do If You Have Hidradenitis Suppurativa

Due to the high risk of heart disease and mortality associated with metabolic syndrome and diabetes, it is extremely important that patients with HS have early screenings for these conditions. If any of these diseases are identified in individuals with HS, it is important that they receive proper and aggressive treatment to avoid further complications. Lifestyle modifications in the way of a healthy diet, exercise, smoking cessation, and reduced alcohol intake should always be the first step in the prevention and management of conditions such as metabolic syndrome, obesity, and diabetes. 

Conclusion

Hidradenitis suppurativa is a chronic inflammatory skin condition characterized by painful lumps in areas of skin-to-skin contact, such as the underarms, groin, between the buttocks, and under the breasts. It may be associated with various dangerous comorbidities, such as metabolic syndrome, obesity, diabetes, depression, and suicidality. It is crucial that these patients be screened for all of these conditions and receive appropriate treatment, if necessary, to avoid any further complications.