Clinical Review

Depression As a Potential Contributing Factor in Hidradenitis Suppurativa and Associated Racial Gaps

Cutis. 2024 March;113(3):137-140,E1-E2 | doi:10.12788/cutis.0963

The etiology of hidradenitis suppurativa (HS)—a chronic, relapsing, inflammatory disorder—is multifactorial, encompassing lifestyle, microbiota, hormonal status, and genetic and environmental factors. These factors propagate the production of deep-seated inflammatory nodules seen in HS through aberrant immune response activation and inflammation. The high prevalence of depression in individuals with HS and its association with systemic inflammation increases the likelihood that depression also may be a contributing etiology to HS. Because depression frequently has been discovered as a concomitant diagnosis in patients with HS, we hypothesize that there is a common susceptibility to depression in patients with HS, which we investigated through a literature search of articles published from 2000 to 2022 involving depression and HS.

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Practice Points

Hidradenitis suppurativa (HS) is known to be associated with systemic inflammation and comorbidities, including depression.
Depression may be a potential contributing factor to HS in affected patients, and studies on HS with comorbid depression in patients with skin of color are lacking.

References

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Van Der Zee HH, De Ruiter L, Van Den Broecke DG, et al. Elevated levels of tumour necrosis factor (TNF)-α, interleukin (IL)-1β and IL-10 in hidradenitis suppurativa skin: a rationale for targeting TNF-α and IL-1β. Br J Dermatol. 2011;164:1292-1298.
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Soliman YS, Hoffman LK, Guzman AK, et al. African American patients with hidradenitis suppurativa have significant health care disparities: a retrospective study. J Cutan Med Surg. 2019;23:334-336.
Garg A, Malviya N, Strunk A, et al. Comorbidity screening in hidradenitis suppurativa: evidence-based recommendations from the US and Canadian Hidradenitis Suppurativa Foundations. J Am Acad Dermatol. 2022;86:1092-1101.
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Wright S, Strunk A, Garg A. Prevalence of depression among children, adolescents, and adults with hidradenitis suppurativa. J Am Acad Dermatol. 2022;86:55-60.
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Theut Riis P, Pedersen OB, Sigsgaard V, et al. Prevalence of patients with self-reported hidradenitis suppurativa in a cohort of Danish blood donors: a cross-sectional study. Br J Dermatol. 2019;180:774-781.
Senthilnathan A, Kolli SS, Cardwell LA, et al. Depression in hidradenitis suppurativa. Br J Dermatol. 2019;181:1087-1088.
Pavon Blanco A, Turner MA, Petrof G, et al. To what extent do disease severity and illness perceptions explain depression, anxiety and quality of life in hidradenitis suppurativa? Br J Dermatol. 2019;180:338-345.
Butt M, Sisic M, Silva C, et al. The associations of depression and coping methods on health-related quality of life for those with hidradenitis suppurativa. J Am Acad Dermatol. 2019;80:1137-1139.
Calao M, Wilson JL, Spelman L, et al. Hidradenitis suppurativa (HS) prevalence, demographics and management pathways in Australia: a population-based cross-sectional study. PLoS One. 2018;13:e0200683.
Ingram JR, Jenkins-Jones S, Knipe DW, et al. Population-based Clinical Practice Research Datalink study using algorithm modelling to identify the true burden of hidradenitis suppurativa. Br J Dermatol. 2018;178:917-924.
Kimball AB, Sundaram M, Gauthier G, et al. The comorbidity burden of hidradenitis suppurativa in the United States: a claims data analysis. Dermatol Ther (Heidelb). 2018;8:557.
Thorlacius L, Cohen AD, Gislason GH, et al. Increased suicide risk in patients with hidradenitis suppurativa. J Invest Dermatol. 2018;138:52-57.
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Huilaja L, Tiri H, Jokelainen J, et al. Patients with hidradenitis suppurativa have a high psychiatric disease burden: a Finnish nationwide registry study. J Invest Dermatol. 2018;138:46-51.
Kirby JS, Butt M, Esmann S, et al. Association of resilience with depression and health-related quality of life for patients with hidradenitis suppurativa. JAMA Dermatol. 2017;153:1263.
Egeberg A, Gislason GH, Hansen PR. Risk of major adverse cardiovascular events and all-cause mortality in patients with hidradenitis suppurativa. JAMA Dermatol. 2016;152:429-434.
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Hidradenitis suppurativa (HS)—a chronic, relapsing, inflammatory disorder involving terminal hair follicles in apocrine gland–rich skin—manifests as tender inflamed nodules that transform into abscesses, sinus tracts, and scarring.^1,2 The etiology of HS is multifactorial, encompassing lifestyle, microbiota, hormonal status, and genetic and environmental factors. These factors activate the immune system around the terminal hair follicles and lead to hyperkeratosis of the infundibulum of the hair follicles in intertriginous regions. This progresses to follicular occlusion, stasis, and eventual rupture. Bacterial multiplication within the plugged pilosebaceous units further boosts immune activation. Resident and migrated cells of the innate and adaptive immune system then release proinflammatory cytokines such as tumor necrosis factor, IL-1β, and IL-17, which further enhance immune cell influx and inflammation.^3,4 This aberrant immune response propagates the production of deep-seated inflammatory nodules and abscesses.^3-8

The estimated prevalence of HS is 1% worldwide.⁹ It is more prevalent in female and Black patients (0.30%) than White patients (0.09%) and is intermediate in prevalence in the biracial population (0.22%).¹⁰ Hidradenitis suppurativa is thought to be associated with lower socioeconomic status (SES). In a retrospective analysis of HS patients (N=375), approximately one-third of patients were Black, had advanced disease, and had a notably lower SES.¹¹ Furthermore, HS has been reported to be associated with systemic inflammation and comorbidities such as morbid obesity (38.3%) and hypertension (39.6%) as well as other metabolic syndrome–related disorders and depression (48.1%).¹

Hidradenitis suppurativa may contribute to the risk for depression through its substantial impact on health-related quality of life, which culminates in social withdrawal, unemployment, and suicidal thoughts.¹² The high prevalence of depression in individuals with HS¹ and its association with systemic inflammation¹³ increases the likelihood that a common genetic predisposition also may exist between both conditions. Because depression frequently has been discovered as a concomitant diagnosis in patients with HS, we hypothesize that a shared genetic susceptibility also may exist between the 2 disorders. Our study sought to explore data on the co-occurrence of depression with HS, including its demographics and racial data.

Methods

We conducted a PubMed search of articles indexed for MEDLINE as well as Google Scholar using the terms depression and hidradenitis suppurativa to obtain all research articles published from 2000 to 2022. Articles were selected based on relevance to the topic of exploration. English-language articles that directly addressed the epidemiology, etiology, pathophysiology, and co-occurrence of both depression and HS with numerical data were included. Articles were excluded if they did not explore the information of interest on these 2 disorders or did not contain clear statistical data of patients with the 2 concurrent medical conditions.

Results

Twenty-two cross-sectional, prospective, and retrospective studies that fit the search criteria were identified and included in the analysis (eTable).^1,14-34 Sixteen (72.7%) studies were cross-sectional, 5 (22.7%) were retrospective, and only 1 (4.5%) was a prospective study. Only 6 of the studies provided racial data,^{1,14,17,26,28,32} and of them, 4 had predominately White patients,^1,14,26,32 whereas the other 2 had predominantly Black patients.^17,28

Hidradenitis suppurativa was found to coexist with depression in all the studies, with a prevalence of 1.2% to 48.1%. There also was a higher prevalence of depression in HS patients than in the control patients without HS. Furthermore, a recent study by Wright and colleagues¹⁴ stratified the depression prevalence data by age and found a higher prevalence of depression in adults vs children with HS (30% vs 12%).

Comment

Major depression—a chronic and debilitating illness—is the chief cause of disability globally and in the United States alone and has a global lifetime prevalence of 17%.³⁵ In a study of 388 patients diagnosed with depression and 404 community-matched controls who were observed for 10 years, depressed patients had a two-thirds higher likelihood of developing a serious physical illness than controls. The depression-associated elevated risk for serious physical illness persisted after controlling for confounding variables such as alcohol abuse, smoking, and level of physical activity.³⁶ Studies also have demonstrated that HS is more prevalent in Black individuals¹⁰ and in individuals of low SES,³⁷ who are mostly the Black and Hispanic populations that experience the highest burden of racial microaggression³⁸ and disparities in health access and outcomes.^39,40 The severity and chronicity of major depressive disorder also is higher in Black patients compared with White patients (57% vs 39%).⁴¹ Because major depression and HS are most common among Black patients who experience the highest-burden negative financial and health disparities, there may be a shared genetic disposition to both medical conditions.

Depression As a Potential Contributing Factor in Hidradenitis Suppurativa and Associated Racial Gaps

References

Methods

Results

Comment

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