Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2023;13(2):e2023076 1 Psychosocial Implications and Quality of Life in Patients with Hidradenitis Suppurativa Compared to Those With Atopic Dermatitis and Psoriasis: a Cross-sectional Case-control Study AlSiyoufi Alya1, AlMohaimeed Saleh1, AlSiyoufi Sawsan1, Salah Louai2 1 Department of Dermatology, Faculty of Medicine, King Abdulaziz University and King Abdulaziz University Hospital, Jeddah, Saudi Arabia 2 Department of Dermatology, Ministry of Health, East Jeddah General Hospital, Jeddah, Saudi Arabia Key words: Hidradenitis suppurativa, chronic inflammatory skin disease, quality of life, Dermatology Life Quality Index, Rosenberg Self-Esteem Scale Citation: AlSiyoufi A, AlMohaimeed S, AlSiyoufi S, Salah L. Psychosocial implications and quality of life in patients with hidradenitis suppurativa compared to those with atopic dermatitis and psoriasis: A cross-sectional case-control study. Dermatol Pract Concept. 2023;13(2):e2023076. DOI: https://doi.org/10.5826/dpc.1302a76 Accepted: October 13, 2022; Published: April 2023 Copyright: ©2023 AlSiyoufi et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Alya M. AlSiyoufi, Faculty of medicine, King Abdulaziz University, Jeddah, Saudi Arabia. Postal address: PO Box 23425, Jeddah 7625, Saudi Arabia. Tel: +966565521452 E-mail: alia.moh1997@gmail.com Introduction: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that has been reported to have the greatest negative impact on quality of life (QoL) and psychosocial factors when compared with other skin conditions. Objectives: To assess psychosocial impact and QoL impairment in patients with HS. Methods: This cross-sectional case-control study included a case group with HS and a control group with psoriasis or atopic dermatitis diagnosed by a dermatologist at a public hospital in Jeddah, Saudi Arabia from 2016 to 2019. Data were obtained from medical records at a ratio of 1:2. Patients were contacted via telephone and asked to complete Arabic-validated questionnaires (Dermatology Life Quality Index [DLQI], Rosenberg Self-Esteem Scale, and Hospital Anxiety and Depression Scale) and a survey containing pictures to identify Hurley stage. Results: The study included 46 patients and 101 controls (eczema, 50; psoriasis, 51). Patients had significantly higher DLQI and depression scores than did controls (P < 0.05). Anxiety and depression scores were significantly higher in women than men (P < 0.05). Cases with Hurley stage 3 had signifi- cantly higher DLQI scores than those with Hurley stages 1 and 2. Controls had a significantly higher percentage of employed participants (P < 0.05). ABSTRACT 2 Original Article | Dermatol Pract Concept. 2023;13(2):e2023076 Introduction Hidradenitis suppurativa (HS) is a chronic inflammatory con- dition that affects apocrine gland-containing skin, primarily in the axillary, inguinal, and anogenital regions. HS is character- ized by recurring nodules, abscesses, sinuses, and scarring [1]. The pathogenesis of HS remains inadequately understood; however, it is possible that genetic and environmental factors play a role. Recently, researchers have proposed that follicu- lar occlusion followed by a follicular rupture, leading to an immune response activation, is significant in HS develop- ment [2]. There may also be an association between HS and other inflammatory diseases, including pemphigus vulgaris [3]. HS can range from a simple recurrent cutaneous infection to severe recurrent attacks of sinus discharge and abscess for- mation [4,5] affecting patients psychological well-being and quality of life (QoL) [1,5-7]. Cigarette smoking and obesity are recognized risk and aggravating factors [8,9]. The estimated prevalence of HS globally is 1%–4% [1]. It typically appears after puberty, primarily in young adults, with a lower prevalence among those aged 55 years or older (1.4% versus 0.5%), with female predominance. Women outnumber men in disease incidence by a factor of 3 [10]. Owing to the clinical nature of the disease, patients with HS tend to have poor self-esteem and QoL, as well as de- pression and anxiety [1]. HS has been reported to have the greatest negative impact on QoL when compared with other skin conditions [11]. Such patients are likely to avoid so- cial interactions and have a higher rate of absenteeism from work than do individuals in the general population [1]. Objectives Despite the abovementioned repercussions of the disease, the negative impact of HS on QoL has not been extensively stud- ied, especially in Saudi Arabia. The aim of this study was to assess the impact of HS on patients and society to establish funding priorities and raise awareness of the disease. Methods This cross-sectional case-control study was conducted at a hospital facility between January 2016 and December 2019. The inclusion criteria were patients with HS (case group) and patients with psoriasis or atopic dermatitis (control group) aged 16 years or older. All cases and controls were diagnosed by dermatologists and presented at the dermatology clinic of our hospital and were extracted from medical records at a ratio of 1:2 to improve study power. Patients with any psy- chiatric disorder were excluded to prevent confounding from psychosocial impairment from various causes other than HS. Interviews with patients were conducted via telephone. Data on demographics (age, sex, nationality, educational level, income, occupation, body mass index, and marital status) were collected. Patients were also asked to complete the following standardized Arabic-validated questionnaires: 1)  the Dermatology Life Quality Index (DLQI), a popular tool that is used exclusively for those with skin conditions and allows comparison between HS and other skin condi- tions [12]; 2) the Rosenberg Self-Esteem Scale (RSES), which measures patients self-esteem [13]; and 3) the Hospital Anxi- ety and Depression Scale (HADS), utilized to measure anxiety and depression levels. The HADS is a 14-item scale that gen- erates ordinal data [14]. Seven items are related to depression (HADS-D) and seven to anxiety (HADS-A). Furthermore, Hurley staging was included by asking patients to choose the picture and the descriptions that matched their Hurley stage. The source of the pictures was the HS online website [15]. Statistical analyses were performed using SPSS version 26 (IBM Corp.). Qualitative data were presented as numbers and percentages, and correlations were determined using chi-squared (χ2) tests. Quantitative data were expressed as means and standard deviations. Data were analyzed using the Mann–Whitney and Kruskal–Wallis tests and indepen- dent samples t-tests. To analyze correlations, Spearman cor- relation coefficient was used, and tests with a P < 0.05 were considered significant. This study was approved by an Institutional Review Board in Saudi Arabia (H-02-J002). All participants pro- vided verbal informed consent during the telephonic inter- views. The participants were assured of confidentiality, and anonymity was strictly maintained. Results This study included 46 cases of HS (out of 75 patients) and 101 controls (out of 150 patients) who consented to and completed the surveys. Of the controls, 50 had eczema and Conclusions: HS had a greater psychosocial impact on QoL than psoriasis or atopic dermatitis and was associated with a lower employment rate. Women were more affected by the disease than men. Therefore, we recommend paying close attention to the psychosocial aspects of the disease and estab- lishing educational programs and support groups for patients with HS. Original Article | Dermatol Pract Concept. 2023;13(2):e2023076 3 Table 1. Difference between cases and controls according to their demographics, body mass index, and age at diagnosis. Variable Cases N (%) Controls N (%) χ2 P Age (years), mean ± SD 32.06 ± 10.3 26.5 ± 6.53 3.27a 0.001 Sex Female 25 (54.3) 49 (48.5) 0.43 0.512 Male 21 (45.7) 52 (51.5) Educational level Illiterate 1 (2.2) 0 (0.0) 8.65 0.194 Primary 1 (2.2) 0 (0.0) Middle school 3 (6.5) 2 (1.98) High school 15 (32.6) 35 (34.65) Diploma 0 (0.0) 5 (4.95) Bachelor 24 (52.2) 54 (53.47) Master 2 (4.3) 5 (4.95) Monthly income (Saudi Riyals) <1000 1 (2.2) 7 (6.9) 5.13 0.399 1000–3000 6 (13) 10 (9.9) 3001–5000 8 (17.4) 16 (15.8) 5001–10000 5 (10.9) 14 (13.9) >10000 8 (17.4) 28 (27.7) No response 18 (39.1) 26 (25.7) Marital status Widowed 0 (0.0) 2 (2) 3.66 0.3 Single 23 (50) 59 (58.4) Married 19 (41.3) 37 (36.6) Divorced 4 (8.7) 3 (3) Employment Employed 14 (30.4) 40 (39.6) 11.2 0.003Unemployed 30 (65.2) 29 (28.7) Student 2 (4.3) 32 (31.7) Nationality Saudi 41 (89.1) 95 (94.1) 1.1 0.292 Non-Saudi 5 (10.9) 6 (5.9) Smoking No 28 (60.9) 66 (65.3) 0.27 0.6 Yes 18 (39.1) 35 (34.7) Body mass index 29.22 ± 7.04 26.65 ± 7.12 2.3* 0.021 Age at diagnosis 28.76 ± 8.79 20.1 ± 8.28 5.75b < 0.001 Disease duration 3.3 ± 4.38 6.39 ± 7.42 2.68 < 0.001 SD = standard deviation. aMann–Whitney test, bIndependent samples t-test 51 had psoriasis. Of the 46 patients with HS, only 6 had another concurrent chronic skin disease. Cases of HS had a higher mean age of diagnosis when compared with controls (28.76 ± 8.79 versus 20.1 ± 8.28 years, P < 0.05), while controls had a higher rate of employment (39.6%) and a longer disease duration (6.39 ± 7.42 years) when compared with cases of HS (3.3 ± 4.38 years, P < 0.05; Table 1). In HS cases (N = 46), topical and oral antibiotics were the most frequently used treatments (78.2% and 73.9%, 4 Original Article | Dermatol Pract Concept. 2023;13(2):e2023076 (15.11) were significantly higher than those of Hurley stage 1 (6.85) and 2 (9.81) (P < 0.05; Table 3). The site of the lesion was not significantly correlated with DLQI, RSES, and HADS scores (p > 0.05). Smoking and body mass index were also not found to significantly affect Hurley stage (P > 0.05). A non-significant positive correlation was found between disease duration and DLQI and HADS scores (P > 0.05), while RSES scores had a non-significant negative correlation (P > 0.05). Regarding controls, higher RSES scores were as- sociated with significantly longer disease duration (r = 0.24, P < 0.014). Furthermore, longer disease duration was asso- ciated with non-significant lower DLQI and HADS scores (P > 0.05). respectively), while biological injections were used the least (28.2%). Armpits were the most commonly affected areas (69%). Regarding patient-reported Hurley staging, 45.7%, 34.8%, and 19.6% of patients had Hurley stages 1, 2, and 3, respectively. Patients with HS had significantly higher mean DLQI and HADS-D scores when compared with controls with ec- zema or psoriasis (P < 0.05). No significant difference was found in HADS-A and RSES scores (P > 0.05; Figure 1 and Table 2). Among cases of HS, HADS-A and HADS-D scores for women were 6.14 and 5.54, respectively, which were signifi- cantly higher than those of men (4.41 and 3.8, respectively, P < 0.05; Figure 2). Similarly, Hurley stage 3 DLQI scores 31.71 DEPRESSIONANXIETYSELF ESTEEMDERMATOLOGY LIFE QUALITY INDEX (DLQI) P-VALUE = 0.017P-VALUE=0.089 P-VALUE = 1.63 P-VALUE = 0.008 32.67 5.97 4.97 9.5 0 5 10 15 20 25 30 35 6.53 5.78 4.17 CONTROLSCASE CONTROLS CASE Figure 1. Difference between cases and controls according to Dermatology Life Quality Index, self-esteem, anxiety, and depression scores. Table 2. Difference between hidradenitis suppurativa cases and controls with eczema and psoriasis according to Dermatology Life Quality Index, Rosenberg Self-Esteem Scale, and Hospital Anxiety and Depression Scale scores. Variable Case Atopic dermatitis Psoriasis P Dermatology Life Quality Index score, mean ± SD 9.5 ± 6.92 5.82 ± 6.03 7.23 ± 6.92 0.017 Self-esteem scale score, mean ± SD 31.71 ± 4.53 33 ± 4.69 32.35 ± 5.82 0.377 Anxiety score, mean ± SD 5.97 ± 3.57 4.9 ± 3.24 5.03 ± 3.78 0.226 Depression score, mean ± SD 5.78 ± 4.14 4.48 ± 4.27 3.88 ± 4.33 0.038 SD = standard deviation. Original Article | Dermatol Pract Concept. 2023;13(2):e2023076 5 more likely to be unemployed than controls. All the above- mentioned features of HS have a significant impact on pa- tients mental health. Cases of HS in our study had higher depression scores than controls, consistent with the findings reported in litera- ture [16]. Self-esteem and anxiety were also affected, as such individuals had lower self-esteem scores and higher anxiety scores compared with the control group, although the differ- ence was not significant. Patients with HS are usually misdiagnosed, as they often initially visit general physicians, surgeons, urologists, and gynecologists before consulting a dermatologist [19], which may lead to delayed diagnosis, as shown in our study, along with avoidance of contact with physicians [20]. In general, depression and anxiety experienced by women with HS were greater than those experienced by their male counterparts; other studies using different scales Conclusions HS is a chronic skin condition characterized by episodes of mild to severe recurrent flares, deteriorating the QoL for patients and impairing their psychological well-being [1,5-7]. Numerous studies have shown that this disease has a significantly greater impact on QoL than other skin conditions such as psoriasis and atopic dermatitis [16]. Our findings support those of previous studies that have proposed that HS impairs QoL, as the disease involves de- bilitating characteristics such as persistent pain, abscess formation, development of disfiguring scars, and smelly discharge [17]. Moreover, these characteristics compel pa- tients to wear covered attire to hide their skin lesions [18]. These insecurities force patients to isolate themselves from the outside world, affecting their work performance [1]; this was also observed in our study, as cases of HS were 31.96 DEPRESSIONANXIETYSELF ESTEEM DERMATOLOGY LIFE QUALITY INDEX (DLQI) P-VALUE = 0.03P-VALUE=0.005 P-VALUE = 0.903 P-VALUE = 0.264 31.42 6.14 4.41 8.36 0 5 10 15 20 25 30 35 10.85 5.54 3.8 FEMALES MALES FEMALES MALES Figure 2. Difference between men and women according to Dermatology Life Quality Index, self-esteem, anxiety, and depression scores. Table 3. Relationship between hidradenitis suppurativa stages and Dermatology Life Quality Index, Rosenberg Self-Esteem Scale, and Hospital Anxiety and Depression Scale scores. Variable Hurley stage 1 Hurley stage 2 Hurley stage 3 P Dermatology Life Quality Index score, mean ± SD 6.85 ± 7.3 9.81 ± 5.03 15.11 ± 5.86 0.006 Self-esteem score, mean ± SD 32.71 ± 4.02 31.43 ± 3.79 29.88 ± 6.54 0.432 Anxiety score, mean ± SD 5.47 ± 3.77 6.25 ± 2.64 6.66 ± 4.66 0.447 Depression score, mean ± SD 5.76 ± 4.87 5.06 ± 3.15 7.11 ± 3.91 0.436 Kruskal–Wallis test was used for comparison. 6 Original Article | Dermatol Pract Concept. 2023;13(2):e2023076 References 1. Kouris A, Platsidaki E, Christodoulou C, et al. Quality of life and psychosocial implications in patients with hidradeni- tis suppurativa. Dermatology. 2019;232(6):687–691. DOI: 10.1159/000453355. PMID: 28052274. 2. Ruggiero A, Martora F, Picone V, Marano L, Fabbrocini G, Mar- asca C. Paradoxical hidradenitis suppurativa during biologic therapy, an emerging challenge: a systematic review. Biomedi- cines. 2022;10(2):455. DOI: 10.3390/biomedicines10020455. PMID: 35203664. PMCID: PMC8962303 3. Martora F, Martora L, Fabbrocini G, Marasca C. A case of pem- phigus vulgaris and hidradenitis suppurativa: may systemic ste- roids be considered in the standard management of hidradenitis suppurativa? Skin Appendage Disord. 2022;8(3):265–268. DOI: 10.1159/000521712. PMID: 35707292. PMCID: PMC9149405 4. Shirah B, Shirah H. The clinical pattern of axillary hidradenitis suppurativa among Saudi Arabians: mode of presentation and treatment challenges. J Cutan Aesthet Surg. 2017;10(2):95–100. DOI: 10.4103/JCAS.JCAS_80_16. PMID: 28852296. PMCID: PMC5561718 5. Ather S, Chan DSY, Leaper DJ, Harding KG. Surgical treatment of hidradenitis suppurativa: case series and review of the liter- ature. Int Wound J. 2006;3(3):188–189. DOI: 10.1111/j.1742- 481X.2006.00235.x. PMID: 16984573. PMCID: PMC7951451 6. Balik E, Eren T, Bulut T, Buyukuncu Y, Bugra D, Yamaner S. Surgi- cal approach to extensive hidradenitis suppurativa in the perineal /perianal and gluteal regions. World J Surg. 2009;33(3):481–487. DOI: 10.1007/s00268-008-9845-9. PMID: 19067039. 7. Jemec GB. Clinical practice. Hidradenitis suppurativa. N Engl J Med. 2012;366(2):158–164. DOI: 10.1056/NEJMcp1014163. PMID: 22236226.6. 8. König A, Lehmann C, Rompel R, Happle R. Cigarette smoking as a triggering factor of hidradenitis suppurativa. Dermatol- ogy. 1999;198(3):261–264. DOI: 10.1159/000018126. PMID: 10393449. 9. Sartorius K, Emtestam L, Jemec G, Lapins J. Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smok- ing and obesity. Br J Dermatol. 2009;161(4):831–839. DOI: 10.1111/j.1365-2133.2009.09198.x. PMID: 19438543. 10. Alhusayen R, Shear NH. Pharmacologic interventions for hidra- denitis suppurativa. Am J Clin Dermatol. 2012;13(5):283–291. DOI: 10.2165/11631880-000000000-00000. PMID: 22676319. 11. Alavi A, Anooshirvani N, Kim WB, Coutts P, Sibbald RG. Quality-of-life impairment in patients with hidradenitis suppura- tiva: a Canadian study. Am J Clin Dermatol. 2015;16(1):61–65. DOI: 10.1007/s40257-014-0105-5. PMID: 25432664. 12. Bin Saif GA, Al-Balbeesi AO, Binshabaib R, et al. Quality of life in family members of vitiligo patients: a questionnaire study in Saudi Arabia. Am J Clin Dermatol. 2013;14(6):489–495. DOI: 10.1007/s40257-013-0037-5. PMID: 23839260. 13. Rice V, Weglicki L, Templin T, Hammad A, Jamil H, Kulwicki A. Predictors of Arab American adolescent tobacco use. Merrill Palmer Q. 2006;52(2):327–342. DOI: 10.1353/mpq.2006.0020. PMID: 16909165. PMCID: PMC1533871 14. Terkawi AS, Tsang S, AlKahtani GJ, et al. Development and validation of Arabic version of the Hospital Anxiety and De- pression Scale.  Saudi J Anaesth. 2017;11(Suppl 1):S11–S18. DOI: 10.4103/sja.SJA_43_17. PMID: 28616000. PMCID: PMC5463562 and measures have reported similar findings, showing that women are more psychologically affected than men. A pos- sible explanation is that women tend to be more emotional, sensitive, and self-aware of their bodies and appearance as compared to men; therefore, severe dermatological disease may lead to anxiety and depression in women [1,21,22]. As with many other studies [1,16,23], our findings in- dicate that the progression of the disease to severe clinical manifestations (widespread boils with connecting tracts along the affected area accompanied by an unpleasant smell- ing secretion, Hurley stage 3) has a greater impact on sat- isfaction and enjoyment of QoL-related activities among patients with HS. Interestingly, throughout our analysis, the site of the lesion did not affect the QoL, anxiety, depression, and self-esteem scores of patients with HS, consistent with two Canadian studies [11,22]. However, while other studies have suggested that anogenital lesions have a significant ef- fect on psychosocial aspects and QoL, a Polish study noted that the occurrence of lesions in visible skin areas plays a major role in stigmatization, which is logical, as other areas can be hidden [16,23]. The limitations of our study were confined to the small sample size and it being a single- center study. Controls rep- resenting patients with other dermatological diseases have both limitations and strengths. Despite the absence of a healthy population in our study, it fairly demonstrates the impact of HS and emphasizes the burden of this disease in comparison with other dermatological diseases. In conclusion, we found that patients with HS experi- enced a greater psychosocial impact on QoL as well as a lower employment rate when compared with patients with psoriasis or atopic dermatitis. The greater the severity of HS, the greater the impact; however, women tended to be more affected by the disease than men. Our recommendation is for dermatologists to pay close attention to the psychosocial aspects of the disease and to refer the patient to a psychiatrist if needed. Furthermore, governments should establish educational programs and support groups for patients with HS owing to the impact of the disease on not only individuals but also the healthcare system and society. Addressing the disease burden will help direct the required funds and attention to the issue. We also recommend that researchers develop HS-specific validated questionnaires for use in future multicenter case-control studies with larger sample sizes to identify the significant im- pacts of the disease. Acknowledgments We thank Editage (www.editage.com) for English language editing. Original Article | Dermatol Pract Concept. 2023;13(2):e2023076 7 20. Saunte DM, Boer J, Stratigos A, et al. Diagnostic delay in hi- dradenitis suppurativa is a global problem. Br J Dermatol. 2015;173(6):1546–1549. DOI: 10.1111/bjd.14038. PMID: 26198191. 21. Abolfotouh MA, Al-Khowailed MS, Suliman WE, et al. Qual- ity of life in patients with skin diseases in central Saudi Arabia. Int J Gen Med. 2012;5:633–642. DOI: 10.2147/IJGM.S33276. PMID: 22866015. PMCID: PMC3410718 22. Alavi A, Farzanfar D, Rogalska T, Lowes MA, Chavoshi S. Qual- ity of life and sexual health in patients with hidradenitis suppura- tiva. Int J Womens Dermatol. 2018;4(2):74-79. DOI: 10.1016/j. ijwd.2017.10.007. PMID: 30023423. PMCID: PMC6047191 23. Janse IC, Deckers IE, van der Maten AD, et al. Sexual health and quality of life are impaired in hidradenitis suppurativa: a multicentre cross-sectional study. Br J Dermatol. 2017;176(4): 1042–1047. DOI: 10.1111/bjd.14975. PMID: 27534591. 15. European HS Foundation. Hidradenitis suppurativa online. Ac- cessed October 22, 2019. Available from https://www. hsonlinearabia .com/en_ae/home.html 16. Matusiak L, Bieniek A, Szepietowski JC. Psychophysical aspects of hidradenitis suppurativa. Acta Derm Venereol. 2010;90(3): 264–268. DOI: 10.2340/00015555-0866. PMID: 20526543. 17. Smith HS, Chao JD, Teitelbaum J. Painful hidradenitis suppu- rativa. Clin J Pain 2010; 26(5):435–444. DOI: 10.1097/AJP .0b013e3181ceb80c. PMID: 20473053. 18. Esmann S, Jemec GB. Psychosocial impact of hidradenitis sup- purativa: a qualitative study. Acta Derm Venereol. 2011;91(3): 328–332. DOI: 10.2340/00015555-1082. PMID: 21394419. 19. Kokolakis G, Wolk K, Schneider-Burrus S, et al. Delayed diag- nosis of hidradenitis suppurativa and its effect on patients and healthcare system. Dermatology 2020;236(5):421–430. DOI: 10.1159/000508787. PMID: 32610312. PMCID: PMC7592906