10.5826/dpc.1302a76
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 &lt; 0.05). Anxiety and depression scores were significantly higher in women than men (P &lt; 0.05). Cases with Hurley stage 3 had significantly higher DLQI scores than those with Hurley stages 1 and 2. Controls had a significantly higher percentage of employed participants (P &lt; 0.05).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 establishing educational programs and support groups for patients with HS.
text/xml
2160-9381
2617
en
Louai Salah
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Rosenberg Self-Esteem Scale
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
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-04-29
2022-05-29
2023-04-29
2023-05-31
e2023076
Dermatol Pract Concept
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 &lt; 0.05). Anxiety and depression scores were significantly higher in women than men (P &lt; 0.05). Cases with Hurley stage 3 had significantly higher DLQI scores than those with Hurley stages 1 and 2. Controls had a significantly higher percentage of employed participants (P &lt; 0.05).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 establishing educational programs and support groups for patients with HS.
Louai Salah
2023/04/29
10.5826/dpc.1302a76
e2023076
Department of Dermatology, Ministry of Health, East Jeddah General Hospital, Jeddah, Saudi Arabia
2160-9381
Rosenberg Self-Esteem Scale
en
e2023076
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.
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
https://dpcj.org/index.php/dpc/article/download/2617/1984
    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




  ABSTRACT             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).




Original Article | Dermatol Pract Concept. 2023;13(2):e2023076                                                                            1
                      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.




Introduction                                                       patients with psoriasis or atopic dermatitis (control group)
                                                                   aged 16 years or older. All cases and controls were diagnosed
Hidradenitis suppurativa (HS) is a chronic inflammatory con-       by dermatologists and presented at the dermatology clinic of
dition that affects apocrine gland-containing skin, primarily in   our hospital and were extracted from medical records at a
the axillary, inguinal, and anogenital regions. HS is character-   ratio of 1:2 to improve study power. Patients with any psy-
ized by recurring nodules, abscesses, sinuses, and scarring [1].   chiatric disorder were excluded to prevent confounding from
The pathogenesis of HS remains inadequately understood;            psychosocial impairment from various causes other than HS.
however, it is possible that genetic and environmental factors        Interviews with patients were conducted via telephone.
play a role. Recently, researchers have proposed that follicu-     Data on demographics (age, sex, nationality, educational
lar occlusion followed by a follicular rupture, leading to an      level, income, occupation, body mass index, and marital
immune response activation, is significant in HS develop-          status) were collected. Patients were also asked to complete
ment [2]. There may also be an association between HS and          the following standardized Arabic-validated questionnaires:
other inflammatory diseases, including pemphigus vulgaris          1) the Dermatology Life Quality Index (DLQI), a popular
[3]. HS can range from a simple recurrent cutaneous infection      tool that is used exclusively for those with skin conditions
to severe recurrent attacks of sinus discharge and abscess for-    and allows comparison between HS and other skin condi-
mation [4,5] affecting patients psychological well-being and       tions [12]; 2) the Rosenberg Self-Esteem Scale (RSES), which
quality of life (QoL) [1,5-7]. Cigarette smoking and obesity       measures patients self-esteem [13]; and 3) the Hospital Anxi-
are recognized risk and aggravating factors [8,9].                 ety and Depression Scale (HADS), utilized to measure anxiety
    The estimated prevalence of HS globally is 1%–4% [1].          and depression levels. The HADS is a 14-item scale that gen-
It typically appears after puberty, primarily in young adults,     erates ordinal data [14]. Seven items are related to depression
with a lower prevalence among those aged 55 years or older         (HADS-D) and seven to anxiety (HADS-A). Furthermore,
(1.4% versus 0.5%), with female predominance. Women                Hurley staging was included by asking patients to choose the
outnumber men in disease incidence by a factor of 3 [10].          picture and the descriptions that matched their Hurley stage.
    Owing to the clinical nature of the disease, patients with     The source of the pictures was the HS online website [15].
HS tend to have poor self-esteem and QoL, as well as de-              Statistical analyses were performed using SPSS version
pression and anxiety [1]. HS has been reported to have the         26 (IBM Corp.). Qualitative data were presented as numbers
greatest negative impact on QoL when compared with other           and percentages, and correlations were determined using
skin conditions [11]. Such patients are likely to avoid so-        chi-squared (χ2) tests. Quantitative data were expressed as
cial interactions and have a higher rate of absenteeism from       means and standard deviations. Data were analyzed using
work than do individuals in the general population [1].            the Mann–Whitney and Kruskal–Wallis tests and indepen-
                                                                   dent samples t-tests. To analyze correlations, Spearman cor-
Objectives                                                         relation coefficient was used, and tests with a P < 0.05 were
                                                                   considered significant.
Despite the abovementioned repercussions of the disease, the          This study was approved by an Institutional Review
negative impact of HS on QoL has not been extensively stud-        Board in Saudi Arabia (H-02-J002). All participants pro-
ied, especially in Saudi Arabia. The aim of this study was to      vided verbal informed consent during the telephonic inter-
assess the impact of HS on patients and society to establish       views. The participants were assured of confidentiality, and
funding priorities and raise awareness of the disease.             anonymity was strictly maintained.


Methods                                                            Results
This cross-sectional case-control study was conducted at a         This study included 46 cases of HS (out of 75 patients) and
hospital facility between January 2016 and December 2019.          101 controls (out of 150 patients) who consented to and
The inclusion criteria were patients with HS (case group) and      completed the surveys. Of the controls, 50 had eczema and



2                                                                      Original Article | Dermatol Pract Concept. 2023;13(2):e2023076
51 had psoriasis. Of the 46 patients with HS, only 6 had             employment (39.6%) and a longer disease duration (6.39
another concurrent chronic skin disease.                             ± 7.42 years) when compared with cases of HS (3.3 ±
    Cases of HS had a higher mean age of diagnosis when              4.38 years, P < 0.05; Table 1).
compared with controls (28.76 ± 8.79 versus 20.1 ±                       In HS cases (N = 46), topical and oral antibiotics were
8.28 years, P < 0.05), while controls had a higher rate of           the most frequently used treatments (78.2% and 73.9%,




               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
                                                                                                    a
 Age (years), mean ± SD                   32.06 ± 10.3            26.5 ± 6.53                3.27                  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)
 Primary                                     1 (2.2)                 0 (0.0)
 Middle school                               3 (6.5)                2 (1.98)
 High school                                15 (32.6)              35 (34.65)                8.65                  0.194
 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)
 1000–3000                                    6 (13)                10 (9.9)
 3001–5000                                  8 (17.4)               16 (15.8)
                                                                                             5.13                 0.399
 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)
 Single                                      23 (50)               59 (58.4)
                                                                                             3.66                  0.3
 Married                                    19 (41.3)              37 (36.6)
 Divorced                                    4 (8.7)                  3 (3)
 Employment
 Employed                                   14 (30.4)              40 (39.6)
 Unemployed                                 30 (65.2)              29 (28.7)                11.2                   0.003
 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
                                                                                                    b
 Age at diagnosis                         28.76 ± 8.79            20.1 ± 8.28                5.75                < 0.001
 Disease duration                          3.3 ± 4.38             6.39 ± 7.42                2.68                < 0.001

SD = standard deviation.
a
 Mann–Whitney test, bIndependent samples t-test



Original Article | Dermatol Pract Concept. 2023;13(2):e2023076                                                                3
respectively), while biological injections were used the least              (15.11) were significantly higher than those of Hurley stage
(28.2%). Armpits were the most commonly affected areas                      1 (6.85) and 2 (9.81) (P < 0.05; Table 3).
(69%). Regarding patient-reported Hurley staging, 45.7%,                         The site of the lesion was not significantly correlated
34.8%, and 19.6% of patients had Hurley stages 1, 2, and 3,                 with DLQI, RSES, and HADS scores (p > 0.05). Smoking
respectively.                                                               and body mass index were also not found to significantly
      Patients with HS had significantly higher mean DLQI                   affect Hurley stage (P > 0.05).
and HADS-D scores when compared with controls with ec-                           A non-significant positive correlation was found between
zema or psoriasis (P < 0.05). No significant difference was                 disease duration and DLQI and HADS scores (P > 0.05),
found in HADS-A and RSES scores (P > 0.05; Figure 1 and                     while RSES scores had a non-significant negative correlation
Table 2).                                                                   (P > 0.05). Regarding controls, higher RSES scores were as-
      Among cases of HS, HADS-A and HADS-D scores for                       sociated with significantly longer disease duration (r = 0.24,
women were 6.14 and 5.54, respectively, which were signifi-                 P < 0.014). Furthermore, longer disease duration was asso-
cantly higher than those of men (4.41 and 3.8, respectively,                ciated with non-significant lower DLQI and HADS scores
P < 0.05; Figure 2). Similarly, Hurley stage 3 DLQI scores                  (P > 0.05).




                                                         P-VALUE = 1.63
               35


               30


               25


               20


               15
                           P-VALUE = 0.008


                                                                                                                     P-VALUE = 0.017
               10                                                                         P-VALUE=0.089



                5


                0
                    DERMATOLOGY LIFE QUALITY
                                                          SELF ESTEEM                      ANXIETY                    DEPRESSION
                          INDEX (DLQI)
       CASE                     9.5                         31.71                           5.97                         5.78
       CONTROLS                6.53                         32.67                           4.97                         4.17
                                                               CASE        CONTROLS



    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.



4                                                                                Original Article | Dermatol Pract Concept. 2023;13(2):e2023076
                 35                                    P-VALUE = 0.903


                 30

                 25

                 20

                 15
                          P-VALUE = 0.264

                 10                                                              P-VALUE=0.005                P-VALUE = 0.03


                   5

                   0
                         DERMATOLOGY LIFE
                                                        SELF ESTEEM                    ANXIETY                 DEPRESSION
                        QUALITY INDEX (DLQI)

         FEMALES               8.36                       31.96                         6.14                      5.54
         MALES                10.85                       31.42                         4.41                       3.8

                                                            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.




Conclusions                                                              more likely to be unemployed than controls. All the above-
                                                                         mentioned features of HS have a significant impact on pa-
HS is a chronic skin condition characterized by episodes                 tients mental health.
of mild to severe recurrent flares, deteriorating the QoL                   Cases of HS in our study had higher depression scores
for patients and impairing their psychological well-being                than controls, consistent with the findings reported in litera-
[1,5-7]. Numerous studies have shown that this disease                   ture [16]. Self-esteem and anxiety were also affected, as such
has a significantly greater impact on QoL than other skin                individuals had lower self-esteem scores and higher anxiety
conditions such as psoriasis and atopic dermatitis [16].                 scores compared with the control group, although the differ-
Our findings support those of previous studies that have                 ence was not significant.
proposed that HS impairs QoL, as the disease involves de-                   Patients with HS are usually misdiagnosed, as they often
bilitating characteristics such as persistent pain, abscess              initially visit general physicians, surgeons, urologists, and
formation, development of disfiguring scars, and smelly                  gynecologists before consulting a dermatologist [19], which
discharge [17]. Moreover, these characteristics compel pa-               may lead to delayed diagnosis, as shown in our study, along
tients to wear covered attire to hide their skin lesions [18].           with avoidance of contact with physicians [20].
These insecurities force patients to isolate themselves from                In general, depression and anxiety experienced by
the outside world, affecting their work performance [1];                 women with HS were greater than those experienced by
this was also observed in our study, as cases of HS were                 their male counterparts; other studies using different scales



Original Article | Dermatol Pract Concept. 2023;13(2):e2023076                                                                         5
and measures have reported similar findings, showing that          References
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Original Article | Dermatol Pract Concept. 2023;13(2):e2023076                                                                               7
