Hidradenitis Suppurativa and Depression

Hidradenitis suppurativa (HS) is a chronic and debilitating inflammatory disorder of the skin characterized by the development of painful, erythematous papules and nodules evolving into abscesses in the intertriginous regions of the body. Lesions commonly occur in the skin folds of the axillary, inguinal, perianal, and gluteal areas.¹ When the abscesses rupture, a foul-smelling odor is produced and dermal tunnels, fibrosis, and scarring ensue, all of which can be highly distressing. The course of HS is usually prolonged and marked by periods of relapse and remission.¹

Although the exact cause of HS is unknown, it may involve the rupturing of plugged follicles and subsequent local inflammatory responses.¹ Immune dysregulation is likely a contributing factor to the disorder because levels of proinflammatory cytokines are high in HS lesions.² Altered skin microbiome may play a role in HS pathogenesis, making it easier for bacteria to cling to dermal tunnels and promote further inflammation.³ Regardless of the contributing factors, living with HS is life-altering, with devastating implications for a patient’s self-esteem and general mental state.

Due to the physical and emotional impact of HS, there is a significant association with depression and an increased risk of suicidality.⁴ HS is among the worst 5 skin diseases with the greatest negative impact on quality of life, with more than 50% of patients with HS experiencing a very large or extremely large negative effect on quality of life as measured by the Dermatology Life Quality Index.⁵

What Is the Connection?

Major depressive disorder (MDD) worsens the number and severity of chronic inflammatory disease flareups.⁶ In both psoriasis and HS, MDD reduced quality of life without affecting objective disease severity.⁶ To improve patient-perceived outcomes, it may be helpful to evaluate the patient’s subjective perception of the disease and correct and prevent depressive symptoms through possible psychiatric referral.⁶ Clinicians may also consider referral to a psychiatric provider if the patient shows objective improvement in lesions but continues to rate poorly on depression assessment scales.

One strategy used to screen for depression in the fast-paced environment of primary care is to administer a brief screening tool followed by a longer tool for positive screens. The Patient Health Questionnaire-2 (PHQ-2), which consists of the first 2 items (depressed mood and anhedonia) of the Patient Health Questionnaire-9 (PHQ-9), has been recommended as a timesaving prescreening tool before administering the remaining PHQ-9 items.⁷ Utilizing the PHQ-2 for patients with HS in the dermatology setting may be efficient for depression screening. Well-conducted trials that compare screening with no screening in an HS exam are needed to determine whether screening improves mental health and other outcomes for patients with HS.

In one study, there was no significant relationship between PHQ-9 scores, Hurley stage, age, sex, and race.⁴ Depression was common in patients with HS, with 33% meeting criteria for the diagnosis of MDD based on the PHQ-9 assessment tool. This comorbidity burden is consistent with previous studies. The disfiguring skin manifestations of HS may contribute to stigma and possibly psychosocial dysfunction. The treatment of HS involves more than managing the cosmetic aspects of the disease. Because it is a physically and socially debilitating disease contributing to poor well-being, HS requires a multifaceted approach to address all the patient health domains.⁴ An interesting study would be to assess the correlation between mental health outcomes and subsequent skin improvement, if any occurs.

Several studies point to the importance of proinflammatory cytokines, such as IL-1, IL-10, IL-17, and tumor necrosis factoralpha (TNF-α), in the pathogenesis of HS.⁸ Immune dysregulation may also play a role in the pathophysiology of depression. In MDD, the levels of proinflammatory cytokines, mainly TNF-α), IL-6, and IL-1, are increased. In addition, the concentrations of other cytokines, such as IL-2, IL-5, and IL-12, are elevated in depression, which could subsequently impact the amount and severity of skin flareups.^6,9 These same proinflammatory cytokines are responsible for a decreased level of serotonin in the synaptic cleft, which may influence neuroplasticity and lead to depression.⁹

The pathophysiology of both HS and MDD shares the affected proinflammatory cytokines IL-1, IL-12, and TNF-α), suggesting that the utilization of certain biologic therapies may have overlapping benefits for both diseases. However, clinical trials are needed. Psychiatric therapies for smoking cessation and weight loss, such as bupropion and naltrexone, could be an adjunctive therapy for patients struggling with cravings for unhealthy foods or nicotine, both of which exacerbate HS.

The negative psychological effects of the painful and malodorous nodules and fistulas characteristic of HS increase the risk of comorbid depression. The proinflammatory nature of both HS and MDD, paired with the psychological link between the 2 chronic disorders, should open the door to treatment options that take both conditions into account. A person with mild HS may be in a better mental state than someone with severe disease; however, even objectively mild HS may have a severe impact on patients’ well-being. Keeping the patient’s mental health in mind may be important regardless of the status of their HS.

Where Do We Go From Here?

Overall, HS is a mentally taxing, chronic disease that can have a profound negative impact on an individual’s well-being. A holistic approach is strongly recommended when treating patients with HS because the disfiguring effects of the disorder are compounded with social stigma. HS and MDD are closely linked in their respective pathogenesis, suggesting that untreated underlying depression may worsen the frequency and severity of HS exacerbations. The level of psychiatric intervention required should not be assumed based on the objective severity of HS skin lesions, but rather on the individual’s perception and unique needs. Although further research is needed to identify specific associations between patients’ mental health and disease severity, the early assessment of mental state may help optimize health outcomes for individuals living with HS.

Patricia Delgado is a nurse practitioner at Sunrise Skin and Wellness in St. Petersburg, FL. Ruth Fanfan is a doctoral nurse practitioner student at Florida Atlantic University.

Disclosure: The authors report no relevant financial relationships.

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References

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3. Napolitano M, Megna M, Timoshchuk EA, et al. Hidradenitis suppurativa: from pathogenesis to diagnosis and treatment. Clin Cosmet Investig Dermatol. 2017;10:105-115. doi:10.2147/CCID.S111019
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7. Levis B, Sun Y, He C, et al. Accuracy of the PHQ-2 alone and in combination with the PHQ-9 for screening to detect major depression: systematic review and meta-analysis. JAMA. 2022;323(22):2290-2300. doi:10.1001/jama.2020.6504
8. Fisher S, Kagan I, Zoller L, Cohen AD, Kridin K. Hidradenitis suppurativa: evaluating activity patterns and predictors of recalcitrant course–a populationbased study. Australas J Dermatol. 2022;63(3):321-327. doi:10.1111/ajd.13854
9. Zhan Y, Zhou Y, Zheng W, et al. Alterations of multiple peripheral infl ammatory cytokine levels after repeated ketamine infusions in major depressive disorder. Transl Psychiatry. 2022;10(1):246-246. doi:10.1038/s41398-020-00933-z