When It's Not Just HS
It's hard enough having one chronic illness, let alone multiple. But for many people with hidradenitis suppurativa, that's exactly what they face. Get the details on the most common conditions that cluster with HS.by Stacey Colino
Anyone with hidradenitis suppurativa (HS) knows it's a challenging disease, physically and mentally. Add another chronic condition to the equation, and managing your symptoms and taking care of your overall health can feel like a very tall order. And this is exactly what many HS patients have to deal with since hidradenitis suppurativa is often accompanied by other physical and mental health conditions—what doctors refer to as comorbidities. What's more, as HS progresses from mild to more severe forms, the burden from comorbidities increases significantly, according to recent research published in Dermatology and Therapy.
It's news that can feel scary, but having more information—especially when it comes to your health and getting the best possible care—is power. Which health conditions often accompany HS? They fall into five categories:
Cardiovascular and related conditions such as type 2 diabetes, hypertension, high cholesterol, metabolic syndrome, and obesity
Inflammatory conditions such as inflammatory bowel disease (particularly Crohn’s), asthma, and rheumatoid arthritis
Hormonal disorders such as polycystic ovary syndrome (PCOS) and thyroid abnormalities
Skin disorders such as psoriasis, acne, dissecting cellulitis of the scalp (a rare condition, marked by pus-filled lesions), pilonidal cysts (which occur near the tailbone and contain hair and skin debris), and pyoderma gangrenosum (which causes painful ulcers on the skin)
Psychological conditions such as depression, anxiety, impaired sexual health, and social isolation
Depending on the particular disorder or condition, these comorbidities are two to 12 times more common among people with HS than among their HS-free peers, according to research. Notably, pilonidal cysts are 35 times more common among people with severe HS than among those who don’t have HS.
Why Does HS Have So Many Comorbidities?
Some of these connections between conditions make sense intuitively. For example, because HS is a follicular occlusion disorder—meaning, it involves inflammation of the skin's hair follicles—it's not all that surprising that acne or pilonidal cysts might accompany HS. Those too develop when blockages form in parts of the skin. Similarly, because HS can be such a painful, debilitating, and embarrassing condition, psychological ripple effects such as anxiety and depression are understandable. It's hard.
The cardiovascular and hormonal comorbidities, however, are more confounding. One leading theory: "Hidradenitis suppurativa is a chronic inflammatory disease that goes beyond the skin—there’s systemic inflammation as well," explains Jennifer Hsiao, M.D., an assistant clinical professor at UCLA Dermatology. "Inflammation is a driver for some of these other conditions." That’s especially true for cardiovascular diseases and inflammatory bowel disease.
What's more, there appears to be a hormonal component to HS, too. "The hair follicle is very sensitive to the sex hormone androgen," adds Martina Porter, M.D., a dermatologist and co-director of the Clinical Laboratory for Epidemiology and Applied Research in Skin (CLEARS) at Beth Israel Deaconess Medical Center in Boston. (Androgen production kicks into gear during puberty and is the horomone responsible for hair growth on the genitals and under the arms.) In women with PCOS, a condition that causes multiple ovarian cysts and dysfunction, they too tend to have higher-than-normal androgen levels.
Monthly hormonal fluctuations may be at play, too. "A lot of my patients say their HS flares with their periods," notes Dr. Hsiao. (The exact role of androgens and estrogen in HS have been explored in numerous studies, but so far, those studies have had conflicting results.)
Complicating matters, it's fairly common for people with HS to have more than one comorbid condition. Just for example, a woman with HS could also have PCOS and metabolic syndrome, a cluster of conditions—high blood pressure, elevated blood sugar, low HDL (the "good") cholesterol, high triglycerides, and excess abdominal fat—that often occur together and increase the risk of developing heart disease, stroke, and type 2 diabetes. Or, a woman with HS could also have arthritis and depression; a man with HS might also be afflicted with hypertension and inflammatory bowel disease.
While HS is more prevalent among women, certain associated conditions such as acne, type 2 diabetes, and Crohn's disease are more common among men with HS, Dr. Hsiao notes. Indeed, a study in the Journal of the American Academy of Dermatology found that while the overall prevalence of type 2 diabetes among patients with HS was 24.8%, compared to 15.6% among patients without HS, the prevalence of type 2 diabetes was slightly higher (28.2 percent) among men with HS.
HS: Taking Care of All of You
The take-home message: "It's important to recognize that skin inflammation symptoms, such as those from HS, are what bring people into the doctor's office but that other inflammatory conditions could be going on in the background,” says Chris Sayed, M.D., an associate professor of dermatology at the UNC School of Medicine in Chapel Hill.
Obviously, it's important for co-occurring conditions to be diagnosed and treated early, before they lead to lasting damage or complications. "With some of these comorbidities, we have medicines that can treat all the conditions at once," says Dr. Porter. For example, the biologic drug Humira (adalimumab can treat HS, IBD, and sometimes arthritis, she explains. By contrast, spironolactone [a diuretic] can be used to treat PCOS, acne, hirsutism, and HS. And metformin, an oral drug used to treat diabetes, often helps control symptoms of HS and facilitates weight loss, according to the Hidradenitis Suppurativa Foundation.
If you have HS, you know how difficult it can be just to get a diagnosis of this frequently misunderstood skin condition. So if you're (finally) seeing a dermatologist who's knowledgeable about HS, be sure to speak up about getting screened for these common HS comorbidities, too. You can develop a treatment plan together, which may include assembling a team of other specialists to help you manage both your physical and mental health.
- Comorbidity Burden and HS: Dermatology and Therapy. (2018). "The Comorbidity Burden of Hidradenitis Suppurativa in the United States: A Claims Data Analysis." www.ncbi.nlm.nih.gov/pmc/articles/PMC6261111/
- Comorbidities Background: Hidradenitis Suppurativa Foundation (n.d.). "Comorbidities and Hidradenitis Suppurativa." www.hs-foundation.org/comorbidities/