Comorbidities in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic, recurrent inflammatory skin disease characterized by inflamed abscesses, nodules forming tunnels that can lead to scarring in intertriginous areas. Inflammation appears to be folliculocentric, arising from pilosebaceous-apocrine units, although the exact disease mechanism is yet to be determined.¹ HS is reported to affect 1% of the general population and is associated with a variety of comorbidities, thought to have a higher overall comorbidity burden than psoriasis.² Comorbidities associated with HS lead to poor health, impaired quality of life, and risk of mortality, making screening for these comorbidities a crucial part of disease management. In this article, we provide a literature review on comorbidities associated with HS (see Table) as mentioned in the introduction of this series.

Metabolic and cardiovascular disorders are the most common comorbidities associated with HS, likely secondary to a greater systemic inflammatory load that leads to increased metabolic and cardiovascular risk factors. The chronic inflammatory burden associated with HS has poor cardiovascular outcomes. HS patients are more likely to have major adverse cardiovascular events (MACE), namely myocardial infarction, cardiovascular-associated death, and cerebrovascular accidents.³ The adjusted risk of MACE and cardiovascular death among patients with HS has been reported as 1.5 (95% CI, 1.27 to 1.86) and 1.6 (95% CI, 1.2 to 2.1) times higher than controls, respectively.⁴ The prevalence of metabolic syndrome is significantly higher in HS patients compared to controls, with a reported odds ratio of 2.66 (95% CI, 1.90 to 3.72) in one review.⁵ Optimization of cardiovascular risk factors including testing for insulin resistance, prudent management of hyperlipidemia, type 2 diabetes, hypertension, tobacco use, and obesity are crucial parts of managing a patient with HS.

An association between HS and obesity due to release of proinflammatory cytokines and adipokines in the adipose tissue has been observed. High levels of leptin and resistin as well as low levels of adiponectin and omentin in obese patients are associated with metabolic syndrome and a mild chronic inflammatory state. Overexpression of inflammatory cytokines including TNF-a, IL-1b, IL-8, and IL-17 have been observed in HS as well as metabolic syndrome and cardiovascular disease.⁵ Higher baseline BMI was found to be a risk factor for development of HS as well as rate of increasing BMI, particularly in younger female patients.⁶

Non-immune thyroid abnormalities have been associated with HS in the setting of smoking.⁷ Insulin resistance has been observed in up to half of patients with HS, as well as association with type 2 diabetes, metabolic associated fatty liver disease, and polycystic ovarian syndrome (PCOS).⁸ Release of pro-inflammatory cytokines observed in HS also contributes to its association with comorbidities such as inflammatory bowel disease, notably Crohn’s disease (CD), and inflammatory spondyloarthropathies.⁹ CD and HS share common clinical features, and HS could be difficult to distinguish from cutaneous Crohn’s clinically. It is postulated that pathogenesis of both HS and CD involve an abnormal response to commensal bacteria of the skin and the gut, respectively. Fistula and tract formation and exacerbation by smoking are other common features. However, NOD2 mutations implicated in CD have not been found in HS patients.¹⁰ Referral to a gastroenterologist is warranted if gastrointestinal signs or symptoms portend possibility of associated CD which could impact management modalities. 

Patients with HS experience debilitating psychiatric comorbidities. The prevalence of depression and generalized anxiety disorder are reported in 26% and 5% of HS patients, respectively. Risk of completed suicide has been reported to be up to 2.8 times higher in HS patients compared to the general population.4 Depression in HS is correlated with increased inflammatory CRP levels.¹¹ Sleep disturbances, sexual dysfunction, and social stigmatization are common in patients living with HS.¹² There is also an increased risk of suicide and substance abuse.¹³ Thoughtful conversations to screen for psychiatric comorbidities should be considered after establishing rapport with HS patients. Referral to psychiatrist as needed should be initiated by the dermatologist to manage these comorbidities and improve quality of life for patients. 

An increased risk of cancer of up to 50% has been reported in HS patients.¹⁴ These cancers include nonmelanoma skin cancers (NMSC), lymphomas, oropharyngeal, central nervous system, colorectal, prostate, and vulvar cancers. Risks of non-Hodgkin lymphoma, Hodgkin lymphoma, and cutaneous T-cell lymphoma are higher due to chronic inflammation leading to an increase in clonal immune cell production.¹⁵ Risk of squamous cell carcinoma (SCC) is higher in gluteal, perianal, and perineal areas. This has been attributed to effects of chronic inflammation in HS, impaired cellular immunity, as well as presence of human papillomavirus (HPV).¹⁶ Cases of SCC after treatment with TNF-a inhibitors have been reported in the literature, however, the role of these treatments in the development of SCC remains to be determined.¹⁷ Another paper have reported a case of concomitant HS and psoriasis with development of rapidly progressive HPV positive perianal SCC.¹⁸ Careful assessments including physical examination and appropriate screenings are imperative in management of HS for timely diagnosis and management of potentially associated cancers. 

The exact role of hormonal influence in HS is unknown, however, worsening of HS in pregnancy and the premenstrual period is observed. The effect of pregnancy on severity of HS is variable. Patients could experience either improvement or worsening of HS during pregnancy. However, a 60% disease flare has been reported in the post-partum period.¹⁹  Some adverse pregnancy outcomes in HS are associated with modifiable comorbidities such as obesity. Close collaboration between the dermatologist and obstetrician is important to manage HS during and after pregnancy.

Comorbidities affecting patients with HS impact their quality of life and lead to poor clinical outcomes. Increased education and advocacy efforts can support better screening guidelines to detect the extent of comorbidities associated with HS. A multidisciplinary approach for timely diagnosis and management of HS comorbidities is crucial for proper care of the patient with HS. Weight management with calorie-restricted diets, medications, and surgery can be considered. Pain management, infection control, screening and management of metabolic and cardiovascular comorbidities, psychiatric support, and screening for malignancies are integral components of HS management in addition to treatments targeted at the disease process. These efforts can improve quality of life and clinical outcomes for HS patients. 

1. Hoffman LK, Ghias MH, Lowes MA. Pathophysiology of hidradenitis suppurativa. Semin Cutan Med Surg. 2017;36(2):47-54.

2. Reddy S, Strunk A, and Garg A. Comparative overall comorbidity burden among patients with hidradenitis suppurativa. JAMA Dermatol. 2019;155(7):797-802.

3. Reddy S, et al. Incidence of myocardial infarction and cerebrovascular accident in patients with hidradenitis suppurativa. JAMA Dermatol. 2020;156(1):65-71.

4. Garg 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(5):1092-1101.

5. Mintoff D, et al. Metabolic syndrome and hidradenitis suppurativa: epidemiological, molecular, and therapeutic aspects. Intl J Derm. 2022;61(10):1175-1186.

6. Wright S, Strunk A, and Garg A. Trends in body mass index before and after diagnosis of hidradenitis suppurativa. Brit J Derm. 2021;185(1):74-79.

7. Sherman S, et al. Hidradenitis suppurativa is associated with hypothyroidism and hyperthyroidism: a large-scale population-based study. Int J Dermatol. 2021;60(3):321-326.

8. Nowak-Liduk, A., et al., Hidradenitis suppurativa: An interdisciplinary problem in dermatology, gynecology, and surgery-pathogenesis, comorbidities, and current treatments. Life (Basel). 2023;13(9).

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12. Nguyen TV, et al. Hidradenitis suppurativa: an update on epidemiology, phenotypes, diagnosis, pathogenesis, comorbidities and quality of life. J Eur Acad Dermatol Venereol. 2021;35(1):50-61.

13. Cartron A, Driscoll MS. Comorbidities of hidradenitis suppurativa: A review of the literature. Int J Womens Dermatol. 2019;5(5):330-334.

14. Abu Rached N, et al. A state-of-the-art systematic review of cancer in hidradenitis suppurativa. Ann Med. 2024;56(1):2382372.

15. Tannenbaum R, Strunk A, Garg A. Association between hidradenitis suppurativa and lymphoma. JAMA Dermatol. 2019;155(5):624-625.

16. Napolitano, M., et al., Hidradenitis suppurativa: from pathogenesis to diagnosis and treatment. Clin Cosmet Investig Dermatol. 2017;10:105-115.

17. Cohen PR, Cohen-Kurzrock RA, Riahi RR. Cancer and hidradenitis suppurativa. Clinics in Dermatology. 2024;42(6):585-601.

18. Hurtová T, et al. Human papillomavirus (HPV)-positive perianal squamous cell carcinoma in a patient Wwth hidradenitis suppurativa and psoriasis. Cureus. 2025;17(1):e77059.

19. Seivright JR, et al. Impact of pregnancy on hidradenitis suppurativa disease course: A systematic review and meta-analysis. Dermatology. 2022;238(2):260-266.