Advances in Hidradenitis Suppurativa

Literature Review: Evaluating the Psychological Burden of HS and Its Impact on Relationships and Sexual Function

12 December 2017

Hessel H van der Zee, MD, PhD Erasmus University Medical Center Rotterdam, the Netherlands

The impact of hidradenitis suppurativa (HS) on patients’ psychological and sexual health is often overlooked, and there is limited published evidence on this association.¹ But as we know from our practice—the painful lesions, draining abscesses, and disfiguring scars—not to mention the malodour can be extremely humiliating. HS is associated with depression or another psychiatric comorbidity in as many as half of patients.^2,3

A few important publications in 2017 are giving clinicians some preliminary information on the current burden of psychological and sexual health in HS, and what we can do about it in our practice.

A survey by Ineke Janse in the Netherlands in 2017, was the first substantial study to show that sexual health is impaired in patients with HS, at least for women. This multicentre, cross-sectional, questionnaire-based study of 300 patients found that HS had a major negative impact on sexual health and quality of life (QoL). Factors associated with sexual health impairment included female sex and late onset disease, whereas factors associated with QoL impairment included anogenital involvement, early onset HS, and higher disease severity and activity. The data did not show an association between HS and decreased sexual health in men, possibly, as suggested by the authors, because men don’t have as high of an emotional and neuroendocrine responsiveness.⁴

Based on these results, the authors recommend that clinicians ask patients with HS about their sexual function and offer psychological intervention if needed. They also noted that early and aggressive treatment of HS may prevent permanent physical impairment, and should be considered in this context.⁴

The perceived impact of HS on patients’ sexual life was investigated in another survey, using item 9 of the Dermatology Life Quality Index (DLQI). This was a multicentre, European study of 3,485 dermatologic outpatients conducted by Francesca Sampogna and colleagues in 2017. HS was one of 24 dermatologic conditions assessed, and was ranked as having the highest frequency of sexual impact based on responses to question 9 in the DLQI: “Over the last week, how much has your skin caused any sexual difficulties?” As many as 67% of patients with HS responded “a lot,” “very much,” or “a little” to this question, as compared with 42% for patients with prurigo and even less for those with psoriasis, urticaria, and other skin conditions. Authors concluded, similarly to the Janse study, that psychosocial problems such as sexual health are important to evaluate when assessing dermatologic disease severity and treatment response.⁵

In our practice, we usually use the DLQI and emphasise item 9 to evaluate patients’ sexual health and function. It can be useful to also ask patients who respond to item 9 with “a lot” or “very much,” to clarify what that means for them, in order to help with better assessing the need for further support.

What about the psychological aspects of HS? A recent small (154 patient) cross-sectional survey by Jocelyn Kirby and colleagues looked at the role of resilience in preventing the negative effects of HS on patients’ mental health and QoL. This was of interest because resilience is a modifiable behaviour rather than a fixed trait, thus there is potential for patients to learn resiliency. Indeed the authors showed that having higher resilience levels correlated with a smaller decrease in health-related QoL as depressive symptoms increased in patients with HS. They concluded, therefore, that resilience training may be useful as an adjuvant therapy for HS.⁶

In summary, HS results in a substantial psychological burden and has a negative impact on sexual health. Beyond the prompt and efficacious dermatologic and surgical management of HS, patients should be asked about their sexual health and referred for support when needed; and resilience training may help our patients avoid the negative impact of HS on mental health and QoL.

References