Unraveling the mental health burden of hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, recurrent, and debilitating inflammatory skin disease of the hair follicle. Clinically characterized by painful, deep-seated inflammatory lesions affecting apocrine gland-bearing areas of the body. Its hallmark symptoms include pain, pruritus, malodor, and suppuration. Over a period, frequent recurrence causes fibrosis, dermal contractures, and induration of the skin, with permanent scarring leading to impairment in quality of life (QoL) which in turn imposes a significant physical and psychological burden. Despite this, they are often underdiagnosed by clinicians, and the current scientific evidence remains scarce and heterogeneous. This article aims to explore the psychological and emotional impact of HS, with a specific focus on psychiatric comorbidities, particularly depression, suicidal ideation, self-esteem, and substance abuse. HS is associated with a broad spectrum of systemic comorbidities, including metabolic syndrome, cardiovascular risk, diabetes, inflammatory bowel disease, and psychiatric comorbidities. The interaction between the skin’s immune system and the nervous system due to associated chronic inflammation in HS fosters the development of psychiatric comorbidities and heightened psychosocial stress. Despite its clinical and epidemiological relevance, its pathogenesis for the psychological correlates is still largely unexplored. Chronic dermatological disease like HS exposes individuals to a protracted level of suffering. This includes the involvement of the affective and relationship domain, with a profound negative impact on self-image and self-esteem and in turn their social life. Psychiatric conditions such as anxiety, depression, bipolar disorder, psychosis, schizophrenia, substance abuse, and an increased risk of suicide are more prevalent in HS patients as compared to the general population. This is often exacerbated by the chronic pain, frequent recurrences, social stigma, and absenteeism associated with HS. Patients frequently report embarrassment, unemployment, sexual dysfunction, self-consciousness, and reduced participation in social and athletic activities which further compound the disease’s impact on different spheres of life. Emotional fragility can contribute to increased experiences of discomfort and feelings of inadequacy in dealing with HS which can activate a cycle between HS flares and maladaptive emotional responses. These patients are at greater risk of psychiatric disorders than those with other dermatological conditions like psoriasis. These findings highlight the urgent need for a multidisciplinary approach to HS management, integrating dermatologic care with psychosocial and psychiatric support. Psychosocial evaluations during the initial few clinical visits are crucial for identifying patients at risk of emotional distress. Referrals to psychiatric specialists and psychologists should be incorporated into routine practice. This interdisciplinary collaboration can help address the multifaceted challenges of HS and improve mental health outcomes with the enhancement of patients’ QoL. We emphasize that HS is not merely a dermatological condition but a systemic disease with radical implications for mental health. It compels patients to sustain physical, psychological, and socioeconomic impairments. Comprehensive management strategies that address both the physical and psychological domains of the disease are essential for improving patient and disease outcomes. Creating greater awareness among dermatologists and other healthcare providers of the comorbidities and psychosocial burden associated with HS will pave the way for holistic, patient-centered care.