|Year : 2021 | Volume
| Issue : 2 | Page : 95-101
Quality of life and psychological aspects of patients with hidradenitis suppurativa in Saudi Arabia: A hospital-based multi-center study
Sahar Alsharif1, Zakaria Khan2, Fahad Almuntashri2, Ahmad Alghamdi2
1 Department of Dermatology, Al-Noor Hospital, Makkah, Saudi Arabia
2 College of Medicine, Umm AlQura University, Makkah, Saudi Arabia
|Date of Submission||13-Mar-2021|
|Date of Acceptance||30-Jun-2021|
|Date of Web Publication||29-Mar-2022|
Dr. Sahar Alsharif
Department of Dermatology, Al-Noor Hospital, Makkah
Source of Support: None, Conflict of Interest: None
Background: Hidradenitis suppurativa (HS) is a chronic recurrent painful auto-inflammatory skin disease of the terminal hair follicle, causing nodules, abscesses, sinus tracts, and scars on intertriginous areas. Purpose: This study aims is to determine the effect of HS on patients' psychology and quality of life in the Makkah population. Methods: This is a cross-sectional, multi-center study conducted on HS patients who visited the dermatology clinic during 2017−2020. A total of 165 patients participated in the study by completing a questionnaire consisting of demographic data, the dermatology life quality index, depression, anxiety, and stress score. Results: In total, 147 patients were included in the final analysis, and the mean age of the participants was 32.0 ± 10.6. HS had a very large effect on the quality of life of 32% of the participants. Quality of life was worse with the number of flares per year (P < 0.003) and with axillary and perianal involvement, (P < 0.018 and P < 0.024, respectively). Moreover, a higher level of depression was associated with a higher body mass index (P < 0.020). Conclusion: HS had a large effect on the quality of life regardless of Hurley stage and was correlated with the number of flares per year and area of disease involvement.
Keywords: Acne inversa, anxiety, depression, hidradenitis suppurativa, psychological aspect, quality of life, stress
|How to cite this article:|
Alsharif S, Khan Z, Almuntashri F, Alghamdi A. Quality of life and psychological aspects of patients with hidradenitis suppurativa in Saudi Arabia: A hospital-based multi-center study. J Dermatol Dermatol Surg 2021;25:95-101
|How to cite this URL:|
Alsharif S, Khan Z, Almuntashri F, Alghamdi A. Quality of life and psychological aspects of patients with hidradenitis suppurativa in Saudi Arabia: A hospital-based multi-center study. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 Jul 2];25:95-101. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/95/341204
| Introduction|| |
Skin disease can affect an individual's social and interpersonal life. HS is a chronic, recurrent, painful auto-inflammatory skin disease of the terminal hair follicle, presenting with a nodule, abscesses, sinus tracts, and scars on the intertriginous areas including axillary, genitofemoral, and perianal, as well as the infra-mammary and inter-mammary folds.,, Patients with hidradenitis suppurativa (HS), also known as acne inversa, can feel unattractive, embarrassed, and shameful about their body image.,
In clinical settings, HS severity may be assessed using the Hurley classification: Stage I, transient nonscarring inflammatory lesion; Stage II, recurrent abscesses with sinus tracts formation and scarring, and single or multiple nodules separated by normal-looking skin; and Stage III, diffuse involvement or multiple interconnected tracts and abscess. HS is associated significantly with depression, anxiety, and a major impact on quality of life when compared with other dermatological diseases, as measured by the dermatology life quality index (DLQI).,, Several factors are associated with worse quality of life in patients with HS, including single or multiple scars (specifically in the anogenital area), malodor from single or multiple abscesses, a random flare of lesions, unendurable pain, advanced stage, and characteristic recurrence and chronicity.,
A 2015 Canadian study found a moderate to very large effect of HS on patients' quality of life., A 2017 Greek study found worse quality of life in female patients and higher Hurley stage. The impact of HS in the Middle East is not well characterized. Therefore, the aim of this study is to determine the effect of HS on patients' psychology and quality of life in Makkah, Saudi Arabia.
| Methods|| |
This is a cross-sectional, multi-center study that focused on HS patients who visited the dermatology clinics at Al-Noor Hospital, Hera General Hospital, King Abdulaziz Hospital, and King Faisel Hospital in Makkah, Saudi Arabia. The inclusion criteria were patients diagnosed with HS at least 6 months before study initiation and age between 18 and 60 years. Patients with depression or those older than 60 years were excluded from the study.
We contacted 292 patients, 29 from King Faisel Hospital, 15 from King Abdulaziz Hospital, 91 from Hera General Hospital, and 157 from Al-Noor Hospital, with 165 patients agreeing to participate in the study. We excluded 18 patients who did not fit our inclusion criteria.
Data were collected using an adapted Arabic language electronic questionnaire. Verbal consent was obtained from patients by the authors by phone, with contact details and Hurley stage obtained from the four study hospital databases between 2017 and 2020. Then, an electronic questionnaire was sent to all HS patients through Whatsapp. The questionnaire was structured into three parts: Demographics, quality of life, and psychological aspects.
In the first section, the questionnaire collated data on demographics, socioeconomics, and disease characteristics, including age, gender, height, weight, smoking status, level of education, occupation, marital status, age at onset of symptoms, age at diagnosis, number of flairs per year, area affected by the disease, treatment used for this condition, and other comorbidities (e.g., diabetes mellitus, hypertension, cardiovascular disease, and psychological disease). Body mass index (BMI) was calculated using the following formula: BMI= (body weight [Kg]/body height [m2]). Then, the BMI was used to categorize the participants into normal (BMI = 18.5–24.9), overweight (BMI = 25–29.9), and obese (BMI= ≥30) groups according to the national institutes of health.
Quality of life was assessed in the second section of the questionnaire using the DLQI, which is a simple, valid, self-administered, and most commonly used tool to assess the impact of dermatological disease on a patient's quality of life in the last week through 10 questions. Each question has four possible answers (very much, a lot, a little, not at all), with a maximum of three points for each question and a total score of 30 points for the whole index. The cutoff value includes 0-1 point indicating no effect on quality of life, 2-5 points indicating a small effect, 6-10 points indicating a moderate effect, 11-20 points indicating a very large effect, and 20-30 points indicating an extreme effect on a patient's quality of life. License for this index was taken from the official site of Cardiff University (license ID code: CUQoL2654).
Finally, in section three of the questionnaire, psychological aspects were assessed using the short version of the Depression Anxiety and Stress Scale (DASS-21), which is a validated and self-reported scale used to assess the emotional stress during the week before assessment using three subcategories: Depression, anxiety, and stress., Each subcategory consists of seven items based on a four-point rating scale. Answers for the questions include 'did not apply to me at all' (never) (0), “applied to me to some degree or sometimes” (sometimes) (1), “applied to me to a considerable degree” (often) (2), and “applied to me very much or most of the time” (almost always) (3). For calculation, each of the seven items is multiplied by two. The total score ranges from 0 to 120, with 42 maximum points for each. For interpretation, depression divides into normal (0−9), mild (10−12), moderate (13−20), severe (21−27), and extremely severe (28−42). Anxiety divides into normal (0−6), mild (7−9), moderate (10−14), severe (15−19), and extremely severe (20−42). Stress divides into normal (0−10), mild (11−18), moderate (19−26), severe (27−34), and extremely severe (35−42).
Data analysis: Microsoft Office Excel 2013 was used for data entry, whereas SPSS version 25 was used for the statistical analysis. Mean and standard deviations were calculated to describe the continuous variables, whereas numbers and percentages were used for the categorical variables. The Chi-square test was used for the comparison between the qualitative variables, whereas the one-way ANOVA test was used for the comparison between qualitative and quantitative variables. P < 0.05 was considered statistically significant.
All information in this study is kept confidential, and participant data are robustly protected with no unauthorized access to the data. The participants were recruited voluntarily, and they all had the right to refuse to participate or to withdraw from the study without any consequences. This survey was legally permitted and socially accepted. Ethical approval was obtained from the Research Ethical Committee of the Ministry of Health in Makkah.
| Results|| |
The mean age for the participants was 32.0 ± 10.6 standard deviation (SD), with age divided into two categories: 17–30 years (78; 53%) and 31–69 years (69; 47%). In regard to gender, there were 69 males (47%) and 78 females (53%). More than half of the participants were obese (78; 53%), whereas 32 were overweight (22%). Other comorbidities included diabetes mellitus and hypertension, in 22 (15%) and 14 (9%) of the patients, respectively. Almost half the patients (73; 45%) were at Hurley Stage 3, whereas 47 (32%) were at Stage 1. Most of the patients were nonsmokers (99; 67%). More than 60% of the participants experience flares of the diseases more than five times a year (93; 63%), whereas 10 (7%) of the patients have only one flare per year. The mean age of onset of symptoms was 22.3 years (SD ± 10.5), whereas the age of diagnosis was 26.7 years (SD ± 9.6) [Table 1].
The mean DLQI score was 12 ± 8.1, which indicates a very large effect on the patient's life [Figure 1] and [Table 2]. About 15% of male patients found that HS has a very large effect on their quality of life, and (4%) reported no effect, whereas in female patients, (18%) reported a very large effect and (5%) reported no effect. The percentage of patients in Hurley Stage I and Stage III that had a very large effect of HS on their quality of life was 17 (12%) and 14 (9%), respectively (P < 0.092). Quality of life was worse with a greater number of areas affected and flares per year (P < 0.001 and P < 0.003, respectively). Of those who have axillary lesions, 41 (28%) reported a very large effect on quality of life, whereas 22 (15%) reported an extremely large effect (P < 0.018). Moreover, for those with perianal lesions, 33 (22%) reported a very large effect, while 18 (12%) an extremely large effect (P < 0.024) [Table 3].
|Figure 1: Percent of dermatology life quality index among patients with hidradenitis suppurativa|
Click here to view
|Table 3: Dermatology life quality index categories compared with demographic|
Click here to view
The mean score for depression was 4.3 ± 4.8, and most of the patients were in the normal depression category (126; 86%) [Figure 2]. The number of flares is insignificantly related to depression levels as52% of total participants had more than 5 flares and were classified as having normal depression, P value (0.381). Depression was associated with higher BMI (P = 0.020) [Table 4].
|Figure 2: Percent of depression among patients with hidradenitis suppurativa|
Click here to view
The mean score for anxiety was 3.44 ± 3.60, and the majority of the patients were in the normal anxiety category (133; 90%) [Figure 3], and the level of anxiety was similar between males and females 44% and 47%, respectively Higher number of flares per year were significantly correlated with a higher level of anxiety (P < 0.015). More than half of the participants (65%) have lesions in the axillary area, 41 (28%) have lesions under the breast classified as normal anxiety category. Statistically, higher high BMI was associated with a higher level of anxiety (P < 0.001) [Table 5].
|Figure 3: Percent of anxiety among patients with hidradenitis suppurativa|
Click here to view
| Discussions|| |
HS had a significant effect on the quality of life., In our study, HS had a very large effect on patient's quality of life. In a recent systemic review and a cross-sectional study, HS has a moderate to large effect on patient's QOL. Moreover, the systemic review, Canadian, and Denmark studies showed greater quality of life impact with higher Hurley stage (r = 0.67, P < 0.001, and P < 0.001 respectively).,, Patients who have more flares per year significantly have a lower QOL (P < 0.003). A similar result was reached by the Denmark study (P < 0.04). Meanwhile, the Canadian study showed no relationship between DLQI and the number of flares per year (P < 0.388). The area affected by the disease plays a role in the disease severity and quality of life., Our study shows patients with axillary and perianal involvement have a lower QOL, (P < 0.018) and (P < 0,024) respectively. This is consistent with the systemic review, which showed that the mean DLQI score for patients with anogenital lesions was 14.7 ± 7.2, while the mean score for other areas was 9.5 ± 7.6.
Depression is highly associated with HS clinical stage. In our study, Hurley stage was not associated with different depression categories (P < 0.299). A review study showed the number of flares is one of the major factors that affects the well-being and health of patients with HS. However, in the current study, the majority of patients had more than five flares per year (77; 52%) and were in the normal depression category. A cross-sectional study conducted on 212 patients in 2014 showed that certain risk factors (e.g., smoking) could be triggering factors for HS. High BMI and smoking result in significant increase in the rates of depression (P < 0.059 and P < 0.020, respectively). Lifestyle modification and weight reduction are associated with a higher likelihood of HS remission. Therefore, taking into consideration such risk factors as part of treatment improves outcomes.,
Given that this study involved a hospital-based population, it may not be fully representative of patients seen exclusively in the outpatient setting. Further limitations of the study were influenced by the COVID-19 lockdown, which limited the ability to identify Hurley stage by examination and necessitated dependence on the database's information. In addition, the level of physical activity was not measured.
| Conclusion|| |
A large effect on the quality of life was noticed in relation to the number of flares per year and location of the predilection area, regardless of the Hurley stage. Rates of depression were higher in patients with higher BMI. Lifestyle modification may be helpful as an early intervention to reduce the psychological impact of the disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vekic DA, Cains GD. Hidradenitis suppurativa, a review of pathogenesis, associations and management. Part 2. Australas J Dermatol 2018;59:261-6.
Machado MO, Stergiopoulos V, Maes M, Kurdyak PA, Lin PY, Wang LJ, et al.
Depression and anxiety in adults with hidradenitis suppurativa: A systematic review and meta-analysis. JAMA Dermatol 2019;155:939-45.
Kluger N, Sintonen H, Ranta M, Serlachius M. Health-related quality of life of patients with hidradenitis suppurativa measured with the 15D instrument and comparison with the general population and patients with psoriasis. Skin Appendage Disord 2018;4:131-5.
Kouris A, Platsidaki E, Christodoulou C, Efstathiou V, Dessinioti C, Tzanetakou V, et al.
Quality of life and psychosocial implications in patients with hidradenitis suppurativa. Dermatology 2016;232:687-91.
Matusiak L, Bieniek A, Szepietowski JC. Psychophysical aspects of hidradenitis suppurativa. Acta Derm Venereol 2010;90:264-8.
Matusiak Ł. Profound consequences of hidradenitis suppurativa: A review. Br J Dermatol 2020;183:e171-7.
Senthilnathan A, Kolli SS, Cardwell LA, Richardson IM, Feldman SR, Pichardo RO. Depression in hidradenitis suppurativa. Br J Dermatol 2019;181:1087-8.
Tzellos T, Zouboulis CC. Review of comorbidities of hidradenitis suppurativa: Implications for daily clinical practice. Dermatol Ther (Heidelb) 2020;10:63-71.
Alavi A, Anooshirvani N, Kim WB, Coutts P, Sibbald RG. Quality-of-life impairment in patients with hidradenitis suppurativa: A Canadian study. Am J Clin Dermatol 2015;16:61-5.
James WP, Jackson-Leach R, Mhurchu CN, Kalamara E, Shayeghi M, Rigby NJ, et al
. Overweight and obesity (high body mass index). Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. 2004;1:497-596.
Finlay AY, Khan GK. Dermatology life quality index (DLQI) – A simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6.
Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther 1995;33:335-43.
Ali AM, Ahmed A, Sharaf A, Kawakami N, Abdeldayem SM, Green J. The Arabic version of the depression anxiety stress scale-21: Cumulative scaling and discriminant-validation testing. Asian J Psychiatr 2017;30:56-8.
Miller IM, Ellervik C, Vinding GR, Zarchi K, Ibler KS, Knudsen KM, et al.
Association of metabolic syndrome and hidradenitis suppurativa. JAMA Dermatol 2014;150:1273-80.
Onderdijk AJ, van der Zee HH, Esmann S, Lophaven S, Dufour DN, Jemec GB, et al.
Depression in patients with hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2013;27:473-8.
Chernyshov PV, Zouboulis CC, Tomas-Aragones L, Jemec GB, Svensson A, Manolache L, et al.
Quality of life measurement in hidradenitis suppurativa: Position statement of the European Academy of Dermatology and Venereology task forces on quality of life and patient-oriented outcomes and acne, rosacea and hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2019;33:1633-43.
Kromann CB, Deckers IE, Esmann S, Boer J, Prens EP, Jemec GB. Risk factors, clinical course and long-term prognosis in hidradenitis suppurativa: A cross-sectional study. Br J Dermatol 2014;171:819-24.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]