JEADV
DOI: 10.1111/jdv.12567
ORIGINAL ARTICLE
Psychiatric comorbidities in 3207 patients with hidradenitis suppurativa E. Shavit,1,2 J. Dreiher,3,4 T. Freud,4 S. Halevy,1,2 S. Vinker,5,6, A.D. Cohen4,5,* 1
Department of Dermatology and Venereology, Soroka University Medical Center, Beer-Sheva, Israel Faculty of Health Sciences, Division of Medicine, Ben-Gurion University of the Negev, Beer-Sheva, Israel 3 Hospital Division, Central Headquarters, Clalit Health Services, Tel Aviv, Israel 4 Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel 5 Chief Physician Office, Central Headquarters, Clalit Health Services, Tel Aviv, Israel 6 Department of Family Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel *Correspondence: A.D. Cohen. E-mail: [email protected] 2
Abstract Background Hidradenitis suppurativa (HS) is a chronic recurrent inflammatory disease affecting skin that bears apocrine glands. Only anecdotal reports and a few small studies have demonstrated a possible association between HS and depression, but these studies were uncontrolled or were based on small sample sizes. To the best of our knowledge, the association between HS and other psychiatric disorders has never been investigated. Objectives To investigate the association between HS and psychiatric disorders: depression, anxiety, psychoses, schizophrenia and bipolar disorder. Methods A cross-sectional study was conducted utilizing the database of Clalit Health Services (over 4 100 000 patients). Case patients were defined as having HS when diagnosed by a dermatologist. Control patients without HS were age and gender matched in a 2 : 1 manner. The proportions of patients with psychiatric diseases were compared between patients with and without HS. The association between HS and psychiatric diseases was assessed in multivariate models using logistic regression analyses. Results The study included 3207 patients with HS and 6412 age- and gender-matched controls. Depression was diagnosed in 5.9% of patients with HS vs. 3.5% of patients without HS (P < 0.001). Anxiety was diagnosed in 3.9% of patients with HS vs. 2.4% of patients without HS (P < 0.001). These associations were significant after controlling for the confounders age and gender (Depression: OR = 1.7, 95% CI: 1.4–2.1; Anxiety: OR = 1.7, 95% CI: 1.3–2.1). Conclusions Hidradenitis suppurativa was associated with depression and anxiety. Dermatologists treating patients with HS should be aware of this important association. Received: 4 December 2013; Accepted: 29 April 2014
Conflicts of interest None declared.
Funding sources None declared.
Introduction Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic, recurrent, debilitating skin disease with abscess and often fistula formation, predominantly affecting the axillae and groin regions.1 HS is manifested clinically as painful deep-seated inflamed nodules, sinus tracts and abscesses. Assessment of the severity of HS is helpful in guiding treatment and is based on the Hurley staging system.2,3 Women are more commonly affected with HS (female: male ratio is 3 : 1). Flares of the disease may involve suppuration of foul-smelling discharge as well as pain.
JEADV 2015, 29, 371–376
HS is considered a relatively uncommon medical condition. Although the exact prevalence of HS is unknown, reports have varied from as low as 1 in 3000 to as high as 4%4–7; the latter may have been influenced by referral bias and variation in the definition of HS. European studies have suggested that HS is not a rare disease in persons in their twenties, and the prevalence of HS has been shown to decline over the age of 50 years.4–7 Hidradenitis suppurativa is difficult to treat and has a severe impact on the quality of life.5–7 A long delay in diagnosis of HS is common and the pathogenesis remains unclear. Histological
© 2014 European Academy of Dermatology and Venereology
Shavit et al.
372
studies suggest that HS is a multifocal disease, in which atrophy of the sebaceous glands is followed by an early lymphocytic inflammation and hyperkeratosis of the pilosebaceous unit, and later by hair-follicle destruction and granuloma formation.8 Hidradenitis suppurativa is a clinical diagnosis, usually made by a dermatologist. On physical examination, inflammatory nodules, abscesses and sinus tracts are found, some or all of which can be found in the anogenital, inguinal and axillary regions. Small sample studies have shown a possible association between HS and depression.9–11 Nevertheless, HS has only rarely been associated with anxiety or any other psychiatric disorders. Most of the studies were anecdotal or based on small sample sizes.9–11 Since HS is a suppurative disease and the discharges produce a foul odour, it is correct to claim that the symptoms are not only physical. Moreover, the disease affects ‘sensitive’ areas such as the axilla and the genitals, leading to embarrassment and affecting interpersonal relationships, self-esteem and even public image perception. We have therefore speculated that the psychological and psychiatric impact of this disease is tremendous. In this study, we examined the possible association between HS and several psychiatric disorders, including depression, anxiety, psychoses, schizophrenia and bipolar disorder.
Material and methods The study was conducted in Clalit, the largest managed care organization in Israel. Clalit serves a population of more than 4.1 million enrollees. Clalit has a comprehensive computerised database with continuous real-time input from pharmaceutical, medical and administrative computerised operating systems. This Registry combines the diagnoses registered by physicians working in hospitals and in outpatient clinics. The psychiatric diagnoses are registered only by physicians working in hospitals and in the outpatient clinics of Clalit; these data combine both psychiatric diagnoses and psychiatric medications given to these patients. The information from psychiatric hospitals is classified and not accessible. Nevertheless, the validity of Clalit’s registry of diagnoses has previously been found to be high.12 In recent years, we have utilized the Clalit database to study disease associations in patients with psoriasis,13–17 pemphigus,18 lichen planus19 and mycosis fungoides.20 The study was designed as a cross-sectional study using data mining techniques utilizing the Clalit database. Patients were defined as having HS when there was at least one documented diagnosis of HS in the medical records between 1997 and 2011, registered by a Clalit dermatologist (3207 patients). Patients without HS consisted of a computer-selected random sample of the general population of Clalit enrollees without HS (6412 patients). Study and control group patients were age and gender matched.
JEADV 2015, 29, 371–376
The proportion of patients with HS and the associated disease was compared between patients with and without HS by univariate analyses. Chi-squared tests have been used to compare categorical parameters between the groups. T-tests have been used to compare continuous parameters between the groups. Logistic regression models have been used to measure the association between HS and the psychiatric comorbidities, while controlling for confounders. Statistical analysis was performed using SPSS software, version 19 (Chicago, IL, USA). The study was approved by the Institutional Review Board of Meir Medical Center.
Results The study included 3207 patients with HS and 6412 age- and gender-matched patients without HS. Most of the patients with HS were women (61.6%). Also, the vast majority of the patients suffering from HS were in the younger age group, namely, between 21 and 50 years of age; fewer patients were shown in the younger and older age groups (e.g. 0.2% for the 1–10 years and 2.2% for the 71–80 years age groups). These data are in accordance with the literature.5–7 The socio-demographic characteristics of study participants are summarised in Table 1. The univariate association between HS and mental comorbidities is shown in Table 2. Depression was diagnosed in 5.9% of patients with HS, compared with 3.5% of patients without HS [P < 0.001, odds ratio (OR) = 1.7, 95% confidence interval (CI): 1.4–2.1]. Anxiety was diagnosed in 3.9% of patients with HS, compared with 2.4% of patients without HS (P < 0.001; OR = 1.7, 95% CI: 1.3–2.2). Psychoses were diagnosed in 1.3% of patients with HS, compared with 0.8% of patients without HS (P = 0.03; OR = 1.5, 95% CI: 1.0–2.3). There was also a trend of association towards other psychiatric diagnoses, including schizophrenia and bipolar disorder, although these were not statistically significant (Table 2). Depression was more prevalent in women than in men, in both patients with HS (4.2% in women vs. 1.7% in men) and patients without HS (2.5% vs. 1.1% respectively). The association between depression and HS persisted in both females and males, and was significant in patients aged 21–50 years. Anxiety was also more prevalent in women than in men, in both patients with HS (2.6% vs. 1.2%) and patients without HS (1.5% vs. 0.8% respectively; Table 3). The association between anxiety and HS was statistically significant in females, but not in males or in patients aged 21–50 years. In logistic regression models, the multivariate association between HS and depression was found to be statistically significant (P-value < 0.001, OR = 1.7, 95% CI: 1.4–2.1). Similarly, the multivariate association between HS and anxiety was found to be statistically significant (P < 0.001; OR = 1.7, 95% CI: 1.3– 2.1; Table 4).
© 2014 European Academy of Dermatology and Venereology
Psychiatry and hidradenitis suppurativa
373
Table 1 Socio-demographic characteristics of the study population HS patients (N = 3207)
N
P-value
Patients without HS (N = 6412) N
%
%
Age group (years) 1–10
6
0.2
10
11–20
242
7.5
484
7.5
21–30
864
26.9
1728
26.9
31–40
766
23.9
1532
23.9
41–50
508
15.8
1016
15.8
51–60
482
15.0
964
15.0
61–70
226
7.0
452
7.0
71–80
71
2.2
142
2.2
81–90
37
1.2
74
1.2
91–100
5
0.2
10
0.2
39.6 15.5
Mean age Range (years)
0.2
1
39.6 15.5
4–99
4–99
Gender Male
1232
38.4
2464
38.4
Female
1975
61.6
3948
61.6
0.505
Due to matching for age and gender, all P-values were not statistically significant (>0.05).
Table 2 Uni-variable analyses: association between HS mental comorbidities HS patients (N = 3207) N
Patients without HS (N = 6412) %
N
OR (95% CI)
P-value
%
Psychoses
42
1.3
53
0.8
1.5 (1.0–2.3)
0.03
Schizophrenia
51
1.5
75
1.1
1.3 (0.9–1.9)
0.09
Bipolar disorder
13
0.4
12
0.1
2.1 (0.9–4.7)
0.06
Depression
189
5.8
227
3.5
1.7 (1.4–2.0)
DOI: 10.1111/jdv.12567
ORIGINAL ARTICLE
Psychiatric comorbidities in 3207 patients with hidradenitis suppurativa E. Shavit,1,2 J. Dreiher,3,4 T. Freud,4 S. Halevy,1,2 S. Vinker,5,6, A.D. Cohen4,5,* 1
Department of Dermatology and Venereology, Soroka University Medical Center, Beer-Sheva, Israel Faculty of Health Sciences, Division of Medicine, Ben-Gurion University of the Negev, Beer-Sheva, Israel 3 Hospital Division, Central Headquarters, Clalit Health Services, Tel Aviv, Israel 4 Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel 5 Chief Physician Office, Central Headquarters, Clalit Health Services, Tel Aviv, Israel 6 Department of Family Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel *Correspondence: A.D. Cohen. E-mail: [email protected] 2
Abstract Background Hidradenitis suppurativa (HS) is a chronic recurrent inflammatory disease affecting skin that bears apocrine glands. Only anecdotal reports and a few small studies have demonstrated a possible association between HS and depression, but these studies were uncontrolled or were based on small sample sizes. To the best of our knowledge, the association between HS and other psychiatric disorders has never been investigated. Objectives To investigate the association between HS and psychiatric disorders: depression, anxiety, psychoses, schizophrenia and bipolar disorder. Methods A cross-sectional study was conducted utilizing the database of Clalit Health Services (over 4 100 000 patients). Case patients were defined as having HS when diagnosed by a dermatologist. Control patients without HS were age and gender matched in a 2 : 1 manner. The proportions of patients with psychiatric diseases were compared between patients with and without HS. The association between HS and psychiatric diseases was assessed in multivariate models using logistic regression analyses. Results The study included 3207 patients with HS and 6412 age- and gender-matched controls. Depression was diagnosed in 5.9% of patients with HS vs. 3.5% of patients without HS (P < 0.001). Anxiety was diagnosed in 3.9% of patients with HS vs. 2.4% of patients without HS (P < 0.001). These associations were significant after controlling for the confounders age and gender (Depression: OR = 1.7, 95% CI: 1.4–2.1; Anxiety: OR = 1.7, 95% CI: 1.3–2.1). Conclusions Hidradenitis suppurativa was associated with depression and anxiety. Dermatologists treating patients with HS should be aware of this important association. Received: 4 December 2013; Accepted: 29 April 2014
Conflicts of interest None declared.
Funding sources None declared.
Introduction Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic, recurrent, debilitating skin disease with abscess and often fistula formation, predominantly affecting the axillae and groin regions.1 HS is manifested clinically as painful deep-seated inflamed nodules, sinus tracts and abscesses. Assessment of the severity of HS is helpful in guiding treatment and is based on the Hurley staging system.2,3 Women are more commonly affected with HS (female: male ratio is 3 : 1). Flares of the disease may involve suppuration of foul-smelling discharge as well as pain.
JEADV 2015, 29, 371–376
HS is considered a relatively uncommon medical condition. Although the exact prevalence of HS is unknown, reports have varied from as low as 1 in 3000 to as high as 4%4–7; the latter may have been influenced by referral bias and variation in the definition of HS. European studies have suggested that HS is not a rare disease in persons in their twenties, and the prevalence of HS has been shown to decline over the age of 50 years.4–7 Hidradenitis suppurativa is difficult to treat and has a severe impact on the quality of life.5–7 A long delay in diagnosis of HS is common and the pathogenesis remains unclear. Histological
© 2014 European Academy of Dermatology and Venereology
Shavit et al.
372
studies suggest that HS is a multifocal disease, in which atrophy of the sebaceous glands is followed by an early lymphocytic inflammation and hyperkeratosis of the pilosebaceous unit, and later by hair-follicle destruction and granuloma formation.8 Hidradenitis suppurativa is a clinical diagnosis, usually made by a dermatologist. On physical examination, inflammatory nodules, abscesses and sinus tracts are found, some or all of which can be found in the anogenital, inguinal and axillary regions. Small sample studies have shown a possible association between HS and depression.9–11 Nevertheless, HS has only rarely been associated with anxiety or any other psychiatric disorders. Most of the studies were anecdotal or based on small sample sizes.9–11 Since HS is a suppurative disease and the discharges produce a foul odour, it is correct to claim that the symptoms are not only physical. Moreover, the disease affects ‘sensitive’ areas such as the axilla and the genitals, leading to embarrassment and affecting interpersonal relationships, self-esteem and even public image perception. We have therefore speculated that the psychological and psychiatric impact of this disease is tremendous. In this study, we examined the possible association between HS and several psychiatric disorders, including depression, anxiety, psychoses, schizophrenia and bipolar disorder.
Material and methods The study was conducted in Clalit, the largest managed care organization in Israel. Clalit serves a population of more than 4.1 million enrollees. Clalit has a comprehensive computerised database with continuous real-time input from pharmaceutical, medical and administrative computerised operating systems. This Registry combines the diagnoses registered by physicians working in hospitals and in outpatient clinics. The psychiatric diagnoses are registered only by physicians working in hospitals and in the outpatient clinics of Clalit; these data combine both psychiatric diagnoses and psychiatric medications given to these patients. The information from psychiatric hospitals is classified and not accessible. Nevertheless, the validity of Clalit’s registry of diagnoses has previously been found to be high.12 In recent years, we have utilized the Clalit database to study disease associations in patients with psoriasis,13–17 pemphigus,18 lichen planus19 and mycosis fungoides.20 The study was designed as a cross-sectional study using data mining techniques utilizing the Clalit database. Patients were defined as having HS when there was at least one documented diagnosis of HS in the medical records between 1997 and 2011, registered by a Clalit dermatologist (3207 patients). Patients without HS consisted of a computer-selected random sample of the general population of Clalit enrollees without HS (6412 patients). Study and control group patients were age and gender matched.
JEADV 2015, 29, 371–376
The proportion of patients with HS and the associated disease was compared between patients with and without HS by univariate analyses. Chi-squared tests have been used to compare categorical parameters between the groups. T-tests have been used to compare continuous parameters between the groups. Logistic regression models have been used to measure the association between HS and the psychiatric comorbidities, while controlling for confounders. Statistical analysis was performed using SPSS software, version 19 (Chicago, IL, USA). The study was approved by the Institutional Review Board of Meir Medical Center.
Results The study included 3207 patients with HS and 6412 age- and gender-matched patients without HS. Most of the patients with HS were women (61.6%). Also, the vast majority of the patients suffering from HS were in the younger age group, namely, between 21 and 50 years of age; fewer patients were shown in the younger and older age groups (e.g. 0.2% for the 1–10 years and 2.2% for the 71–80 years age groups). These data are in accordance with the literature.5–7 The socio-demographic characteristics of study participants are summarised in Table 1. The univariate association between HS and mental comorbidities is shown in Table 2. Depression was diagnosed in 5.9% of patients with HS, compared with 3.5% of patients without HS [P < 0.001, odds ratio (OR) = 1.7, 95% confidence interval (CI): 1.4–2.1]. Anxiety was diagnosed in 3.9% of patients with HS, compared with 2.4% of patients without HS (P < 0.001; OR = 1.7, 95% CI: 1.3–2.2). Psychoses were diagnosed in 1.3% of patients with HS, compared with 0.8% of patients without HS (P = 0.03; OR = 1.5, 95% CI: 1.0–2.3). There was also a trend of association towards other psychiatric diagnoses, including schizophrenia and bipolar disorder, although these were not statistically significant (Table 2). Depression was more prevalent in women than in men, in both patients with HS (4.2% in women vs. 1.7% in men) and patients without HS (2.5% vs. 1.1% respectively). The association between depression and HS persisted in both females and males, and was significant in patients aged 21–50 years. Anxiety was also more prevalent in women than in men, in both patients with HS (2.6% vs. 1.2%) and patients without HS (1.5% vs. 0.8% respectively; Table 3). The association between anxiety and HS was statistically significant in females, but not in males or in patients aged 21–50 years. In logistic regression models, the multivariate association between HS and depression was found to be statistically significant (P-value < 0.001, OR = 1.7, 95% CI: 1.4–2.1). Similarly, the multivariate association between HS and anxiety was found to be statistically significant (P < 0.001; OR = 1.7, 95% CI: 1.3– 2.1; Table 4).
© 2014 European Academy of Dermatology and Venereology
Psychiatry and hidradenitis suppurativa
373
Table 1 Socio-demographic characteristics of the study population HS patients (N = 3207)
N
P-value
Patients without HS (N = 6412) N
%
%
Age group (years) 1–10
6
0.2
10
11–20
242
7.5
484
7.5
21–30
864
26.9
1728
26.9
31–40
766
23.9
1532
23.9
41–50
508
15.8
1016
15.8
51–60
482
15.0
964
15.0
61–70
226
7.0
452
7.0
71–80
71
2.2
142
2.2
81–90
37
1.2
74
1.2
91–100
5
0.2
10
0.2
39.6 15.5
Mean age Range (years)
0.2
1
39.6 15.5
4–99
4–99
Gender Male
1232
38.4
2464
38.4
Female
1975
61.6
3948
61.6
0.505
Due to matching for age and gender, all P-values were not statistically significant (>0.05).
Table 2 Uni-variable analyses: association between HS mental comorbidities HS patients (N = 3207) N
Patients without HS (N = 6412) %
N
OR (95% CI)
P-value
%
Psychoses
42
1.3
53
0.8
1.5 (1.0–2.3)
0.03
Schizophrenia
51
1.5
75
1.1
1.3 (0.9–1.9)
0.09
Bipolar disorder
13
0.4
12
0.1
2.1 (0.9–4.7)
0.06
Depression
189
5.8
227
3.5
1.7 (1.4–2.0)
