Original article
Association between hidradenitis suppurativa, depression, anxiety, and suicidality: A systematic review and meta-analysis

https://doi.org/10.1016/j.jaad.2019.11.068Get rights and content

Background

Previous studies found conflicting results about whether hidradenitis suppurativa (HS) is associated with depression or anxiety.

Objectives

To determine the relationship of HS with depression and anxiety.

Methods

A systematic review was performed of published observational studies in MEDLINE, PubMed, Embase, Global Resource for Eczema Trials (GREAT), Latin American and Caribbean Health Sciences Literature (LILACS), Cochrane, Scopus, and PsychInfo that analyzed depression or anxiety in HS. Two reviewers performed title/abstract review and data extraction. Meta-analysis was performed with random-effects weighting.

Results

Thirty-eight studies met inclusion criteria; 27 had sufficient data for meta-analysis. The prevalences of depression (26.5% vs 6.6%) and anxiety (18.1% vs 7.1%) were higher in persons with versus without HS. Patients with HS had higher odds of depression in 12 of 13 studies and pooled analysis (odds ratio, 2.54; 95% confidence interval, 2.15-3.01), and anxiety in 6 of 6 studies and pooled analysis (odds ratio, 2.00; 95% confidence interval, 1.66-2.42). Similar results were found in sensitivity analyses for different methods of HS diagnosis (physician diagnosed and chart review) and control groups (healthy and dermatologic control individuals). HS was associated with higher antidepressant and anxiolytic use and with suicidality, but not mean depression and anxiety scale scores.

Limitations

Individual-level data were unavailable.

Conclusions

Patients with HS have higher odds of depression, anxiety, and suicidality.

Section snippets

Literature search

The following databases were searched for articles from the earliest entry in the respective databases up to May 9, 2018: MEDLINE, PubMed, EMBASE, Cochrane Library, Latin American and Caribbean Health Sciences (LILACS), Scopus, PsychInfo, and Global Resource for Eczema Trials (GREAT). Search strategies were modified from previous reviews of HS,8 anxiety,9 and depression and suicidal ideation10 (Supplemental Table I available via Mendeley at https://data.mendeley.com/datasets/bnj8znmdwp/1).

Literature search

Overall, 1036 nonduplicate citations were identified; 907 were excluded during title and abstract review, and 91 were excluded during full-text review. Thirty-eight observational studies met inclusion/exclusion criteria and were included in this systematic review, as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Fig 1)11; 27 articles were included in the quantitative meta-analyses.

Study characteristics

All studies were published from 1963 through 2018.

Discussion

This systematic review and meta-analysis found that approximately 1 in 4 adults with HS had depression and that 1 in 5 had anxiety (summarized in Table I). Specifically, adults with HS had significantly higher odds of depression and anxiety, regardless of the study design, control population, and disease classification. Patients with HS had higher rates of antidepressant and anxiolytic medication use. HS was associated with increased depression and/or anxiety scores in some studies in the

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      Also associated with significant morbidity, HS is associated with increased mortality, in particular owing to cardiovascular events, with increased cancer risk also recorded (Egeberg et al., 2016; Jung et al., 2020). Depression, anxiety, and substance misuse are also common (Garg et al., 2018; Patel et al., 2020). The cause of HS is incompletely understood, with follicular occlusion; dysregulated inflammatory response of cytokines such as TNF-α, IL-1β, and IL-17; and an altered microbiota thought to play a role (Balato et al., 2019; Guet-Revillet et al., 2014; Kelly et al., 2015; Nikolakis et al., 2015; Ring et al., 2015; Sabat et al., 2020; von Laffert et al., 2010).

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    Dr Patel and Mr Lee are cofirst authors.

    Funding sources: None.

    Conflicts of interest: None disclosed.

    Accepted for publication November 22, 2019.

    IRB approval status: Not applicable.

    Reprints not available from the authors.

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