Title: Hidradenitis suppurativa markedly decreases quality of life and professional activity
Abstract: To the Editor: We read with great interest the comprehensive review by Alikhan et al1Alikhan A. Lynch P.J. Eisen D.B. Hidradenitis suppurativa: a comprehensive review.J Am Acad Dermatol. 2009; 60: 539-561Abstract Full Text Full Text PDF PubMed Scopus (469) Google Scholar in the April 2009 issue of the Journal and would like to comment on our own recent findings regarding hidradenitis suppurativa (HS) and the Dermatology Life Quality Index (DLQI). Our study was conducted on a group of 54 Polish patients (28 women, 26 men) between 16 and 65 years of age (mean, 39.94 ± 11.63 years) suffering from HS diagnosed in accordance with the well established clinical criteria.2Poli F. Jemec G.B. Revuz J. Clinical presentation.in: Jemec G.B. Revuz J. Leyden J.J. Hidradenitis suppurativa. Springer, Heidelberg, Germany2006: 11-24Crossref Scopus (53) Google Scholar The disease duration ranged from 1.5 to 36 years (mean, 10.16 ± 7.64 years). Clinical manifestation of disease staging was based on the three-degree scale proposed by Hurley.3Hurley H. Dermatologic surgery, principles and practice. Marcel Dekker, New York1989Google Scholar Among our subjects, 13 patients (24.1%) were diagnosed as exhibiting first-degree disease severity, 29 patients (53.7%) fulfilled the criteria for second-degree severity, and 12 patients (22.2%) suffered from the third-degree severity of HS. Males and females showed similar morbidity rates (male:female ratio, 0.93). For quality of life (QOL) evaluations, we used the validated Polish version of the DLQI questionnaire developed in 1994 by Finlay and Khan.4Finlay A.Y. Khan G.K. Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use.Clin Exp Dermatol. 1994; 19: 210-216Crossref PubMed Scopus (3463) Google Scholar Global Question (GQ) indexing was used to determine the relationship between DLQI scores (0-30 points) and patients' views on the overall impairment of their skin-related quality of life. The scoring was as follows: GQ = 0 (0-1 = no effect at all on patient's life); GQ = 1 (2-5 = small effect on patient's life); GQ = 2 (6-10 = moderate effect on patient's life); GQ = 3 (11-20 = very large effect on patient's life); and GQ = 4 (21-30 = extremely large effect on patient's life).5Hongbo Y. Thomas C.L. Harrison M.A. Salek M.S. Finlay A.Y. Translating the science of quality of life into practice: what do dermatology life quality index scores mean?.J Invest Dermatol. 2005; 125: 659-664Crossref PubMed Scopus (535) Google Scholar The study was approved by the local ethical committee, and written informed consents were obtained from all studied individuals. Statistical analysis was performed using the Mann-Whitney U test, the Kruskal–Wallis test, and the Spearman rank correlation coefficient. P < .05 was considered statistically significant. Two of studied individuals refused to fill out the questionnaire. The mean DLQI score among our HS sufferers (n = 52) was assessed as 12.67 ± 7.7 (range, 1-30; median, 12). Statistically significant differences (P < .0001) regarding DLQI scores between each of particular group (according to the Hurley classification) were found. The patients with more severe disease had markedly higher DLQI scores (5.77 ± 4.59, 13.1 ± 6.41, and 20.4 ± 6.67 for Hurley I, II, and III classifications, respectively; Table I, available online at www.eblue.org). Moreover, a statistically significant, strong positive correlation between DLQI scores and disease activity was shown (R = 0.67; P < .0001). Further analysis of the questionnaire revealed a slight but statistically significant positive correlation between DLQI scores and the number of skin areas (range, 0-8) involved in HS lesions (R = 0.28; P = .045). In addition, the anogenital localization (with reference to any other body regions [eg, axillas, groins, head, and nape]) displayed a significant impact on QOL (P = .0051). The DLQI mean score for anogenital involvement was assessed as 14.69 ± 7.15, whereas 9.45 ± 7.61 was found for other localizations. Other factors, including gender of the patients, their place of residence, level of education, employment status, age of HS onset, and HS duration did not reveal significant relationships. The analysis of grade of HS impact on sufferers' QOL expressed by GQ indexing showed that the disease had no effect at all on the patient's life for only one (1.92%) patient (GQ = 0). For nine patients (17.31%), this influence had a small effect (GQ = 1), for 11 patients (21.15%), it had a moderate effect (GQ = 2), for 21 patients (40.38%) it had a very large effect (GQ = 3), and for the additional 10 patients (19.23%) it had an extremely large effect (GQ = 4; Fig 1, available online at www.eblue.org). The disease caused the work absence of 58.1% of patients among the 30 employed and professionally active HS patients. Annually, the absence from work caused by HS occurred from one to 10 times (mean, 2.9 ± 2.4 times). Furthermore, the mean absence from work duration was assessed as 33.6 ± 26.1 days (range, 3-96 days). During 2 years of follow-up, three employees (10%) were dismissed from work because of the frequent absences and inability to perform their work duties properly. Moreover, the next seven individuals (23.3%) reported that they were unable to be promoted or experienced disease-related obstacles to promotion or advancement. Studies concerning QOL in HS patients are very limited6von der Werth J.M. Jemec G.B. Morbidity in patients with hidradenitis suppurativa.Br J Dermatol. 2001; 144: 809-813Crossref PubMed Scopus (264) Google Scholar, 7Wolkenstein P. Loundou A. Barrau K. Auquier P. Revuz J. Quality of life impairment in hidradenitis suppurativa: a study of 61 cases.J Am Acad Dermatol. 2007; 56: 621-623Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar and usually were performed for the assessment of anti–tumor necrosis factor-alfa agent efficacy.8Cusack C. Buckley C. Etanercept: effective in the management of hidradenitis suppurativa.Br J Dermatol. 2006; 154: 726-729PubMed Google Scholar, 9Fardet L. Dupuy A. Kerob D. Levy A. Allez M. Begon E. et al.Infliximab for severe hidradenitis suppurativa: transient clinical efficacy in 7 consecutive patients.J Am Acad Dermatol. 2007; 56: 624-628Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 10Giamarellos-Bourboulis E.J. Pelekanou E. Antonopoulou A. Petropoulou H. Baziaka F. Karagianni V. et al.An open-label phase II study of the safety and efficacy of etanercept for the therapy of hidradenitis suppurativa.Br J Dermatol. 2008; 158: 567-572Crossref PubMed Scopus (113) Google Scholar, 11Mekkes J.R. Bos J.D. Long-term efficacy of a single course of infliximab in hidradenitis suppurativa.Br J Dermatol. 2008; 158: 370-374Crossref PubMed Scopus (98) Google Scholar According to our findings, the HS impact on QOL was estimated as having a large or extremely large effect on the patient's life in nearly 60% of examined patients. A great effect on QOL was also shown in a study from Denmark by von der Werth and Jemec.6von der Werth J.M. Jemec G.B. Morbidity in patients with hidradenitis suppurativa.Br J Dermatol. 2001; 144: 809-813Crossref PubMed Scopus (264) Google Scholar In contrast to our results, von der Werth and Jemec6von der Werth J.M. Jemec G.B. Morbidity in patients with hidradenitis suppurativa.Br J Dermatol. 2001; 144: 809-813Crossref PubMed Scopus (264) Google Scholar uncovered a negative relationship between age at disease onset and DLQI scores. The results found for HS in our study showed greater QOL impairment than those found in some other dermatoses, including psoriasis,12Gladman D.D. Mease P.J. Cifaldi M.A. Perdok R.J. Sasso E. Medich J. Adalimumab improves joint-related and skin-related functional impairment in patients with psoriatic arthritis: patient-reported outcomes of the Adalimumab Effectiveness in Psoriatic Arthritis Trial.Ann Rheum Dis. 2007; 66: 163-168Crossref PubMed Scopus (105) Google Scholar, 13Revicki D. Willian M.K. Saurat J.H. Papp K.A. Ortonne J.P. Sexton C. et al.Impact of adalimumab treatment on health-related quality of life and other patient-reported outcomes: results from a 16-week randomized controlled trial in patients with moderate to severe plaque psoriasis.Br J Dermatol. 2008; 158: 549-557Crossref PubMed Scopus (134) Google Scholar, 14Tyring S. Gottlieb A. Papp K. Gordon K. Leonardi C. Wang A. et al.Etanercept and clinical outcomes, fatigue, and depression in psoriasis: double-blind placebo-controlled randomised phase III trial.Lancet. 2006; 367: 29-35Abstract Full Text Full Text PDF PubMed Scopus (889) Google Scholar atopic dermatitis,15Holm E.A. Wulf H.C. Stegmann H. Jemec G.B. Life quality assessment among patients with atopic eczema.Br J Dermatol. 2006; 154: 719-725Crossref PubMed Scopus (180) Google Scholar, 16Misery L. Finlay A.Y. Martin N. Boussetta S. Nguyen C. Myon E. et al.Atopic dermatitis: impact on the quality of life of patients and their partners.Dermatology. 2007; 215: 123-129Crossref PubMed Scopus (105) Google Scholar acne vulgaris,17Klassen A.F. Newton J.N. Mallon E. Measuring quality of life in people referred for specialist care of acne: comparing generic and disease-specific measures.J Am Acad Dermatol. 2000; 43: 229-233Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 18Matsuoka Y. Yoneda K. Sadahira C. Katsuura J. Moriue T. Kubota Y. Effects of skin care and makeup under instructions from dermatologists on the quality of life of female patients with acne vulgaris.J Dermatol. 2006; 33: 745-752Crossref PubMed Scopus (62) Google Scholar alopecia,19Williamson D. Gonzalez M. Finlay A.Y. Quality of life in patients with hair loss.Br J Dermatol. 1997; 137: 47Google Scholar Darier disease,20Harris A. Burge S.M. Dykes P.J. Finlay A.Y. Handicap in Darier's disease and Hailey–Hailey disease.Br J Dermatol. 1996; 135: 959-963Crossref PubMed Scopus (52) Google Scholar Hailey–Hailey disease,20Harris A. Burge S.M. Dykes P.J. Finlay A.Y. Handicap in Darier's disease and Hailey–Hailey disease.Br J Dermatol. 1996; 135: 959-963Crossref PubMed Scopus (52) Google Scholar and even chronic urticaria.21Grob J.J. Auquier P. Dreyfus I. Ortonne J.P. Quality of life in adults with chronic idiopathic urticaria receiving desloratadine: a randomized, double-blind, multicentre, placebo-controlled study.J Eur Acad Dermatol Venereol. 2008; 22: 87-93PubMed Google Scholar Wolkenstein et al7Wolkenstein P. Loundou A. Barrau K. Auquier P. Revuz J. Quality of life impairment in hidradenitis suppurativa: a study of 61 cases.J Am Acad Dermatol. 2007; 56: 621-623Abstract Full Text Full Text PDF PubMed Scopus (296) Google Scholar also noted a significantly greater HS impact on QoL than observed in chronic urticaria, atopic dermatitis, and psoriasis. Tabled 1Comparison of our Dermatology Life Quality Index scores with those obtained by von der Werth and Jemec7Wolkenstein P. Loundou A. Barrau K. Auquier P. Revuz J. Quality of life impairment in hidradenitis suppurativa: a study of 61 cases.J Am Acad Dermatol. 2007; 56: 621-623Abstract Full Text Full Text PDF PubMed Scopus (296) Google ScholarStudyvon der Werth and JemecCurrent studyDLQI total8.9 ± 8.312.67 ± 7.7Min-max (median)0-29 (7)1-30 (12)DLQI by Hurley stage IN/A5.77 ± 4.59 IIN/A13.1 ± 6.41 IIIN/A20.4 ± 6.67DLQI domains Symptoms and feelings2.723.06 ± 1.5 Daily activities1.952.62 ± 1.81 Leisure1.572.37 ± 1.77 Work or school0.821.25 ± 1.31 Personal relationships1.552.42 ± 2.17 Treatment0.640.96 ± 0.97DLQI, Dermatology Life Quality Index; HS, hidradenitis suppurativa; N/A, not available. Open table in a new tab DLQI, Dermatology Life Quality Index; HS, hidradenitis suppurativa; N/A, not available. Hidradenitis suppurativa: A comprehensive reviewJournal of the American Academy of DermatologyVol. 60Issue 4PreviewHidradenitis suppurativa, also known as acne inversa, is a chronic, often debilitating disease primarily affecting the axillae, perineum, and inframammary regions. Prevalence rates of up to 4% have been estimated. Our understanding of the disease has changed over time. It is now considered a disease of follicular occlusion rather than an inflammatory or infectious process of the apocrine glands. Clinically, the disease often presents with tender subcutaneous nodules beginning around puberty. The nodules may spontaneously rupture or coalesce, forming painful, deep dermal abscesses. Full-Text PDF