Translate this page into:
Unraveling the mental health burden of hidradenitis suppurativa
*Corresponding author: Abhineetha Hosthota, Department of Dermatology, The Oxford Medical College Hospital and Research Centre, Bengaluru, Karnataka, India. abhineethahosthota@yahoo.com
-
Received: ,
Accepted: ,
How to cite this article: Hosthota A, Bondade S, Chitturi B, Bharti A, Nilofer A. Unraveling the mental health burden of hidradenitis suppurativa. CosmoDerma. 2025;5:49. doi: 10.25259/CSDM_12_2025
Abstract
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.
Keywords
Hidradenitis suppurativa
Mental health
Psychiatric comorbidity
Psychodermatology
Quality of life
INTRODUCTION
Hidradenitis suppurativa (HS) is not just a dermatological condition, it is a complex disease with profound physical, emotional, and psychological repercussions. HS presents as painful, deep-seated inflammatory lesions in apocrine gland-bearing areas, primarily affecting the axillae, inguinal, and anogenital regions. Patients endure recurrent nodules, abscesses, sinus tract formation, and scarring, leading to chronic pain, malodor, and discharge. These symptoms significantly impact the quality of life (QoL) and contribute to a growing mental health crisis among HS sufferers.[1] Despite its debilitating nature, HS remains underdiagnosed and underrecognized, particularly concerning its psychiatric comorbidities.
This article explores the intricate link between HS and mental health, shedding light on the psychosocial burden of the disease and emphasizing the need for a multidisciplinary approach that integrates dermatologic and psychiatric care.
THE OVERLOOKED PSYCHIATRIC BURDEN
While HS has long been associated with systemic comorbidities such as metabolic syndrome, cardiovascular disease, diabetes, and inflammatory bowel disease, its psychiatric impact is often overlooked.[1] Mounting evidence suggests that HS patients are at significantly higher risk of mental health disorders than the general population. Depression, anxiety, bipolar disorder, psychosis, schizophrenia, substance abuse, and suicidal ideation are all disproportionately prevalent among individuals with HS.
Studies estimate that one in four adults with HS suffers from depression, while one in five experiences anxiety. The risk of completed suicide is more than twice as high in HS patients compared to those with psoriasis, highlighting the urgent need for mental health screenings in dermatologic practice.[2,3] Chronic pain, recurrent flares, social stigma, and absenteeism from work and social activities further exacerbate psychological distress. HS patients frequently report feelings of embarrassment, self-consciousness, social isolation, sexual dysfunction, and unemployment, all of which contribute to emotional exhaustion and reduced self-esteem.
PATHOPHYSIOLOGY: THE SKIN-BRAIN CONNECTION
The interplay between chronic inflammation and psychological stress plays a crucial role in the psychiatric burden of HS. The immune and nervous systems are intimately connected, and persistent inflammation in HS may contribute to neuroinflammation. Elevated levels of pro-inflammatory cytokines, such as TNF-α, IL-1β, and IL-6, have been detected in patients with major depression, schizophrenia, and bipolar disorder. These inflammatory mediators disrupt the blood-brain barrier, leading to monocyte infiltration, microglial activation, and dopaminergic dysregulation, which have been implicated in psychiatric illnesses[4,5] [Table 1].
| Feature | Potential mechanisms | Impact |
|---|---|---|
| Psychiatric comorbidities | Shared inflammatory pathways, HPA axis dysregulation, psychosocial stress | Increased psychological burden, reduced QoL, potential for self-harm |
| Inflammation | Increased levels of pro-inflammatory cytokines (TNF-α, IL-1β, IL-6), microglia activation, disruption of the blood-brain barrier | Contribute to the development of psychiatric comorbidities |
| Psychosocial impact | Negative body image, social isolation, internalization of feelings of shame and hopelessness | Embarrassment, social stigma, sexual dysfunction, unemployment, reduced participation in social activities |
| Impact on QoL | Chronic pain, recurrence of HS, sleep disturbances, functional impairment | Reduced physical and emotional well-being, limitations in daily activities and social participation |
| Management | Use of validated screening tools, establishment of therapeutic alliance | Timely intervention and support to prevent the development or worsening of psychiatric comorbidities |
TNF-α: Tumor necrosis factor-alpha, IL: Interleukin, HS: Hidradenitis suppurativa, QoL: Quality of life, HPA: Hypothalamic-pituitary-adrenal.
The chronic, relapsing nature of HS fosters a cycle of stress and immune dysregulation, exacerbating both psychological distress and disease severity. This bi-directional relationship suggests that managing psychiatric comorbidities may also improve HS outcomes, making an integrated approach to care even more critical.
PSYCHOSOCIAL IMPACT AND STIGMATIZATION
HS extends far beyond its physical manifestations. The visible, malodorous, and painful nature of the disease leads to stigma and social avoidance, often affecting personal relationships, professional opportunities, and overall well-being. Many patients withdraw from intimate relationships and social interactions, fearing rejection or embarrassment due to visible lesions, scarring, and odor.
Sexual dysfunction is another overlooked yet significant issue in HS patients, further impairing mental health. The psychological toll of the disease is particularly devastating in younger patients, whose personal and professional aspirations are frequently derailed by low self-esteem and chronic absenteeism[4] [Table 1].
Substance abuse has also been reported as a coping mechanism among HS patients, with studies indicating that 4% of affected individuals engage in alcohol, opioid, or cannabis use.[3] This highlights the importance of early psychological interventions to prevent maladaptive coping strategies and ensure holistic disease management.
THE NEED FOR A MULTIDISCIPLINARY APPROACH
Given the significant psychiatric burden of HS, a multidisciplinary approach is essential. Early psychosocial evaluations during clinical visits can help identify patients at risk of emotional distress. Validated screening tools such as the dermatology life quality index and patient health questionnaire can facilitate early detection of mental health concerns.[2]
Routine collaboration between dermatologists, psychiatrists, and psychologists should be a cornerstone of HS management. Timely referrals to mental health specialists can mitigate psychological distress, reduce suicidal risk, and enhance overall well-being. Moreover, addressing psychiatric comorbidities may lead to improved disease control, given the link between stress, inflammation, and HS flares.
SCOPE IN FUTURE
Despite growing awareness of the psychiatric impact of HS, significant gaps remain in research and clinical practice. Prospective studies and clinical trials are needed to clarify the cause-and-effect relationship between HS and psychiatric disorders. Understanding how mental health interventions influence disease outcomes will be a key to developing more effective, patient-centered treatment strategies.
Greater awareness among healthcare providers is also necessary to ensure early recognition and intervention. Medical education curricula should emphasize the psychological burden of HS, encouraging dermatologists to adopt a more holistic and empathetic approach to patient care.
CONCLUSION
HS is more than a dermatological disease – it is a systemic condition with profound mental health implications. The chronic pain, recurrent lesions, social stigma, and psychiatric comorbidities associated with HS contribute to one of the most severe QoL impairments among dermatological conditions. Recognizing the bidirectional relationship between inflammation and mental health is crucial in ensuring comprehensive patient care.
An interdisciplinary approach integrating dermatologic, psychiatric, and psychosocial support can significantly improve outcomes for HS patients. By prioritizing mental health screenings, early interventions, and holistic treatment strategies, healthcare providers can help break the cycle of physical and psychological distress, ultimately enhancing the QoL for individuals living with HS.
Ethical approval
Institutional Review Board approval is not required.
Declaration of patient consent
Patient’s consent is not required, as there are no patients in this study.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- Comorbidities of hidradenitis suppurativa: A review of the literature. Int J Womens Dermatol. 2019;5:330-34.
- [CrossRef] [PubMed] [Google Scholar]
- Psychiatric comorbidities in patients with hidradenitis suppurativa. Dermatol Ther. 2020;33:e13541.
- [CrossRef] [Google Scholar]
- Hidradenitis suppurativa: Epidemiology, clinical presentation, and pathogenesis. J Am Acad Dermatol. 2020;82:1045-58.
- [CrossRef] [PubMed] [Google Scholar]
- Hidradenitis suppurativa: An update on epidemiology, phenotypes, diagnosis, pathogenesis, comorbidities and quality of life. J Eur Acad Dermatol Venereol. 2021;35:50-61.
- [CrossRef] [PubMed] [Google Scholar]
- Hidradenitis suppurativa burdens on mental health: A literature review of associated psychiatric disorders and their pathogenesis. Life (Basel). 2023;13:189.
- [CrossRef] [PubMed] [Google Scholar]
