Dermatological Conditions in Skin of Color—Overburdened and Undertreated: Hidradenitis Suppurativa in Skin of Color

by Archana M. Sangha, MMS, PA-C

Ms. Sangha is a senior medical science liaison for Incyte Corporation in Wilmington, Delaware. Prior to that, she spent over a decade as a dermatology PA specializing in general, surgical, and cosmetic dermatology. She is a fellow of the American Academy of Physician Assistants in Alexandria, Virginia. She is also a Past President of the Society of Dermatology Physician Assistants.

Funding: No funding was provided for this article.

Disclosures: Ms. Sangha is an employee of Incyte Corporation in Wilmington, Delaware.

J Clin Aesthet Dermatol. 2024;17(7–8 Suppl 1):S38–S39.

Hidradenitis suppurativa (HS) is a devastating chronic inflammatory disease. Its cutaneous manifestations are characterized by painful nodules, abscesses, sinus tracts, and scarring.¹ It is also associated with numerous comorbid conditions, such as cardiovascular disease and inflammatory bowel disease, as well as psychological diseases.² HS was found to have the greatest disease burden among all chronic dermatological disorders.³ This article will highlight HS in skin of color (SOC) patients.

Longer Delay in Diagnosis

From the time of symptom presentation to diagnosis of HS, there is an estimated 7 to 10 year delay in diagnosis.⁴ Interestingly, numerous studies have found that patients with the longest diagnostic delay had seen the most number of physicians before being correctly diagnosed (nearly 5).^4–7

In a study by Serrano et al,⁸ this diagnostic delay was found to be 1.62 times greater for Black patients than White patients. This diagnostic delay is of no small consequence. The longer the delay in diagnosis, the more severe the disease and the greater the number of comorbidities.⁵ In fact, one study found that Black patients were nearly three times more likely to have Hurley Stage III disease than White patients.⁹ Prompt diagnosis and care is necessary to minimize this diagnostic delay gap.

Black Patients Often See Surgery Before Dermatology for HS Management

Research has shown that Black patients were more likely to have seen surgery (44.9%) before dermatology as opposed to White patients (31.6%). The authors suggested that this might be due to greater disease severity at time of presentation or difficulty accessing dermatological care.⁸

Studies have shown that SOC patients are less likely to visit dermatology overall. In a retrospective analysis, it was found that non-Hispanic White patients had more than double the number of dermatology outpatient visits than Hispanic or Black patients. These differences in dermatological visits could be due to multiple reasons, such as access to care, cultural beliefs, and low socioeconomic class. More studies are needed to investigate possible causes for this discrepancy in seeking dermatological care among non-White patients.¹⁰

Black Patients Are More Likely to Experience Severe Pain Related to HS

The primary symptom associated with the greatest disease burden in HS is pain. One study found that over half of the 537 survey respondents missed at least two days of work per month due to HS-related pain. What’s more concerning is that, annually, the mean number of days missed was 34.7.¹¹ Considering that on average, employees in the United States (US) receive eight days per year for sick leave, you can begin to understand the large disease burden.¹²

Black patients were found to be four times more likely to experience severe HS-related pain than non-Black patients.¹³ However, one study showed that Black patients were less likely than White patients to be prescribed opioids and neuropathic agents for HS pain management.¹⁴ Unsurprisingly, Black patients (26.7%) were more likely to be dissatisfied with their pain management than non-Black patients (15.5%).¹⁵

It is important to ask patients about their pain and to address it appropriately.

Characteristic HS Lesions Present Differently in Skin of Color

HS diagnosis is dependent on lesion morphology, lesion location, and lesion progression or persistence.¹⁶ The characteristic lesion morphology of HS is often described as inflammatory nodules or abscesses. In SOC, erythema often presents as violaceus, gray, or brown versus the characteristic pink or red seen in White skin. A clinical pearl is to look for signs of postinflammatory hyperpigmentation in common HS areas, as this would indicate signs/history of erythema.

Hispanic Patients Are More Likely to Have Major Depression

Major depressive disorder was found to impact 33 percent of all patients with HS.¹⁷ In a study that oversampled Black and Hispanic patients, Hispanic patients were found to have higher rates of depression than White patients (11% vs. 8%).¹⁸ One study found that despite the well-known psychological comorbidities of HS, only two percent of HS visits screened for depression.¹³

More studies are needed to understand the psychosocial comorbidities in HS among different races. It is important to screen your patients for depression and refer them to appropriate care if necessary.

Disease Presentation Might Differ in Non-Western Populations

In a systematic review and meta-analysis study of East and Southeast Asian patients, HS was more common in male individuals.¹⁹ This is the opposite of what is seen in the US, where HS affects women two times more than men.²⁰ Approximately half of patients developed lesions on the axilla and gluteal areas.¹⁹

In a study of over 800 patients in Nigeria, the HS prevalence was found to be 2.2 percent. Male and female individuals were equally affected, and the axilla was the most common site affected. Interestingly, unlike the US, there was no significant difference in body mass index between the HS and control groups.^21,22

It’s important to recognize that there remains a gap in HS research across different ethnicities. This research is needed so that we can better understand the heterogeneity of the disease and therefore diagnose it earlier and manage it more effectively.

References

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