   |
|
E-IJD EPIDEMIOLOGY ROUND |
|
| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 835 |
|
| Perception and knowledge of Hidradenitis Suppurativa in Greece: A cross-sectional study of 1301 individuals |
|
|
Aikaterini I Liakou1, Marios Papadakis2, Andreas G Tsantes3, Konstantina A Tsante3, Georgios Kontochristopoulos1, Ioannis Marnelakis1, Alexandros Katoulis4, Stamatios Grigoriou1, Dimitris Rigopoulos1
1 Department of Dermatology-Venereology, National and Kapodistrian University of Athens, Faculty of Medicine, “Andreas Sygros” Hospital for Cutaneous and Venereal Diseases, Athens, Greece
2 University of Witten Herdecke, Department of Surgery II, Wuppertal, Germany
3 Laboratory of Haematology and Blood Bank Unit, National and Kapodistrian University of Athens, Athens, Greece
4 Second Department of Dermatology-Venereology, National and Kapodistrian University of Athens, Faculty of Medicine, “Attikon” General University Hospital, Athens, Greece
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Aikaterini I Liakou
First Department of Dermatology-Venereology, National and Kapodistrian University of Athens, Faculty of Medicine, Andreas Sygros Hospital for Cutaneous and Venereal Diseases, 5 I. Dragoumi Street, GR-16121, Kaisariani, Athens
Greece
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_622_21
|
|
 Abstract | | |
Background: Hidradenitis suppurutiva (HS) is a chronic auto-inflammatory disease with recurrent painful deep-seated nodules. Aims: The aim of this study was to qualitatively assess patients' perception for HS. Methods: A descriptive two-step questionnaire survey was conducted from January 2017 to December 2018. The survey was performed through self-assessed, online, standardized questionnaires. Clinico-epidemiological characteristics, medical history, comorbidities, personal perceptions and the impact of the disease on participants' professional and everyday life were recorded. Results: A total number of 1301 Greek people completed the questionnaire. Of them, 676 (52%) reported symptoms resembling HS, whereas 206 (16%) reported that have been officially diagnosed with HS. The mean age of the study group was 39.2 ± 11.3 years. More than half of the diagnosed patients (n = 110, 53.3%) reported that they developed their first symptoms between 12 and 25 years of age. Of the diagnosed patients (n = 206), the majority (n = 140, 68.0%) were females and active smokers (n = 124, 60.1%). Seventy-nine (n = 79, 38.3%) patients reported a positive family history for HS. Ninety-nine (n = 99, 48.1%) patients reported that HS has a negative effect on their social life, 95 (46.1%) on personal life, 115 (55.8%) on sexual life, 163 (79.1%) on their mental health and 128 (62.1%) on their overall quality of life. Conclusion: Our study showed that HS seems to be an underteated, time-consuming and cost-intensive disease.
Keywords: Epidemiology, Greece, Hidradenitis suppurutiva, quality of life, survey
How to cite this article:
Liakou AI, Papadakis M, Tsantes AG, Tsante KA, Kontochristopoulos G, Marnelakis I, Katoulis A, Grigoriou S, Rigopoulos D. Perception and knowledge of Hidradenitis Suppurativa in Greece: A cross-sectional study of 1301 individuals. Indian J Dermatol 2022;67:835 |
How to cite this URL:
Liakou AI, Papadakis M, Tsantes AG, Tsante KA, Kontochristopoulos G, Marnelakis I, Katoulis A, Grigoriou S, Rigopoulos D. Perception and knowledge of Hidradenitis Suppurativa in Greece: A cross-sectional study of 1301 individuals. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:835. Available from: https://www.e-ijd.org/text.asp?2022/67/6/835/370330 |
| Introduction | |  |
Hidradenitis Suppurativa (HS) is a chronic recurrent auto-inflammatory disease whic dramatically affects patients' quality of life. Patients develop painful deep-seated nodules in body areas that are rich in apocrine glands, while the disease goes through exacerbations and remissions throughout life. Lifestyle factors such as obesity and smoking have a significant impact on disease severity, whereas genetic predisposition has been also reported as a significant risk factor.[1]
The negative impact of HS on patients' quality of life (QoL) has been well-studied.[2],[3],[4] Several questionnaires and scales have been utilized to estimate this impact of HS, including the Dermatology Life Quality Index (DLQI), the Hospital Anxiety and Depression Scale (HADS), the UCLA Loneliness Scale (UCLA-Version 3), and the Rosenberg Self-Esteem Scale (RSES).[1] Disease severity (based on Hurley's staging) has been reported to correlate with QoL impairment, while also anogenital involvement, early onset of HS and disease activity have been shown to be closely associated with QoL.[3],[5] Last, female sex and late HS onset have been linked with poor sexual function.[3]
However, the low response rate and subsequently the small population size of the cross-sectional studies that have been published so far do not allow for conclusive findings to be drawn. The epidemiology and the impact of the disease on patients' life widely varies among different regions and countries, therefore comparisons between studies should be interpreted with caution. Moreover, despite the considerable number of studies for HS, some important aspects of the disease are still under-studied. The aim of this study is to qualitatively assess Greek patients' perception for HS, regarding treatment-, time- and cost-related issues. Secondarily, QoL issues were also investigated. To the best of our knowledge, this is the first study of this type to be performed in HS patients.
| Materials and Methods | | |
Participant recruitment
A descriptive two-step questionnaire survey was conducted from January 2017 to December 2018. The survey was performed through self-assessed, online, standardized questionnaires. Participants were informed about the survey through banners that were placed in Greek websites related to HS or when individuals were searching for specific terms in Google. The banners were setting questions such as “do you suffer from painful recurrent nodules in armpits or buttocks”. All respondents who clicked on these banners were redirected to the survey questionnaire, designed to filter out ineligible respondents.
Eligible respondents were those who were either diagnosed with HS or have presented symptoms that could indicate HS. No age, gender or area criteria were used. Methods are summarized in [Figure 1].
Questionnaire
The questionnaire contained 39 open and close-ended items, incorporated into 5 sections [Supplementary material]. The first section (screener), containing 4 questions, assessed the disease's presence, based on description of the symptoms (onset, duration, coexistence of skin lesions, exacerbations). Participants were asked if the diagnosis had already been established. In case of patients with established or suspected HS, further epidemiological data were evaluated, such as gender, age, age at presentation of first symptoms, area of residence, smoking status, type of insurance, educational level, monthly household income and disease severity. Disease severity was determined based on objective findings such as the number of exacerbations and the presence of fistulas, as well as on subjective measures such as the impact of the disease on patients' quality of life. The disease was classified as mild when the lesions were contained to one body area, there were 1-2 exacerbations per year, there was no fistula and the impact on quality of life was low. The disease was considered moderate when more than one body area was involved, there were 3-5 exacerbations per year, there were scars and the impact on quality of life was moderate. Finally, disease was classified as severe based on the presence of severe symptoms, frequent exacerbations, large scars and serious impact on quality of life. The disease severity was classified according to the Hurley classification.
The next section contained questions about any comorbidities (e.g. obesity, hypertension), medical consultations (specialties consulted and number of consultations before diagnosis was established), admissions to hospital, surgical treatment and effectiveness of antibiotics. In the last sections several aspects of patients' perception for HS were investigated such as any possible causes of the skin lesions, the effectiveness of other treatment modalities, cost related issues, and the impact on their professional activities and their quality of life (social, personal, sexual, psychological condition).
Statistical analysis
Statistical analysis included descriptive statistics of the study population. Data are presented with mean values, standard deviations, median values and interquartile ranges for continuous variables such as age. Categorical variables, such as gender, comorbidities and treatment measures, are presented with frequencies and percentages. The Chi-square test was used for comparison of disease severity with regards to comorbidities and other variables. In order to assess the association of disease severity stage and certain variables such as age, sex, gender, body mass index (BMI), smoking, family history and comorbidities, ordered logistic regression was performed. Odds ratios (OR) derived from the ordered logistic regression models refer to the odds of being in a more severe rather than less severe stage of disease, and are shown with their 95% confidence intervals (CI) and the respective P values. Statistical analysis was carried out using the R software, version 3.5.2. For all the tests, a P < 0.05 indicates statistical significance
| Results | | |
Overall, 1301 Greek participants answered the questionnaire. There were 676 (51.9%) participants among them who reported symptoms indicative of HS such as “pimples, knobs, abscesses, cysts, fistulas or scars in areas such as armpits or buttocks, and those symptoms were constant or have worsened more than once in the past 6 months”. Among the 676 participants with symptoms indicative of HS, 253 (37.4%) participants had relatives with similar skin lesions, almost half of them (n = 307, 45.4%) had 2-4 times exacerbations during the last months, while 118 (17.4%) had constant symptoms during the last six months. Last there were 206 (30.4%) participants who had been already diagnosed with HS.
Demographics of diagnosed patients (n = 206)
The mean age of the study group was 39.2 ± 11.3 years [Table 1]. The majority of the diagnosed patients (n = 206) were females (n = 140, 68.0%) and active smokers (n = 124, 60.1%). Among the diagnosed patients, 136 patients (66.0%) had public insurance, 47 (22.8%) had private insurance, and 23 (11.1%) had no insurance at all. Also, 79 (38.3%) patients reported a positive family history for HS. Among patients with severe disease, 23 (45.0%) patients had received basic and secondary education, 22 (43.1%) received higher education, and 6 (11.7%) patients had a Master Degree and/or PhD. On the contrary, among those with mild disease, 24 (33.3%) patients had received basic and secondary education, 37 (51.3%) patients had higher education, and 11 (15.2%) patients had a Master Degree and/or PhD. Higher education was associated with milder disease (p = 0.042), probably because patients with higher education have better access to healthcare or seek treatment sooner than patients with lower education.
Age at onset, age at diagnosis and comorbidities (n = 206)
More than half of the diagnosed patients (n = 110, 53.3%) reported that their first symptoms presented at the age between 12 and 25 years old. The same percentage (53.5%) had a quick reaction to their symptoms and visited a doctor within the first two months of the development of their first symptoms. However, the mean age of onset disease was 25.9 ± 8.2 years, while the mean age of diagnosis was 30.3 ± 8.2 years indicating that the average delay between first symptoms and diagnosis was 4.4 years [Table 2]. Comorbidities included overweight/obesity in 68 (33.0%) patients, dyslipidemia in 25 (11.1%), depression in 27 (13.1%), hypertension in 16 (7.8%), diabetes mellitus in 12 (5.7%), thyroid disease in 24 (13.1%) and chronic inflammatory bowel disease in 7 (3.4%) patients [Table 3].
Disease severity (n = 206)
The majority of diagnosed patients (n = 83, 40.2%) reported symptoms indicative of moderate disease, whereas 72 (34.9%) patients reported mild disease and 51 (24.7%) patients reported severe disease [Table 2]. Thyroid diease was associated with a more severe stage of the disease (p = 0.009) as shown in [Table 3]. Patients who reported more frequent medical visits (4-10 times during the last six months, either visiting a doctor, an emergency room, being hospitalized and/or having undergone a surgical procedure) had also more severe symptoms (p = 0.012). Also, patients who reported involvement of the genital area (p = 0.001), gluteal area (p < 0.001), abdomen (p < 0.001), chest (p = 0.001) and axilla (p = 0.002) had more severe disease. Moreover, multivariable analysis demonstrated that among the various covariates, smoking (OR 4.29, 95% CI 2.35–7.84, P < 0.001), thyroid disease (OR 2.95, 95% CI 1.25–6.98, P = 0.013), BMI (OR 1.08; 95% CI 1.02–1.14, P = 0.005) and younger age (OR 0.96; 95% CI 0.94–0.99, P = 0.010) were associated with a more severe HS [Table 4]. | Table 4: Ordered logistic regression for severity disease as dependent variable adjusted for age, smoking status, gender, BMI, family history and comorbidities
Click here to view |
Medical consultation (n = 206)
Of the 206 diagnosed HS patients, 175 (84.9%) patients consulted a dermatologist for their disease, 78 (37.8%) a general surgeon, 47 (22.8%) an internist, 25 (12.1%) a gynecologist, and 18 (8.7)% an infectious disease specialist. One hundred and nine (49%) patients visited a mean number of 1-3 doctors before diagnosis was established. More than one third of the patients (n = 72, 34.9%) visited 3-5 doctors and 33 (16.0%) patients visited six or more doctors before having their disease diagnosed [Table 2]. One hundred and forty-eight (71.8%) patients reported that the physician who made the diagnosis was a dermatologist and 107 (51.9%) patients reported that their current doctor is a dermatologist. However, 31 (15.0%) patients are being treated by a non-dermatologist doctor, and 68 (33.0%) patients reported that they were not followed up by any doctor.
Of the 206 diagnosed patients, 127 (61.6%) patients reported visits in an outpatient office and 60 (29.1%) in the emergency room (ER). Twenty two (10.6%) patients were hospitalized and 64 (31.0%) patients underwent a surgical procedure at least once during the past six months. This highlights the significant economic impact of this disease on the healthcare system of the country. Additionally, it was more commmon for active smokers (p = 0.016) and obese (p = 0.008) patients to visit the emergency room, being hospitalized or undergo a surgical procedure during the past six months,
Perceived possible causes of skin lesions (n = 206)
Interestingly, 53 (25.7%) of the 206 diagnosed patients believed that their symptoms were due to folliculitis caused by hair removal, 39 (18.9%) believed that their symptoms were due to skin irritation from tight or synthetic clothes/underwear, 35 (16.9%) due to skin irritation caused by razor and 27 (13.1%) patients believed that their symptoms were caused by follicular occlusion. One-fourth of the patients (n = 52, 25.2%) had no idea about any possible cause of their symptoms.
Current therapy and effectiveness (n = 206)
Among the diagnosed HS patients, 53.8% (n = 111) patients were under no medication, 14.5% (n = 30) were under oral antibiotics, 22.8% (n = 47) under nonsteroidal anti-inflammatory drugs (NSAIDS) and other analgesics, 4.8% (n = 10) under biologic treatments and 3.8% (n = 6) under isotretinoin [Table 2]. Thirty one (15.0%) patients reported that they are under the current treatment for more than five years.
Among the diagnosed patients who were under medications (n = 95), only 35.9% (n = 74) reported a better health status after receiving the treatment, while 14.0% (n = 29) reported worse health status after the onset of the treatment questioning its effectiveness. All the patients who received local cortisone injections reported worse health status after the injections. Treatment seemed to be more beneficial to younger patients, since 130 (26.7%) young patients reported better health status after the onset of the treatment, while 41 (19.9%) middle-aged (25-34) patients reported worse health status after treatment.
Regarding surgical treatment during the past six months, 54 (26.2%) patients underwent an incision or drainage of the affected area, 62 (30.0%) a local excision, and 26 (12.6%) patients had a fistula removal. Sixty-four (31.0%) patients reported that they had not undergone any surgical procedure during the last six months [Table 2].
Cost caused by patients (n = 206)
Among the 206 diagnosed patients, 124 (60.2%) patients reported daily use of antiseptics for superinfections, 115 (55.8%) daily use of gauzes or sanitary towels or elderly people's diapers, 45 (21.8%) patients used healing drugs for scars, while 70 (33.9%) patients reported that they had limited clothing options because they had to cover their scars with their clothes. This highlights the impact of the disease on their everyday life.
Impact on quality of life and profession (n = 206)
Among the diagnosed patients (n = 206), 99 (48.1%) patients reported that HS has a negative effect on their social life, 95 (46.1%) on personal life, 115 (55.8%) on sexual life, 163 (79.1%) on their mental health and 128 (62.1%) on their overall quality of life. Patients between 25-34 years and those with more severe symptoms were most affected regarding their social life (60.2% and 85.9%, respectively), personal life (55.8% and 85.9%, respectively) and sexual life (70.9% and 85.9%, respectively). On the other hand, younger patients (18-24 years old) reported to be the most affected regarding their mental health (in the astonishing percentage of almost 100%), followed by those with severe symptoms (98.1%). The worst quality of life was reported by patients with severe disease (89.8%), followed by younger patients (79.1%).
Regarding professional activities, 87 (42.2%) of the 206 diagnosed patients reported that HS has an significant negative impact on their job. Forty-one (19.9%) patients reported a negative impact on their income, while 33 (16%) patients reported that they are concerned about losing their job. Of those reporting negative impact on their job, the most affected were the middle-aged (25-34, 57.8%) and those with more severe symptoms (66.9%).
| Discussion | | |
To the best of the authors' knowledge, this is the first study that qualitatively assessed Greek patients' perception on HS regarding its treatment and quality of life, as well as on time- and cost-related issues associated with the disease.
We confirmed the findings of Calao et al.[6] that ”individuals living with HS identified through the screening questionnaire were more likely to be females, young, obese, smokers, unemployed or at home duties and having a lower annual personal income in comparison with non-HS individuals”. In our study, the mean interval between symptoms' onset and diagnosis was more than four years, still shorter than that of most published studies. In a large multicentre study including 29 medical centers from all continents, the mean periods between symptoms' onset and the first physician consultation or between symptoms' onset and diagnosis were reported to be 2.3 and 7.2 years, respectively.[7] In another multinational survey from 14 countries a mean delay of 10.2 years was reported between symptoms' onset and diagnosis.[8] Patients with thyroid disease reported a more severe stage of HS (p = 0.009). This finding is consistent with a recent study of our team, in which thyroid disease and active smoking were also associated with more severe HS.[9] A family history is also associated with a longer delay in diagnosis, probably indicating that HS is perceived as a 'condition of life', resulting in a delay for seeking medical evaluation.[7] Calao et al.[6] attributed the low diagnosis rate of HS among the Australian general population to the decentralization of care, lack of familiarity of some clinicians to the disease, and the fact that patients do not usually seek medical help for single or infrequently recurring boils.
Even though the longest delay to treatment has been reported among patients with more severe disease,[7] more than half of the patients in our survey consulted a physician within the first two months after symptoms' presentation. Prompt consultation seems to be associated with a better treatment response. In line with this, treatment is not very effective in patients with more severe symptoms. This emphasizes the necessity for prompt evaluation treatment, which may alter the course of the disease.
Overall, dermatologists play an important role in the diagnosis and treatment of HS. In our study 85% of the patients had consulted a dermatologist, and the diagnosis was made by a dermatologist in more than 70% of the cases (compared to 50% in other series).[6] In line with the existing literature,[6] we also found that one third of the patients had consulted five doctors for their condition before a definite diagnosis was made. While the majority of patients (52%) reported that they were followed-up by a dermatologist, one third did not have continuation of their medical care and were not followed-up by any doctor. These findings may reflect an overall disappointment from the provided medical care. According to other studies, more than one third of patients report that access to a dermatologist is difficult or very difficult 8.[9] In the US, only one out of five HS patients have an established relationship with a dermatologist,[10] although there is an increased utilization of high-cost settings such as the emergency department (ED) and inpatient care,[11] as in our study.
In our study, one-fourth of the already diagnosed patients claimed to be unaware of basic knowledge of the disease and were totally confused about its pathophysiological origin. This emphasizes the necessity for better education about the disease. Pavon Blanco et al.[12] recommended that future research should include patients' beliefs about the causes of HS as it is one of the most modifiable illness perceptions.
Moreover, only 20% of our patients reported health improvement after receiving therapy, indicating medium treatment effectiveness. Large cohorts have also reported high dissatisfaction rates regarding medications and treatment modalities (47% and 35%, respectively).[8]
We confirmed the association between HS and educational status, since patients with higher educational status seemed to report a milder disease. This finding may be due to the fact that these patients have better and quicker access to medical care or because they are more compliant to the treatment. Although low socioeconomic status (SES)[13],[14] is common in HS patients, low SES may also be a result of the disease due to inability to acquire or maintain gainful employment.[10]
Finally, HS has a detrimental impact on professional activities, sexual life, mental health and quality of life of the patients. The association between disease severity and anxiety, depression, loneliness and social isolation has been well-documented.[2],[3] Two-thirds of our patients reported a very low quality of life. According to published data, 43% of patients report a significant impact on their life, whereas 14.5% report that they are disabled due to HS.[8] However, large cohorts have confirmed the lack of association between people's illness beliefs and their disease severity.[12]
There are some limitations of the study that must be addressed. First, diagnosis of HS was made by dermatologists and non-dermatologist physicians, which can result in suboptimal diagnosis in certain cases. However, diagnosis of HS is based on criteria and guidelines released by international scientific societies and given that the disease is more commonly diagnosed nowadays, dermatologists and non-dermatologists physicians are becoming more familiar with the disease. Therefore, it is becoming a common practice for HS to be diagnosed by non dermatologist physicians as well. Second, although it would be interesting and valuable to investigate the knowledge and perception of HS among non-patients or suspected patients, the study was not designed to collect such data therefore non-patients' or suspected patients' perception of HS cannot be reported. This can be investigated in a future study.
Similar to other chronic diseases such as psoriasis and eczema, HS is a time-consuming and cost-intensive disease. There are indications that HS is an undertreated disease since a considerable dissatisfaction was reported by the patients who feel that their disease is not managed and controlled appropriately, even though they spend considerable time and effort for their treatment. An earlier diagnosis of the disease, better education of the patients, better education of the doctors and more effective treatments seem to be absolutely necessary for the confrontation of the disease. Although extensive research has been conducted evaluating the efficacy of several different medications and modalities such as biologic agents and laser therapy for the treatment of HS, further randomized clinical trials are needed to establish the most efficient therapy for this disease.
Acknowledgments
We acknowledge the company “Alternative Research Solutions” S.A., which assisted with the creation and modification of the questionnaire, both in English and in Greek, as well as with the statistical analysis of the results.
Financial support and sponsorship
The “Abbvie Pharmaceuticals” S.A. of Greece supported financially the conduction of the statistical analysis by “Alternative Research Solutions” S.A.
Conflicts of interest
There are no conflicts of interest.
| Supplementary Material | | |
| References | | |
| 1. | Liakou A, Kontochristopoulos G, Agiasofitou E, Tsantes AG, Papadakis M, Marnelakis I, et al. Colchicine improves clinical outcomes and quality of life in Hidradenitis Suppurativa Patients: A retrospective study. J Clin Med 2021;10:4742.  |
| 2. | Kouris A, Platsidaki E, Christodoulou C, Efstathiou V, Dessinioti C, Tzanetakou V, et al. Quality of life and psychosocial implications in patients with Hidradenitis Suppurativa. Dermatology 2016;232:687-91. |
| 3. | Janse IC, Deckers IE, van der Maten AD, Evers AWM, Boer J, van der Zee HH, et al. Sexual health and quality of life are impaired in hidradenitis suppurativa: A multicentre cross-sectional study. Br J Dermatol 2017;176:1042-7. |
| 4. | Wolkenstein P, Loundou A, Barrau K, Auquier P, Revuz J; Quality of Life Group of the French Society of Dermatology. Quality of life impairment in hidradenitis suppurativa: A study of 61 cases. J Am Acad Dermatol 2007;56:621-3. |
| 5. | Alavi A, Anooshirvani N, Kim WB, Coutts P, Sibbald RG. Quality-of-life impairment in patients with hidradenitis suppurativa: A Canadian study. Am J Clin Dermatol 2015;16:61-5. |
| 6. | Calao M, Wilson JL, Spelman L, Billot L, Rubel D, Watts AD, et al. Hidradenitis Suppurativa (HS) prevalence, demographics and management pathways in Australia: A population-based cross-sectional study. PLoS One 2018;13:e0200683. |
| 7. | Saunte DM, Boer J, Stratigos A, Szepietowski JC, Hamzavi I, Kim KH, et al. Diagnostic delay in hidradenitis suppurativa is a global problem. Br J Dermatol 2015;173:1546-9. |
| 8. | Garg A, Neuren E, Cha D, Kirby JS, Ingram JR, Jemec GBE, et al. Evaluating patients' unmet needs in hidradenitis suppurativa: Results from the Global Survey of impact and healthcare needs (VOICE) Project. J Am Acad Dermatol 2020;82:366-76. |
| 9. | Liakou AI, Kontochristopoulos G, Marnelakis I, Tsantes AG, Papadakis M, Alevizou A, et al. Thyroid disease and active smoking may be associated with more severe Hidradenitis Suppurativa: Data from a prospective cross sectional single-center study. Dermatology 2021;237:125-30. |
| 10. | Garg A, Lavian J, Strunk A. Low utilization of the dermatology ambulatory encounter among patients with Hidradenitis Suppurativa: A population-based retrospective cohort analysis in the USA. Dermatology 2017;233:396-8. |
| 11. | Khalsa A, Liu G, Kirby JS. Increased utilization of emergency department and inpatient care by patients with hidradenitis suppurativa. J Am Acad Dermatol 2015;73:609-14. |
| 12. | Pavon Blanco A, Turner MA, Petrof G, Weinman J. To what extent do disease severity and illness perceptions explain depression, anxiety and quality of life in hidradenitis suppurativa? Br J Dermatol 2019;180:338-45. |
| 13. | Deckers IE, Janse IC, van der Zee HH, Nijsten T, Boer J, Horváth B, et al. Hidradenitis suppurativa (HS) is associated with low socioeconomic status (SES): A cross-sectional reference study. J Am Acad Dermatol 2016;75:755-9. |
| 14. | Wertenteil S, Strunk A, Garg A. Association of low socioeconomic status with Hidradenitis Suppurativa in the United States. JAMA Dermatol 2018;154:1086-8. |
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4] |
|
|
|
|
|
|
|
|
|
|
