A Clinical Retainer in the Treatment of Female Hidradenitis Suppurativa is used

Yeong Kozera^*
*Correspondence: Yeong Kozera, Department of Dermatology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea, Email:

Keywords

Hidradenitis suppurativa • Estrogen • Progesterone • Hormones • Menopause

Introduction

Hidradenitis suppurativa (HS) is a chronic skin disease that manifests as painful nodules and abscesses, as well as malodorous, draining, epithelialized tunnels with a preference for flexural areas of the skin. As a systemic inflammatory disorder, HS is associated with a variety of comorbidities spanning multiple organ systems, such as inflammatory bowel disease, inflammatory arthropathy, and metabolic syndrome (Adelekun et al., 2020). HS has been found to disproportionately affect women of childbearing age in epidemiologic studies conducted in North America and Europe (Adelkun et al, 2021; Garg et al., 2021; Miller et al., 2016). In the United States, African- American and biracial patients have a higher prevalence. However, in global HS clinical trials, most participants have been Caucasian. As a result, available data on the role of hormones and mechanistic and translational studies in HS may not be completely representative across ethnicities. Women bear additional disease burdens due to menstruation, hormonal fluctuations, sexual function, pregnancy, childbirth, and breastfeeding. The purpose of this review article is to discuss and present the mechanistic underpinnings of the role of sex hormones in the pathogenesis of HS in women, as well as the published evidence and clinical management of HS in the context of perimenstrual flares, pregnancy, childbirth, breastfeeding, and menopause [1].

Perimenstrual hidradenitis suppurativa becomes more severe

In recent years, there has been a growing body of observational, experimental, and therapeutic evidence that HS is a chronic, autoinflammatory, keratinization disorder. Given the association of HS with hormonal acne vulgaris, polycystic ovarian syndrome (PCOS), and fluctuations in HS disease severity associated with the menstrual cycle, hormone dysfunction is thought to play a role in the underlying pathogenesis. The well-established links between PCOS, obesity, insulin resistance, and elevated levels of systemic proinflammatory mediators like insulin-like growth factor 1 (IGF-1), leukotrienes, and long chain fatty acids provide theoretical mechanisms for how hormones may influence disease activity in HS; however, mechanistic evidence in HS is lacking. Interleukin-23 has been linked to androgen-receptor-mediated inflammatory pathways. have also observed and may present an alternate hypothesis on how the Th17 inflammatory pathway identified in HS is linked with hormonal dysregulation [2].

The current evidence for the effect of sex hormones on HS disease activity is largely based on an epidemiologic association, with little mechanistic data on how these hormones affect the disease's inflammatory drive. Patients with HS have a crude prevalence of PCOS that is more than three times that of patients without HS. Even among women with HS who do not have PCOS, some show clinical signs of androgen excess, such as acne vulgaris, hirsutism, menstrual cycle irregularities, and infertility the current HS pathogenic paradigm holds that sex hormone end-organ (follicular) activity may play a role in disease pathogenesis. However, when HS patients' lesional skin was compared to healthy controls, no immunohistochemical evidence of dysregulated sex hormone receptors was found. Other studies have shown that sex hormones have immune-modulating (both immune-activating and immune-suppressive) activity on dendritic cells, T-cell maturation, differentiation, and Th1 immune response suppression. The immune system's response to sex hormones differs between men and women and is influenced by the end organ, background cytokine milieu, and endogenous sex hormone levels [3].

The psychological effects of hidradenitis suppurativa

It is not surprising that a chronic, unpleasant, and painful condition like HS is associated with a lower quality of life due to physical, emotional, and psychological difficulties Patients with HS frequently have low self-esteem, sleep problems, sexual dysfunction, relationship dysfunction (both platonic and romantic), and poor mental health. In fact, patients with HS have a 2.42-fold increased risk of suicide when compared to the general population. One key challenge faced by patients with HS is sexual health and intimate relationships, a challenge that is reportedly more profound among women with HS. This difficulty is due in part to the anatomical location of HS lesions, but it is also caused by pain, suppuration, rejection anxiety, and a lower perceived physical attractiveness.

Sexual dysfunction is more common in women with HS, with up to 50% of women experiencing it. found that 59.7% of all HS patients had reduced sexual activity due to the impact of HS on their physical appearance (as reported by 89% of women), a decreased libido (91% of women), and the inconvenience caused by inflammatory disease (99% of women). Physical complications associated with HS (e.g., pain) play a role in the intimate difficulties that patients face, but there are also significant psychosocial aspects. that are equally distressing to patients . The social isolation that is frequently associated with HS has been exacerbated by the coronavirus pandemic. According to one related study, patients with HS responded positively to Zoom video communications and social media interactions as a way to reduce feelings of social isolation and share their experience living with HS with others [4].

Discussion

Although HS has been found to primarily affect women in many parts of the world, the impact of the disease on issues such as pregnancy, breastfeeding, menopause, and the disease's psychosexual effect on women has only recently been studied in depth. Our limited understanding of the impact of HS across a patient's lifespan is a significant knowledge gap, which can be especially devastating when HS begins in adolescence in young women. A cumulative life course impairment model can be used to consider the social, psychosocial, physical, and financial effects of HS (Ibler and Jemec, 2020). Although it is well known that HS has a significant negative impact on quality of life, most published studies present a snapshot of the disease burden rather than a longitudinal view. data.

Developing HS symptoms in private intertriginous areas, unpredictable malodorous suppurative drainage, and managing acute and chronic pain during adolescence can all lead to stigma and a negative self-image. This can have an impact on emerging sexuality and make developing personal relationships difficult. Several studies are needed to advance this field, including mechanistic studies on how reproductive hormones influence disease activity, prospective registries to evaluate the efficacy and safety of HS treatments during pregnancy and pregnancy outcomes in patients with HS, implementation of effective targeted strategies to improve sexual function in women with HS, and longitudinal studies to investigate the cumulative life course imprint of HS. These studies would be part of a larger effort within the HS research community to better understand the disease's pathogenesis, broaden the therapeutic arsenal, and, hopefully, lead to the development of therapeutic and disease biomarkers in HS [5].

Conclusion

When caring for women with HS, we must take into account the unique challenges that these patients may face, such as menstruation, menopause, pregnancy, breastfeeding, and sexual dysfunction. To optimise patient care and quality of life, it is important that a multidisciplinary team is involved; this may include dermatologists, psychiatrists, psychologists, obstetricians, gynaecologists, endocrinologists, and sexologists.

Acknowledgement

None.

Conflict of Interest

None.

References

1. De Oliveira, Erika CV, Valéria RV da Motta, Paola C. Pantoja and Carolina S. de O. Ilha, et al. "Actinic keratosis–review for clinical practice." Int J Dermatol 58 (2019): 400-407.    

Google Scholar, Indexed at, Crossref

2. De Berker, D., J. M. McGregor, M. F. Mohd Mustapa and L. S. Exton, et al. "British association of dermatologists’ guidelines for the care of patients with actinic keratosis 2017." Br J Dermatol 176 (2017): 20-43.

Google Scholar, Indexed at, Crossref

3. Dianzani, Caterina, Claudio Conforti, Roberta Giuffrida and Paola Corneli, et al. "Current therapies for actinic keratosis." Int J Dermatol 59 (2020): 677-684.      

Google Scholar, Indexed at, Crossref

4. Berman, Brian, Arsalan Qazi Shabbir, Tanya MacNeil and Kim Mark Knudsen. "Variables in cryosurgery technique associated with clearance of actinic keratosis." Dermatol Surg 43 (2017): 424-430.

Google Scholar, Indexed at, Crossref

5. Hanna, Edith, Rami Abadi and Ossama Abbas. "Imiquimod in dermatology: an overview." Int J Dermatol 55 (2016): 831-844.

Google Scholar, Indexed at, Crossref