Hidradenitis Suppurativa on Different Skin Tones and Races

Prevalence, presentation, diagnostic challenges

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Hidradenitis suppurativa (HS)—while a common chronic skin condition—is often misunderstood and misdiagnosed, especially in people with darker skin tones. Without a timely diagnosis, people may be left undertreated, which can impact their quality of life, so awareness of this condition is crucial to those it affects most.

Here's what to know about hidradenitis suppurativa and the impact it has on different skin tones and races. 

Doctor discussing with patient in medical room

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Prevalence

Most studies of hidradenitis suppurativa have been done on large groups of people either with light skin or without consideration to skin tone and type.

More recently, studies conducted in the United States have looked at the frequency of HS in people of color and have found a higher prevalence for the condition in these groups, especially Black Americans. The prevalence of HS in Hispanic Americans isn't as high, but the disease burden can be.

For example, one study out of the Henry Ford Medical Center found that 54.4% of the study participants with HS were Black while around 25% were White.

A second study­—this one out of the University of Pittsburgh—showed that 65% of the study population were Black, while 33% were White.

HS prevalence seems to be the highest among Black American women among all women and across all races. High incidences also exist in Black Americans and biracial adolescent girls with the highest incidences in girls ages 15-17.

Presentation

According to a 2018 report in the journal, PLoS One, hidradenitis suppurativa affects up to 4% of the global population. HS is characterized by chronic, recurrent skin lesions on the armpits, under the breasts, around the groin, and between the buttocks.

Lesions may spontaneously rupture and have a smelly discharge. They can cause pain and deep sores and affect the ability to walk, especially when located in the lower part of the body. In severe cases, there will be scarring and sinus tracts.

What Are Sinus Tracts?

Sinus tracts are tunnels under the skin that connect different outbreak areas.

The research shows that HS differs between racial groups in that people with darker skin color tend to have a more severe disease burden than people with fair skin.

In a 2017 report in the journal Dermatology, the report’s authors note that an increase in the number, size, and productivity of sweat glands in people with darker skin tones might explain why HS occurs more frequently and is more severe in Black Americans.

Hidradenitis suppurativa in people of color is often misdiagnosed as other conditions that cause lesions, such as sexually transmitted infections or resistant Staphylococcus aureus infections.

Those delays in diagnosis can lead to HS progression, scarring, disability, and disease co-morbidities, including septic arthritis, pyoderma gangrenosum, and inflammatory bowel diseases.

Unfortunately, there is little and sometimes insufficient research on specific presentations of skin symptoms in people of color who have HS. Much of the research discusses the disease burden, but most doesn't go into specific symptom differences and how they may affect different skin tones and races.

Diagnostic Challenges

A diagnosis of hidradenitis suppurativa is made by examination of the skin and a medical history that includes signs and symptoms. There are no laboratory tests to diagnose HS.

If pus or drainage is present, your healthcare provider will send a sample of the drainage to a laboratory for testing. This is done to rule out other conditions, specifically infections.

People with HS who have darker skin are often misdiagnosed and many go years without access to specialists. Because they go so long without an accurate diagnosis, they don’t receive the treatments they need early on to reduce the burden of HS.

In some cases, people with darker skin tones are not diagnosed until 20 or even 30 years after the initial onset of symptoms.

A piece from The Dermatologist suggests the importance of awareness and encouragement in getting people with darker skin tones to bring attention to skin changes associated with HS to their medical providers.

Because of the way the condition presents—with abscesses, drainage, foul odor, and scarring—and where it presents—under the armpits, the groin, buttocks, etc.—people with the condition might be embarrassed to discuss the condition with their healthcare providers. 

By providing outreach and support in communities of color, it is possible for more people in these groups to receive accurate diagnoses and to have access to early and appropriate treatments that may reduce disease severity and burden. 

Quality of Life and HS Effects

Hidradenitis suppurativa is known for having profound physical and psychological effects. It can cause embarrassment and lead to social isolation and disability. It also affects personal relationships and sexual intimacy. And a long-term burden of HS can cause reduced quality of life, depression, and anxiety.

Research on HS shows serious implications for people of African and Hispanic backgrounds. In the previously mentioned 2017 Dermatology report, the report’s authors note factors that may contribute to these effects, including functional limitations, lack of health insurance coverage, and lifestyle factors like smoking and lack of activity.  

The report’s authors also note the rates of depression in Black Americans that tend to be higher. However, they noted that the data, as it pertains to HS, is lacking and research comparing mental health and quality of life in people with HS among different races is needed.

Treatment and Skin Color

Treatment for hidradenitis suppurativa involves medications and surgery to control symptoms and reduce the potential for complications. You should talk to your doctor about the risk and benefits of all your treatment options and on developing a treatment plan based on your unique health situation.

You will also need regular follow-ups with your dermatologist and you may need to see additional specialists to treat any comorbid conditions like depression and joint disease.

Treatment options for HS include:

  • Antibiotic creams for treating mild skin symptoms
  • Pain medications—both over-the-counter pain relievers and stronger prescription drugs (if needed) can help to manage skin pain
  • Systemic drugs can help if a person with HS has widespread skin symptoms. Humira (adalimumab) is the only approved systemic drug for HS. It is prescribed for moderate to severe disease. While studies show it can be helpful in reducing symptoms, they do not show treatment outcome differences for race or skin tone.

Surgical options may include:

  • Uncovering tunnels is done through a procedure called unroofing to remove tissue and expose tunnels under the skin.
  • Laser therapy is used to clear and remove new breakouts.
  • Draining abscesses is done to provide pain relief.
  • Excision (cutting out) of lesions and scar tissue is done through a surgical procedure. Skin grafts are then done to replace lost skin.

While the disease burden of HS may be higher in people of color, skin color doesn’t play a part in treatment planning. You can ask your doctor to personalize your treatment plan for your skin type or color because some treatments may affect darker skin more harshly.

Currently, there are no specific treatments or drug therapies approved based on skin color and tone. More research is needed to better understand how the disease presents on darker skin types and how symptom differences in skin tone and color may affect treatment outcomes.

A Word From Verywell

Regardless of skin tone or race, everyone with hidradenitis suppurativa should find ways to improve their quality of life. Talk to your doctor about how HS is affecting you.

Your doctor needs to know if you have high levels of pain, if your skin continues to break out, if treatments don’t work, how you are coping emotionally, or if you are feeling depressed. This way, they can help you to find ways to improve pain, skin symptoms, and other disease aspects, which can ultimately improve your quality of life.

Consider reaching out to others living with HS, either through social media or through online and in-person support groups, especially people who may have similar skin tone challenges. You should include family and friends in your support network, as they can be a great source of comfort and help as you live with and manage the complexities of HS.

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