Care Management Considerations for LGBTQIA Patients With Hidradenitis Suppurativa

Comorbidities, infections in HIV-positive individuals, and creating a welcoming environment are a few of the several factors that providers should consider in managing sexual and gender minority (SGM) patients with hidradenitis suppurativa (HS), according to a review published in the Journal of the American Academy of Dermatology.

In the current management guidelines for HS, screening recommendations include several conditions known to be of high risk in LGBTQIA-identifying patients, including depression, anxiety, and substance abuse disorder. Rates of death by suicide are more than double in patients with HS—trends that are similarly elevated in SGM patients—and diagnosis of the disease may further exacerbate discrimination and feelings of shame in these patients.

“Mental health screening and support are important aspects of care for SGM patients with HS. Dermatologists can contribute to normalization by openly discussing anxiety, depression, chronic pain in HS, and sexual orientation, gender identity issues, and diverse sexual behaviors in a supportive manner,” said researchers. “Further, a multidisciplinary approach with pain management and psychiatry or therapy may be helpful when appropriate.”

Other comorbidities associated with HS, such as acne, have also been indicated to exacerbate these behavioral health concerns, as well as potentially trigger gender dysphoria, especially in transgender youth. Although not all patients who identify as transgender experience gender dysphoria, researchers said that it is important for dermatologists to be aware of these mental health issues when treating acne and HS in those patients.

“Furthermore, gender-affirming hormonal therapy (GAHT) can influence the course of acne. Testosterone can trigger or worsen acne, while estrogen and antiandrogen hormonal therapy may improve it,” they added.

GAHT in transgender patients additionally poses risks for systemic conditions as it is associated with worsening cardiovascular disease, increased thromboembolic risk, and sex-specific changes in metabolic syndrome. Sexual minority females in particular have baseline risks for metabolic syndrome and metabolic syndrome risk factors (obesity, smoking, heavy drinking, and depression) that are higher than heterosexual women.

Data has suggested an increased risk of myocardial infarction or ischemic stroke in transgender females taking GAHT as well, but research on the cardiovascular effects of GAHT is limited by the lack of cohort studies inclusive of SGM patients and appropriately matched controls.

“Routine screening in patients with HS for these systemic conditions is essential and even more critical to address if those patients are on GAHT…Dermatologists may find it useful to partner with gender-affirming endocrinologists (if available) or whoever is managing their patients’ hormonal treatments in these cases to optimize GAHT with HS therapy.”

Potentially serious complications to consider in SGM patients with HS include squamous cell carcinoma (SCC) and infections in HIV-positive individuals. SGM individuals have been indicated to be less likely to receive preventive services for cancer while paradoxically having a higher self-reported lifetime prevalence of skin cancer and being at higher risk of human papillomavirus infection, which may confer additional risk for SCC incidence.

As such, researchers said it is crucial that SGM patients with HS routinely follow up with a dermatologist for full-body skin examinations, even in cases of well controlled disease, with special attention to areas affected by their HS. Use of anal Pap smears for men who have sex with men are not currently recommended, but they have shown promise as potential screening tools for anal carcinoma.

“While HS itself is not an infection, the disruption of the skin’s normal barrier function and certain medications used to treat HS, such as adalimumab and other immunosuppressants, predispose patients with HS to serious infections and the risk of sepsis,” said researchers.

“SGM patients are disproportionately at risk for infections, including HIV, that can significantly alter the clinical course and presentation of chronic skin conditions like HS and their complications, including secondary bacterial infections.”

The authors provided several other unique considerations for providers in managing transgender patients:

• discussing physical exams and procedures in advance, including the order in which they will occur, may help alleviate anxiety and empower SGM patients to voice their concerns
• dermatologists should be aware that some patients may have preferred terms they use to refer to their body parts that differ from medical terms and providers should use patients’ preferred terms when explaining each step of the exam
• for transgender individuals with HS seeking gender-affirming genital surgery or breast augmentation or removal, it is important to control HS to optimize surgical outcomes, reduce infection risk, and minimize scarring
• transgender men appear to be at higher risk of developing or exacerbating HS after the initiation of testosterone, although this data is limited to case reports

Researchers concluded that more research inclusive of SGM patients is needed to address gaps in knowledge.

Reference

Gomez J, Barnes LA, Yost JM, Gordon J, Ginsberg BA, Aleshin M. Hidradenitis suppurativa in sexual and gender minorities: A review and considerations for providers. J Am Acad Dermatol. 2022 Mar 10;S0190-9622(22)00385-1. doi:10.1016/j.jaad.2022.03.008