Hidradenitis Suppurativa Disease Severity and Outcomes Among Black Patients From Low-Income Neighborhoods at a Tertiary Care Hospital: A Retrospective Review

Hidradenitis suppurativa (HS) is a debilitating inflammatory condition of apocrine sweat glands. Although most HS studies include majority White cohorts, Black patients are disproportionally affected, which has been largely attributed to an association with lower socioeconomic-status (SES). 1-3 Yet, the paucity of Black patient representation in existing HS literature presents an incomplete understanding of the HS race disparity. 4 We sought to identify specific factors associated with HS disease severity and outcomes among Black patients living in low-income neighborhoods. ABSTRACT Hidradenitis suppurativa (HS) is a debilitating, inflammatory condition of apocrine sweat glands. Black patients are disproportionately affected, a finding largely attributed to lower socioeconomic status (SES) in the literature; yet, most HS studies include majority White cohorts. We present, to our knowledge, the first retrospective review of an entirely Black patient population living in low-income neighborhoods diagnosed with hidradenitis suppurativa (HS) to identify potentially modifiable factors related to disease severity and outcomes. We reviewed charts of Black patients with an encounter for HS from 2010-2020 in the New Orleans University Medical Center database. Hurley stage III (HSt III) disease was associated with early and chronic onset, longer time-to-treatment, higher body mass index, and Medicaid insurance. Flared disease was associated with fewer dermatology visits, more incision and drainage procedures, and higher lost-to-follow-up rates while well-controlled patients had more surgical excisions, biologic use, and lower smoking rates. Patients were nearly evenly split among initial HSt’s, and ~50% of the 473 patients were stable or well-controlled at latest disease status, suggesting low SES alone cannot explain HS race-based discrepancies. Our findings highlight potentially modifiable factors for healthcare providers to consider when holistically treating Black patients living in low-SES communities.


METHODS
We reviewed charts of Black patients with an encounter for HS from 2010-2020 in the New Orleans University Medical Center database.Data was derived from patient records.Median and average household incomes and percent high incomes (households earning ≥$200,000/year) were determined by zipcode. 3,5Hurley Stage (HSt), explicitly documented or determined by the authors using photos and/or physical exams, classified disease severity at initial presentation.Disease status (flaring, stable, well-controlled) was determined using the classification system in Table 1.Descriptive statistics summarized patient demographics, stratified by HSt and disease status.Logistic regression analyses, adjusting for age and sex, identified associations between clinical predictors and HSt and disease status (Table 2).α=0.05 assessed significance.Study approval was granted by the Institutional Review Board of Louisiana State University School of Medicine.22 misdiagnosed patients were excluded.The remaining 473 were nearly evenly split between HSt's and were predominantly middle-aged (41.8 years-old), female (67.6%), flaring (56.5%), and extremely obese (body mass index (BMI) ≥35 kg/m 2 ).HSt I patients presented more acutely, with older ages of onset, fewer years to dermatology, and were less often lost to follow-up (LTF) (p<0.05)(Table 2A

-B).
Medicaid insurance and each 5-point increase in BMI were associated with a 2.5x and 24.9% increased odds of HSt III disease, respectively (p<.05) (Figure 1).Odds of flaring decreased by 3.1%, 34.4%, and 61.0% with each additional dermatology visit, biologic used, and surgical excision, respectively (p<.05).Odds of flaring were 1.7x greater with incision and drainage (I&D) (p<.05).Surgical excision and former tobacco use (compared to current use) were associated with a 7.2x and 3.5x increased odds of well-controlled (WC) disease, respectively (p<.05).Odds of WC status decreased by 39.9% when LTF and 63.4% if currently smoking (p<.05).Never-smokers were 2.7x more likely to have WC status (tabulated data is in reference to neversmokers) (p<.05) (Figure 2).
To our knowledge, we present the first analysis of HS in an entirely Black patient cohort.One-third of patients had mild disease at initial presentation, and half were ultimately stable/WC despite living in lowincome neighborhoods, suggesting that SES alone does not explain the increased severity and prevalence of HS seen among Black patients.
Patients with mild disease presented sooner and followed-up regularly, whereas those with advanced disease had longer time-totreatment, less follow-up, and higher BMI.Better patient outcomes were associated with more clinic visits, surgical excision, and biologic use, whereas poorer outcomes were associated with I&D's, tobacco use, and LTF status.Rather than solely attributing racebased HS disparities to low SES, future studies should further identify actionable items that are associated with improved outcomes among Black patients from lowincome communities.Therefore, healthcare providers can potentially decrease diagnostic delay, misdiagnosis, unoptimized treatment plans, and patient frustration.Emergency room (ER) providers may better treat and refer HS patients who initially present to the ER (of which Black patients are overrepresented). 2,6 and/or pain WC = well-controlled; s/p = status post; I&D = incision and drainage *The tabulated information was either explicitly stated or described in the history of present illness, physical exam, or assessment and plan section of the patient's latest documented note pertaining to HS.

DISCUSSION
Study limitations include the retrospective nature conducted at a single center in New Orleans and the use of a non-validated classification system (Supplemental Table 1).
We hope to inform the holistic treatment of HS and health policy initiatives in the setting of limited race-based HS data.

Figure 1 .
Figure 1.Odds Ratios (ORs) and 95% Confidence Intervals (CIs) for Demographic and Clinical Predictors of Hurley Stage

Figure 2 .
Figure 2. Odds Ratios (ORs) and 95% Confidence Intervals (CIs) for Demographic and Clinical Predictors of Disease Status

Table 2B .
Bold values indicate significance at an α=0.05 level.Years to treatment = time from symptom onset to first provider assessment for HS; Years to dermatology = time from symptom onset to first dermatologist assessment for HS; Acute onset = patients who first presented within 1 year of symptom onset; Chronic onset = patients who first presented >1 year after symptom onset; BMI = body mass index; LTF = lost to follow-up; patients with scheduled follow-up who lacked subsequent encounters/prescriptions for HS; I&D = incision & drainage; ILK = intralesional Kenalog.Demographics by Disease Status