Evaluation of stigmatization in patients with hidradenitis suppurativa using the PUSH-D score

Abstract

A global call was made by the World Health Organization for governments to take action in reducing the stigmatization of patients with skin conditions.¹ The Patient Unique Stigmatization Holistic tool in Dermatology (PUSH-D) is a newly validated tool that assesses stigmatization in skin conditions.² Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that can severely impact patients' quality of life.³ The objective of our study was to assess for the first time the PUSH-D in a large population of patients with HS.

A questionnaire [constructed with HS experts and patient associations, was administered to patients with a confirmed diagnosis of HS by a dermatologist in 26 centers in France between February and May 2024]. We aimed to study the factors impacting stigma in HS patients using the PUSH-D score. The questionnaire included sociodemographic factors and HS characteristics, as well as a dedicated part for the PUSH-D. The PUSH-D questionnaire explores the stigma experienced over the past 4 weeks through 17 questions.² Multivariate linear regression was employed to evaluate the relationship between the PUSH-D score and the following variables: gender, Hurley stage, intensity of discharge, severity of painful flare-ups, BMI ≥25 kg/m², time since diagnosis >3 years, reduced libido, partner's devaluation, and overall unsatisfactory sexual life. Data multicollinearity was tested using the Belsley–Kuh–Welsch technique. Statistical analysis was performed using EasyMedStat.

A total of 1255 responses were obtained, with 419 considered evaluable [respondents had the option not to answer questions related to sexuality], resulting in a female/male ratio of 78.5% to 21.5%. In multivariate analysis, being male [β = 6.23]; Hurley III [β = 3.59], frequent discharge [β = 2.66], intense residual pain outside of a flare-up [β = 7.92], an overweight BMI [β = 2.93], reduced libido [β = 3.73], partner's devaluation[β = 12.09] and a USL [β = 2.45] were associated with a higher PUSH-D score and thus greater stigma.

The duration of time since diagnosis was not associated with a higher stigma score (Figure 1).

Our study is the first to assess the PUSH-D-score in HS patients. Male patients reported higher stigma, contrasting with some studies showing higher psychological burden in female patients due to societal appearance expectations. Some previous studies found that women had higher sexual health⁴ burden from HS. In contrast, others showed no gender difference regarding depression from HS.³ Severe disease presentation (Hurley III), frequent discharge, and intense residual pain were also significant predictors of stigma. In fact, persistent symptoms can lead to social withdrawal and shame, exacerbating stigma. Overweight BMI was associated with higher stigma, which might reflect a compounded stigma from societal biases against obesity and visible skin conditions. This dual stigma highlights the need for comprehensive management addressing both dermatological and metabolic health. Sexual health emerged as crucial, with reduced libido and unsatisfactory sexual life significantly linked to higher stigma. This aligns with other studies reporting HS severely impacts sexual health, causing psychological distress and stigma.^{3, 5, 6} The strong association between partner devaluation and stigma underscores the importance of interpersonal relationships in HS patients' psychological well-being.⁷ Interestingly, the duration of time since diagnosis did not show a significant association with stigma scores in our study. This contrasts with some previous findings⁸ suggesting that longer disease duration may lead to increased stigmatization due to cumulative psychological burden. However, our results suggest that factors related to disease severity and its impact on daily life^{9, 10} may have a more immediate effect on perceived stigma. In conclusion, our study identified critical factors associated with stigma in HS patients, providing insights for targeted interventions. Moreover, our study is the first to use a skin-specific stigmatization tool in HS, which helps to better interpret the PUSH-D-score and facilitate its use in future clinical trials.

This project was funded by La Roche-Posay International & Almirall.

C. Le Floc'h, D. Kerob, A. L. Demessant are Employees of La Roche-Posay. J. M. Joubert & G. Caillet are Employees of Almirall. C. Fite, C. Taieb, A. Nassif, M. Delage-Toriel, C. Cassius, C. Skayem, Y. Benhayoun, M. F. Bru, M. Moulin, B. Halioua, C. Zimmermann, E. Pommaret, I. Nicol, O. Cogrel, M. A. Richard had no conflicts of interest in this work.

The South-East IV Committee for the Protection of Individuals gave a favourable opinion on the project on 31 July 2023 [IDRCB 2022-A05651-42].

The patients have confirmed their agreement to take part. Information note IDRCB 2022-A05651-42 [Committee for the Protection of Individuals South-East IV, dated 31 July 2023].