
==== Front
Arch Dermatol Res
Arch Dermatol Res
Archives of Dermatological Research
0340-3696
1432-069X
Springer Berlin Heidelberg Berlin/Heidelberg

38850290
2971
10.1007/s00403-024-02971-9
Original Paper
Prevalence and association of polycystic ovary syndrome and hidradenitis suppurativa in underrepresented groups
Ch’en Peter Y. peter.chen@einsteinmed.edu

1
Toker Michelle 1
Chen Gloria 2
Hosgood H. Dean 1
Campton Kristina L. 1
Cohen Steven R. src4005@med.cornell.edu

3
1 https://ror.org/05cf8a891 grid.251993.5 0000 0001 2179 1997 Division of Dermatology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY USA
2 grid.47100.32 0000000419368710 Yale School of Medicine, New Haven, CT USA
3 grid.5386.8 000000041936877X Department of Dermatology, Weill Cornell Medical College, 1305 York Avenue 9F, New York, NY 10022 USA
8 6 2024
8 6 2024
2024
316 7 37914 2 2024
20 4 2024
26 4 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Hidradenitis suppurativa (HS) is an inflammatory disorder of follicular biology; androgens are believed to be involved in its pathogenesis. Polycystic ovary syndrome (PCOS) is similarly characterized by hyperandrogenism. Previous studies have found a lasting association of HS and PCOS. Socioeconomic status (SES) has been described as a comorbidity for both HS and PCOS that has not been accounted for in prior studies; we sought to investigate this association while adjusting for this. We also analyzed the prevalence of PCOS among HS patients. Using the All of Us database, female HS patients were stratified by PCOS diagnosis and compared by age, race, and ethnicity. Female HS patients were also nearest-neighbor propensity-score matched to controls at a 4:1 ratio, selecting for race, ethnicity, age, ever smoker, alcohol use disorder, obesity, type II diabetes, Medicaid status, and community deprivation index. Univariable and multivariable logistic regression was conducted to estimate the effect of HS on the presence of PCOS. The distribution of race among HS patients with PCOS was significantly different than HS patients without PCOS. A total of 1,022 female HS patients and 4,088 matched female controls were included. Significantly more patients carried a diagnosis of PCOS compared to controls (8.8% versus 4.3%, p < .001). In multivariable logistic regression, PCOS was significantly associated with HS [OR 1.71 (95% CI 1.34–2.17)]. This is the first study investigating the association of HS and PCOS within the All of Us database. We found that females with HS had a 1.34- to 2.17-fold increased odds of having PCOS, which is consistent with previous analyses. However, our analysis, in addition to controlling for common medical co-morbidities found in both HS and PCOS, also accounts for markers of SES at an individual and community level, further strengthening the association of HS with PCOS.

Keywords

Hidradenitis suppurativa
Polycystic ovary syndrome
PCOS
Social determinants of health
Socioeconomic status
issue-copyright-statement© Springer-Verlag GmbH Germany, part of Springer Nature 2024
==== Body
pmcIntroduction

Hidradenitis suppurativa (HS) is an inflammatory disorder of follicular biology primarily affecting the intertriginous skin regions. It manifests as painful pustules, nodules, abscesses, sinus tracts, and scarring. Androgens are believed to be involved in its pathogenesis [1].

Polycystic ovary syndrome (PCOS) is similarly characterized by hyperandrogenism and manifests with irregular menses and ovulatory dysfunction. PCOS has been shown to be more prevalent among individuals with HS; and, previous studies found a stable association after adjusting for shared comorbidities [1].

Differences in prevalence of PCOS between racial groups among patients with HS is not well established. In addition, socioeconomic status (SES), a comorbidity for both HS and PCOS, has not been accounted for in prior studies investigating the link between the two conditions [2–4]. We sought to investigate the prevalence of PCOS among HS patients and the association of PCOS and HS, adjusting for SES as a potential confounder. Insurance status and community deprivation index (census tract-based score of material deprivation) regarding individual and area SES were used as metrics to explore this association [5]. The NIH All of Us database aims to enroll a large, diverse cohort of the US population from traditionally underrepresented groups in research and was used for this study.

Materials and methods

A total of 409,420 participants were part of the All of Us database at the time of our analysis. Females with hidradenitis suppurativa were identified using International Classification of Diseases (ICD)-10-L73.2 or Systemized Nomenclature of Medicine (SNOMED) 4,241,223/59,393,003 billing and documentation codes. Females with PCOS were identified using ICD-10-E28.2 or SNOMED 40,443,308/237,055,002.

Female HS patients were stratified by PCOS diagnosis and compared by age, race, and ethnicity using Student’s t-test and Pearson’s chi-squared.

Female HS patients were then nearest-neighbor propensity-score matched (i.e., female patients without HS) at a 4:1 ratio, according to race, ethnicity, age, ever smoker status, alcohol use disorder, obesity, type II diabetes, non-Medicaid status, and community deprivation index. Pearson’s chi-squared, Fisher’s exact, and Student’s t-tests were used to assess differences between the HS cohort and matched controls.

Multivariable logistic regression was conducted to estimate HS effect(s) on PCOS.

Results

Of 99/1,073 (9.2%) female HS patients with PCOS, 31.3% were Black, 62.6% were White, and < 20 were Other (Table 1); this distribution varied significantly from those without PCOS (p < .01).

Table 1 Prevalence of PCOS among female patients with HS

Variable	Female HS Patients without PCOS (n = 974)	Female HS Patients with PCOS (n = 99)	p-value	
Age, years [mean (SD)]	47.73 (14.07)	36.77 (8.66)	< 0.001***	
Race (%)			0.006**	
 Black or African American	467 (47.9)	31 (31.3)		
 Other	51 (5.2)	< 20†		
 White	456 (46.8)	62 (62.6)		
Ethnicity = Not Hispanic or Latino (%)	938 (96.3)	94 (94.9)	0.693	
†Per the All of Us Research Program data privacy policy, variables with less than 20 participants are noted as < 20 to protect individual participant data

** p < .01

*** p < .001

A total of 1,022 female HS patients and 4,088 matched female controls with complete data were included in the matched analysis. Significantly more female HS patients had PCOS (8.8% versus 4.3%, p < .001) (Table 2). In multivariable logistic regression, PCOS was significantly associated with HS [OR 1.71 (95% CI 1.34–2.17)]. Markers of SES did not affect this relationship.

Table 2 Female HS patients versus matched female controls

Variable	Matched Female Controls‡ (n = 4088)	Female HS Patients (n = 1022)	p-value	
Age, years [mean (SD)]	48.28 (14.95)	48.14 (14.75)	0.785	
Race (%)			0.359	
 Asian	< 20†	< 20†		
 Black or African American	1849 (45.2)	446 (43.6)		
 Middle Eastern or North African	28 (0.7)	< 20†		
 More than one population	132 (3.2)	42 (4.1)		
 White	2064 (50.5)	519 (50.8)		
Ethnicity = Not Hispanic or Latino (%)	3971 (97.1)	982 (96.1)	0.101	
Ever Smoker

(≥ 100 cigarettes in lifetime)

	2011 (49.2)	503 (49.2)	1	
Alcohol Use Disorder	398 (9.7)	101 (9.9)	0.934	
Obesity	2983 (73.0)	745 (72.9)	0.868	
Type II Diabetes Mellitus (T2DM)	1654 (40.5)	420 (41.1)	0.738	
Non-Medicaid Insurance (%)††	2282 (55.8)	585 (57.2)	0.434	
Community Deprivation Index

[mean (SD)]

	0.33 (0.06)	0.33 (0.06)	0.603	
PCOS	199 (4.9)	90 (8.8)	< 0.001***	
‡Matched controls selected via 4:1 nearest neighbor propensity score matching without replacement with co-variates of race, ethnicity, age, ever smoker, alcohol use disorder, T2DM, insurance status, and community deprivation index that yielded adequate balance ≤ 0.06

†Per the All of Us Research Program data privacy policy, variables with less than 20 participants are noted as < 20 to protect individual participant data

††No insurance/Medicaid versus non-Medicaid insurance serving as a proxy for low SES

***p < .001

Discussion

This is the first study of prevalence and association of HS and PCOS within the All of Us database. We found HS patients with PCOS were more likely to be White; contrary to current prevalence studies of PCOS reporting similarity between Black and White people [6, 7]. The All of Us database overrepresents a diverse population, while previous studies include predominantly Caucasian populations. Further nationally representative prevalence studies are needed to investigate this potential discrepancy, which may influence screening and treatment guidelines.

We also found that females with HS had a 1.71-fold increased odds of having PCOS (95% CI: 1.34–2.17), which aligns with previous analyses [1, 7]. However, we also account for markers of SES at an individual and community level. Considering this potential confounder, our work further strengthens the association of HS with PCOS. Future studies should include measures of SES, as HS disproportionately affects those of lower SES [4].

While the shared pathophysiological mechanism between HS and PCOS is currently unknown, meta-inflammation – a chronic proinflammatory state – may play a role [8, 9]. Meta-inflammation may arise from obesity, a known comorbidity of both HS and PCOS; excess adipose tissue can lead to the upregulation of proinflammatory molecules that may play a role in the manifestation of the two diseases.

Study limitations include retrospective design and the use of diagnostic codes to identify cases of HS and PCOS. The diagnostic criteria for HS and PCOS that is marked by these codes may vary by provider. Data from the All of Us database may not be generalizable to the United States population given its intentional overrepresentation of minority groups. However, our use of propensity score matching and comparisons within the database allows us to make valid inferences.

This study highlights the need for broader prevalence studies and corroborates the postulated association of HS and PCOS in the literature when controlling for a wide range of medical comorbidities. Further investigation of the underlying mechanism, clinical implications, and the role of hormonal therapies are warranted.

Acknowledgements

The All of Us Research Program is supported by the National Institutes of Health, Office of the Director: Regional Medical Centers: 1 OT2 OD026549; 1 OT2 OD026554; 1 OT2 OD026557; 1 OT2 OD026556; 1 OT2 OD026550; 1 OT2 OD 026552; 1 OT2 OD026553; 1 OT2 OD026548; 1 OT2 OD026551; 1 OT2 OD026555; IAA #: AOD 16037; Federally Qualified Health Centers: HHSN 263201600085U; Data and Research Center: 5 U2C OD023196; Biobank: 1 U24 OD023121; The Participant Center: U24 OD023176; Participant Technology Systems Center: 1 U24 OD023163; Communications and Engagement: 3 OT2 OD023205; 3 OT2 OD023206; and Community Partners: 1 OT2 OD025277; 3 OT2 OD025315; 1 OT2 OD025337; 1 OT2 OD025276. In addition, the All of Us Research Program would not be possible without the partnership of its participants.

Author contributions

PYC was responsible for the project conception, data extraction, data analysis, and initial draft of the manuscript. MT, GC, HDH, and KLC assisted in the editing and revisions of the manuscript draft. SRC provided oversight, guidance, subject expertise, and edits to the final draft. All authors reviewed and approved of the submitted manuscript.

Funding

None.

Data availability

Research data supporting the results of the manuscript can be found in the publicly accessible NIH All of Us database.

Declarations

Competing interests

The authors declare no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Garg A Neuren E Strunk A Hidradenitis Suppurativa is Associated with polycystic ovary syndrome: a Population-based analysis in the United States J Invest Dermatol 2018 138 6 1288 1292 10.1016/j.jid.2018.01.009 29378201
Garg A, Neuren E, Strunk A (2018) Hidradenitis Suppurativa is Associated with polycystic ovary syndrome: a Population-based analysis in the United States. J Invest Dermatol 138(6):1288–1292 PubMed PMID: 29378201. Epub 20180219. eng29378201 10.1016/j.jid.2018.01.009
2. Socioeconomic Status and Polycystic Ovary Syndrome J Women’s Health 2011 20 3 413 419 10.1089/jwh.2010.2303
Socioeconomic Status and Polycystic Ovary Syndrome (2011) J Women’s Health 20(3):413–419 PubMed PMID: 2132358410.1089/jwh.2010.2303
3. Merkin SS Phy JL Sites CK Yang D Environmental determinants of polycystic ovary syndrome Fertil Steril 2016 106 1 16 24 10.1016/j.fertnstert.2016.05.011 27240194
Merkin SS, Phy JL, Sites CK, Yang D (2016) Environmental determinants of polycystic ovary syndrome. Fertil Steril 106(1):16–24 PubMed PMID: 27240194. Epub 20160527. eng27240194 10.1016/j.fertnstert.2016.05.011
4. Wertenteil S Strunk A Garg A Association of Low Socioeconomic Status with Hidradenitis Suppurativa in the United States JAMA Dermatol 2018 154 9 1086 1088 10.1001/jamadermatol.2018.2117 30073254
Wertenteil S, Strunk A, Garg A (2018) Association of Low Socioeconomic Status with Hidradenitis Suppurativa in the United States. JAMA Dermatol 154(9):1086–1088 PubMed PMID: 30073254. PMCID: PMC6143032. eng30073254 10.1001/jamadermatol.2018.2117
5. Brokamp C, Beck AF, Goyal NK, Ryan P, Greenberg JM, Hall ES Material community deprivation and hospital utilization during the first year of life: an urban population–based cohort study. Ann Epidemiol. 2019 2019/02/01/;30:37–43
6. Wolf WM, Wattick RA, Kinkade ON, Olfert MD (2018) Geographical prevalence of polycystic ovary syndrome as determined by region and Race/Ethnicity. Int J Environ Res Public Health. ;15(11). PubMed PMID: 30463276. PMCID: PMC6266413. Epub 20181120. eng.
7. Phan K Charlton O Smith SD Hidradenitis suppurativa and polycystic ovarian syndrome: systematic review and meta-analysis Australas J Dermatol 2020 61 1 e28 e33 10.1111/ajd.13110 31261440
Phan K, Charlton O, Smith SD (2020) Hidradenitis suppurativa and polycystic ovarian syndrome: systematic review and meta-analysis. Australas J Dermatol 61(1):e28–e33 PubMed PMID: 31261440. Epub 20190701. eng31261440 10.1111/ajd.13110
8. Mintoff D Agius R Benhadou F Das A Frew JW Pace NP Obesity and hidradenitis suppurativa: targeting meta-inflammation for therapeutic gain Clin Exp Dermatol 2023 48 9 984 990 10.1093/ced/llad182 37171791
Mintoff D, Agius R, Benhadou F, Das A, Frew JW, Pace NP (2023) Obesity and hidradenitis suppurativa: targeting meta-inflammation for therapeutic gain. Clin Exp Dermatol 48(9):984–990 PubMed PMID: 37171791. eng37171791 10.1093/ced/llad182
9. Parker J, O’Brien C, Hawrelak J, Gersh FL (2022) Polycystic ovary syndrome: an evolutionary adaptation to Lifestyle and the Environment. Int J Environ Res Public Health. ;19(3). PubMed PMID: 35162359. PMCID: PMC8835454. Epub 20220125. eng.
