QIs hidradenititis suppuritiva an independent risk factor for MACE (major adverse cardiovascular events)?

Medically reviewed by Nick Brownstone, MD

Perhaps most of us know that there is a heightened prevalence of cardiovascular risk factors such as obesity, metabolic syndrome, and smoking in our patients with hidradenitis suppuritiva (HS), and most research has attributed HS’s elevated cardiovascular risk to these coexisting factors. But is the condition itself an independent risk factor for atherosclerosis development due to its inflammatory nature, thereby elevating the risk of MACE (major adverse cardiovascular events) in these patients? And if so, what should we as dermatology clinicians do with this information?

In a well-written article by PAs Jodi Flynn, Kathryn Harrison, and Viet Le, they point out how much more common HS is in the population than we think. For a long time, it was probably underrecognized. But the global estimated prevalence is actually between 1 to 4%, which is similar to the incidence of psoriasis (usually cited as being around 2% in the literature). Perhaps because the scars and tunneling and cysts of HS occur in areas of the body that are usually hidden (such as the axillae and anogenital region), primary care physicians may not realize a patient has it unless the patient brings it up during a visit. The true prevalence may even be higher than the number quoted above due to frequent misidentification of the disease by non-dermatology clinicians. In fact, many of these patients have up to a10-year diagnostic delay.

It’s important for us as dermatology providers to recognize HS as not only one of the more painful and debilitating skin conditions our patients may experience, but to also educate them on their potentially higher risk for life-threatening cardiac events and make sure they are regularly seeing their primary care physician and/or a cardiologist and making all their other providers aware that they have HS. Especially as cardiovascular disease (CVD) is the current leading cause of mortality in the US. Within the pathophysiology of HS, there’s an upregulation of various inflammatory immune cytokines and cells believed to contribute to the development of CVD. Examples of CVD include myocardial infarction, stroke, and DVT/PE.

A large Danish population cohort study showed that when adjusted confounders were taken into account such as age, sex, socioeconomic status, smoking and medications, those with HS still had a markedly elevated risk of MACE events and all-cause mortality compared to the control group. Therefore, these authors concluded that HS is an independent risk factor for CVD.

And Tiri et al published a large retrospective national registry study based on the population of Finland that reported significantly diminished life expectancy in individuals with HS. Those with hidradenitis suppuritiva had a mean age of death of 60.5 years compared to 71.1 years for those with psoriasis, and 75.2 years for patients serving as controls. So just like other chronic inflammatory diseases such as psoriasis, RA and IBD, HS patients may also have an increased risk of cardiovascular disease independent of traditional CV risk factors.

Therefore it’s important we utilize our dermatology visits as an opportunity to stress the significance of healthy habits, especially in relation to smoking and alcohol use, diet, and physical activity and make sure patients are seeing a PMD at least once yearly who is running labs and screening them for comorbidities such as hyperlipidemia, diabetes, hypertension and metabolic syndrome and potentially referring them to a cardiologist as well.

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References:

1. Flynn J, Harrison K, Viet L. Hidradenitis Suppuritiva: Beyond Skin Concerns to Focus on Cardiovascular Considerations. J Clin Aesthet Dermatol. 2025; 18(7-8 Suppl 1): 10-15.
2. Dufour DN, Emtestam L, Jemec GB. Hidradenitis suppurativa: a common and burdensome, yet under-recognised, inflammatory skin disease. Postgrad Med J. 2014;90(1062):216–221.
3. Egeberg A, Gislason GH, Hansen PR. Risk of major adverse cardiovascular events and all-cause mortality in patients with hidradenitis suppurativa. JAMA Dermatol. 2016;152(4):429–434.
4. Mehta NN, Azfar RS, Shin DB, et al. Patients with severe psoriasis are at increased risk of cardiovascular mortality: cohort study using the General Practice Research Database. Eur Heart J. 2010;31(8):1000–1006