Impact of hidradenitis suppurativa on work productivity and associated risk factors
Authors: Kelsey R. van Straalen, Lisette M. Prens, Tjerk H. Hylkema, Ineke C. Janse, Janine Dickinson, Ronald Houwing, Hessel H. van der Zee, Sandra Brouwer, Errol P. Prens, Barbara Horváth
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: Matusiak et al1Matusiak Ł. Bieniek A. Szepietowski J.C. Hidradenitis suppurativa markedly decreases quality of life and professional activity.J Am Acad Dermatol. 2010; 62: 706-708Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar showed that hidradenitis suppurativa (HS) caused absenteeism in 58.1% of patients. However, work impairment due to HS is not limited to absenteeism but could also lead to presenteeism (reduced productivity while at work) and at-work productivity loss (absenteeism plus presenteeism). Knowledge of which HS-related factors are associated with absenteeism, presenteeism, and at-work productivity loss is essential. Therefore, we aimed to assess differences between working and nonworking patients with HS; quantify absenteeism, presenteeism, and at-work productivity loss caused by HS; and identify associated risk factors. All newly referred consecutive patients participating in the HiCARE (METc 2018/110), HiSure (METc 2015/074), and HiScreen (MEC-2016-246) registries between April 2015 and July 2019 were included. Patient characteristics, disease severity, patient-reported outcomes, and comorbidities were collected, and the Work Productivity and Activity Impairment questionnaire, specific health problem version, was used to assess the influence of HS on absenteeism, presenteeism, and at-work productivity loss. See the Supplemental Methods (available via Mendeley at https://doi.org/10.17632/6nmk748p89.1) for details on the between-group analyses, multiple imputations, and regression analyses. Overall, 62.0% (523/843) of patients had work at the time of inclusion. The presence of inguinal/gluteal HS, increased HS severity, higher pain scores, the presence of fibromyalgia, and higher depression and anxiety scores were significantly more common in nonworkers (Table I). Twenty-six percent of working patients reported actual work time missed, with a median absenteeism of 0% (95% confidence interval [CI], 0.0-5.3). Workers reported a median presenteeism due to HS of 20% (95% CI, 0.0-50.0) and a median at-work productivity loss of 20.0% (95% CI, 0.0-69.0). Results from the univariate regressions analyses are presented in Supplemental Table I (available via Mendeley at https://doi.org/10.17632/6nmk748p89.1). Pain, Dermatology Life Quality Index, and EuroQol–5 Dimensions scores were significantly associated with presenteeism and at-work productivity loss in the multivariate regression models (Table II).Table IPatient characteristics∗Numbers and percentages may not add up to 100% because of rounding of pooled data.Overall†Percentages in this column are reported as percentages of the overall number of patients. (N = 843)Workers‡Percentages in these columns are presented as percentages of the variable on that row. (n = 523)Nonworkers‡Percentages in these columns are presented as percentages of the variable on that row. (n = 320)P value§P-value calculated between workers and nonworkers.Patient characteristics SexFemale, n (%)604 (71.6)373 (61.8)231 (38.2).79 Age, y, mean (SD)38.0 (12.2)37.3 (11.3)39.0 (13.6).06 Age at onset, y, median (IQR)20.0 (15.0-27.0)20.0 (15.0-27.0)19.0 (15.0-28.0).62Missing, n271512 Disease duration, y, median (IQR)12.5 (6.0-22.0)12.8 (6.5-21.0)12.1 (5.1-25.3).51Missing, n271512 BMI, kg/m2, mean (SD)28.7 (6.3)28.5 (6.1)29.1 (6.5).23 Current or ex-smoker, n (%)643 (76.3)390 (60.7)253 (39.3).16 Positive family history121 (23.8)92 (76.0)29 (24.0)<.001Unknown, n (%)115 (22.6)64 (55.7)51 (44.3)Missing, n335195180 Education level, n (%)Low148 (17.6)65 (43.9)83 (56.1)Medium483 (57.3)300 (62.1)183 (37.9)High212 (25.1)158 (74.5)54 (25.5)<.0001Comorbidities Rheumatoid arthritis, n (%)25 (4.2)12 (48.0)13 (52.0).08Missing, n241134107 Fibromyalgia, n (%)9 (1.5)2 (22.2)7 (77.8).008Missing, n242138104 Spondyloarthritis, n (%)5 (0.9)5 (100.0)0 (0.0)NPMissing, n286139147 Crohn's disease, n (%)35 (5.8)19 (54.3)16 (45.7).18Missing, n240133107 Ulcerative colitis, n (%)5 (0.8)3 (60.0)2 (40.0).82Missing, n247137110 Psoriasis, n (%)37 (6.2)20 (54.1)17 (45.9).17Missing, n247139108 Previous depression, n (%)119 (19.3)53 (44.5)66 (55.5)<.0001Missing, n22613492Physician scores Hurley classification, n (%)Stage I390 (46.3)242 (62.1)148 (37.9).18Stage II368 (43.7)224 (60.9)144 (39.1)Stage III85 (10.0)57 (67.1)28 (32.9) Refined Hurley, n (%)Mild (IA, IIA)363 (43.1)227 (61.2)137 (37.7)Moderate (IB, IIB)195 (23.1)132 (77.4)63 (32.3)Severe (IC, IIC, III)285 (33.8)164 (57.5)120 (42.1).003 IHS4, mean (SD)9.4 (15.3)9.5 (17.0)9.1 (11.9).66Mild, n (%)366 (43.4)223 (60.9)144 (39.3).53Moderate, n (%)232 (27.5)151 (65.1)81 (34.9)Severe, n (%)245 (29.1)150 (61.2)96 (39.2) Presence of draining sinus tracts, n (%)349 (41.4)217 (62.2)132 (37.8).94 Affected locations, n (%)Axillae295 (35.0)192 (65.1)102 (34.6).15Groin/buttocks510 (60.5)298 (58.4)212 (41.6).008Patient-reported outcome measures DLQI, mean (SD)11.5 (7.6)10.8 (7.3)12.6 (8.0)<.001 EQ-5D-5 Level, median (IQR)0.75 (0.62-0.84)0.77 (0.66-0.87)0.69 (0.49-0.81)<.001Missing, n278156122 EQ-5D VAS, median (IQR)70.0 (51.0-80.0)70.0 (60.0-80.0)60.0 (45.0-75.0)<.001Missing, n263147116 NRS Pain, mean (SD)5.3 (3.0)5.2 (2.9)5.6 (3.0).04 NRS Pruritus, mean (SD)4.1 (3.0)3.8 (2.9)4.6 (3.1)<.001 NRS Severity, mean (SD)6.0 (2.8)5.8 (2.7)6.2 (2.8).09 HADS Depression, median (IQR)5.0 (2.0-9.0)3.0 (1.0-6.0)8.0 (3.0-11.0)<.001Missing, n481307174 HADS Anxiety, median (IQR)6.0 (3.0-10.0)5.0 (3.0-8.0)8.0 (4.0-12.0)<.001Missing, n481307174BMI, Body mass index; DLQI, Dermatology Life Quality Index; HADS, Hospital Anxiety and Depression Survey; EQ-5D, EuroQol–5 Dimensions; IHS4, International Hidradenitis Suppurativa Severity Score System; IQR, interquartile range; NRS, numeric rating scale; SD, standard deviation; VAS, visual analogue scale.Bold data indicates statistical significance.∗ Numbers and percentages may not add up to 100% because of rounding of pooled data.† Percentages in this column are reported as percentages of the overall number of patients.‡ Percentages in these columns are presented as percentages of the variable on that row.§ P-value calculated between workers and nonworkers. Open table in a new tab Table IIMultivariate∗All multivariate models were corrected for sex, age, BMI, smoking, educational level, and smoking status. linear and logistic regression analysesAssessmentAbsenteeismPresenteeismAt-work productivity lossnBOR (95% CI)P valuenB (95% CI)P valuenB (95% CI)P valueIHS43050.320 (−0.001 to 0.641).051DLQI score3160.0761.079 (1.024 to 1.137).0043021.720 (1.235 to 2.205)<.0013051.904 (1.335 to 2.473)<.001EQ-5D index score316−1.7030.182 (0.030 to 1.111).065302−23.147 (−40.483 to −5.811).009305−29.222 (−49.592 to −8.853).005NRS Pain3160.1461.157 (1.022 to 1.311).0213022.446 (1.464 to 3.428)<.0013052.373 (1.189 to 3.556)<.001CI, Confidence interval; DLQI, Dermatology Life Quality Index; EQ-5D, EuroQol–5 Dimensions; IHS4, International Hidradenitis Suppurativa Severity Score System; NRS, numeric rating scale; OR, odds ratio.∗ All multivariate models were corrected for sex, age, BMI, smoking, educational level, and smoking status. Open table in a new tab BMI, Body mass index; DLQI, Dermatology Life Quality Index; HADS, Hospital Anxiety and Depression Survey; EQ-5D, EuroQol–5 Dimensions; IHS4, International Hidradenitis Suppurativa Severity Score System; IQR, interquartile range; NRS, numeric rating scale; SD, standard deviation; VAS, visual analogue scale. Bold data indicates statistical significance. CI, Confidence interval; DLQI, Dermatology Life Quality Index; EQ-5D, EuroQol–5 Dimensions; IHS4, International Hidradenitis Suppurativa Severity Score System; NRS, numeric rating scale; OR, odds ratio. The level of absenteeism found in our study seems to be slightly lower than that found in a Danish study and substantially lower than that found in a Canadian study: 7.0% ± 21.2% and 14.5% ± 27.0%, respectively.2Yao Y. Jørgensen A.R. Thomsen S.F. Work productivity and activity impairment in patients with hidradenitis suppurativa: a cross-sectional study.Int J Dermatol. 2020; 59: 333-340Crossref PubMed Scopus (5) Google Scholar,3Sandhu V.K. Shah M. Piguet V. Alavi A. The impact of Hidradenitis suppurativa on work productivity and activity impairment.Br J Dermatol. 2020; 182: 1288-1290Crossref PubMed Scopus (3) Google Scholar One explanation could be the larger proportion of nonworking patients in our study. In The Netherlands (and Denmark), adequate unemployment benefits are provided, which might lead to a higher percentage of nonworking patients and potentially lower levels of absenteeism among those still at work. This highlights that unemployment and work productivity data among patients with HS should be interpreted and extrapolated with caution because the results are highly influenced by the work climate and access to unemployment benefits in the study country. Nonetheless, the factors associated with nonwork and at-work productivity loss in our study are modifiable through medical and/or surgical treatment, which could have a favorable effect on work status and productivity. However, this cross-sectional study does not allow for the assessment of causality in the found associations. Overall, this study shows that several potentially modifiable factors such as inguinal/gluteal involvement, more severe disease, and higher depression and anxiety scores are more common among nonworkers. Additionally, among working patients, pain and quality of life are associated with at-work productivity loss. This indicates the need for adequate treatment and pain management to limit work absence and reduce at-work productivity loss among patients with HS.