Hidradenitis suppurativa in transgender and gender diverse patients: A retrospective review with examination of the role of hormone therapy
Authors: Reese L. Imhof, Austin Todd, Caroline J. Davidge-Pitts, Afsaneh Alavi
Journal: Journal of the American Academy of Dermatology (2023)

To the Editor: Hidradenitis suppurativa (HS) is a chronic inflammatory multifactorial disorder with a notable role of hormones in the development and exacerbation of HS, which is supported by typical disease onset after puberty, alterations in disease activity during times of hormonal change such as menses and pregnancy, as well as HS comorbidities such as polycystic ovarian syndrome.1Masson R. Shih T. Jeong C. Shi V.Y. Hsiao J.L. Hormonal treatments in hidradenitis suppurativa: a systematic review.J Drugs Dermatol. 2023; 22: 785-794https://doi.org/10.36849/jdd.7325Crossref PubMed Scopus (1) Google Scholar Individuals who identify as transgender or gender diverse (TGD) have incongruence between their birth sex and gender identity, which can lead to gender dysphoria. Medical interventions such as gender-affirming hormone therapy (GAHT) can help relieve this distress. It has been suggested that TGD individuals taking testosterone for gender affirmation may be at higher risk for development or exacerbation of HS.2Ramos-Rodríguez D. Garcias-Ladaria J. Serra Soler G. Martín-Santiago A. Hidradenitis suppurativa in a transgender man.Clin Exp Dermatol. 2021; 46: 1305-1306https://doi.org/10.1111/ced.14680Crossref PubMed Scopus (4) Google Scholar,3Buonomo M. Mansh M.D. Thorpe D. Goldfarb N. Development or exacerbation of hidradenitis suppurativa in two transgender men after initiation of testosterone therapy.Br J Dermatol. 2021; 184: 1192-1194https://doi.org/10.1111/bjd.19812Crossref PubMed Scopus (9) Google Scholar Similarly, one could hypothesize that TGD individuals taking antiandrogen GAHT could experience improvement in HS. However, the role of GAHT in the etiology and progression of HS in the TGD population remains unclear, with current evidence limited to case reports.2Ramos-Rodríguez D. Garcias-Ladaria J. Serra Soler G. Martín-Santiago A. Hidradenitis suppurativa in a transgender man.Clin Exp Dermatol. 2021; 46: 1305-1306https://doi.org/10.1111/ced.14680Crossref PubMed Scopus (4) Google Scholar, 3Buonomo M. Mansh M.D. Thorpe D. Goldfarb N. Development or exacerbation of hidradenitis suppurativa in two transgender men after initiation of testosterone therapy.Br J Dermatol. 2021; 184: 1192-1194https://doi.org/10.1111/bjd.19812Crossref PubMed Scopus (9) Google Scholar, 4Gomez J. Barnes L.A. Yost J.M. Gordon J. Ginsberg B.A. Aleshin M. Hidradenitis suppurativa in sexual and gender minorities: a review and considerations for providers.J Am Acad Dermatol. 2022; 89: 795-801https://doi.org/10.1016/j.jaad.2022.03.008Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar This retrospective study was approved by Mayo Clinic's Institutional Review Board. We performed a search of our institution's electronic medical records to identify adult patients between 01/01/1990 and 12/31/2022 with gender dysphoria/incongruence and a diagnosis of HS using International Classification of Diseases codes and a text-based search. Adult patients were included if they consented to research, identified as TGD, and met diagnostic criteria for HS.5Zouboulis C.C. Del Marmol V. Mrowietz U. Prens E.P. Tzellos T. Jemec G.B. Hidradenitis suppurativa/acne inversa: criteria for diagnosis, severity assessment, classification and disease evaluation.Dermatology. 2015; 231: 184-190https://doi.org/10.1159/000431175Crossref PubMed Scopus (251) Google Scholar Comparisons were evaluated using Fisher's exact test and P values of < .05 were considered statistically significant. Additional analyses with Wilcoxon rank sum test were performed to investigate associations between age at HS diagnosis, age of GAHT initiation, and body mass index, with HS disease outcome. A total of 24 patients met inclusion criteria. Complete baseline and disease characteristics are outlined in Tables I and II. Overall, 75% (n = 18) were on GAHT, with 50% (n = 9) diagnosed with HS before GAHT. Most presented at Hurley stage I (15, 62.5%); however, only 45.8% (n = 11) remained at Hurley stage I. In patients who initiated testosterone (n = 13), most experienced worsening of their HS (9, 69.2%), or no change (4, 30.8%); no patients experienced improvement. In contrast, in patients who initiated GAHT with estradiol and spironolactone (n = 5), all experienced improvement in their HS (5, 100%). Patients who initiated GAHT with testosterone were more likely to experience worsening of their HS (P = .029). In patients on testosterone, there was no association between age at HS diagnosis (P = .588), age of testosterone initiation (P = .142), or body mass index (P = .246) with worsening of HS. Although all active smokers on testosterone experienced worsening of HS, this association was not statistically significant (P = .070). A preexisting diagnosis of HS was also associated with worsening of HS posttestosterone initiation (P = .021). Three patients underwent chest surgery (mastectomy) with active HS at the time of surgery; 1 patient developed HS lesions involving his surgical site postoperatively. There were 2 cases of transmasculine identified patients started on antiandrogen treatment with spironolactone for HS (neither of these patients were on concomitant testosterone at the time), and ultimately both discontinued spironolactone prior to starting testosterone.Table IPatient baseline characteristics, medical comorbidities, and gender-affirming care receivedResults (n, %)Gender identity Man13, 54.2% Woman5, 20.8% Nonbinary/other6, 25.0%Sex assigned at birth Female18, 75.0% Male6, 25.0%Race African American/Black1, 4.2% Asian1, 4.2% White20, 83.3% Other2, 8.3%Body mass index (BMI) Mean41 Median40 Range27-54Smoking status Current/active smoker10, 41.7% Former smoker5, 20.8% Never smoker9, 37.5%Comorbidities Depression20, 83.3% Metabolic syndrome10, 41.7% Anxiety9, 37.5% Acne8, 33.3% Polycystic ovary syndrome (PCOS)4, 16.7% Pilonidal disease2, 8.3% Psoriatic arthritis2, 8.3% Ankylosing spondylitis1, 4.2% Chronic pain syndrome1, 4.2%Gender-affirming hormone therapy received Testosterone13, 54.2% None6, 25.0% Estrogen/estradiol5, 20.8% Spironolactone5, 20.8% Progesterone4, 16.7%Age of initiation of gender-affirming hormone therapy Mean27 y Median26 y Range18-41 yGender-affirming surgical interventions received Breast augmentation1, 4.2% Facial surgery1, 4.2% Hysterectomy2, 8.3% Masculinizing chest surgery5, 20.8% Orchiectomy2, 8.3% Phalloplasty1, 4.2% Vaginoplasty1, 4.2% Open table in a new tab Table IIHidradenitis suppurativa history, course, and treatmentsResults (n, %)Age at HS diagnosis Mean25 y Median23 y Range13-44 yAge at reported HS symptom onset Mean22 y Median22 y Range11-42 yHS diagnosis before or after initiation of hormone therapy Before9, 37.5% After9, 37.5% Not applicable/patient not on hormone therapy6, 25.0%Hurley stage initial visit I15, 62.5% II7, 29.2% III2, 8.3%Hurley stage most recent visit I11, 45.8% II10, 41.7% III2, 8.3% Disease remission1, 4.2%HS sites of involvement Axillary17, 70.8% Inframammary7, 29.2% Abdomen5, 20.8% Groin/genitals19, 79.2% Thighs9, 37.5% Buttocks5, 20.8%HS treatments received Topical antibiotics17, 70.8% Oral antibiotics16, 66.7% Biologics5, 20.8% Antiseptic washes19, 79.2% HS related surgical procedure9, 37.5% Laser hair removal1, 4.2% Spironolactone2, 8.3% Metformin2, 8.3%HS course post testosterone therapy initiation Improving0, 0% No change4, 16.7% Worsening9, 37.5% Not applicable/patient not on testosterone therapy11, 45.8%HS course post feminizing hormone therapy initiation Improving5, 20.8% No change0, 0% Worsening0, 0% Not applicable/patient not on feminizing hormone therapy19, 79.2%Duration of follow-up (d) Mean1466 Median1021 Range58-5686HS, Hidradenitis suppurativa. Open table in a new tab HS, Hidradenitis suppurativa. In conclusion, our findings suggest that testosterone may worsen HS, while GAHT with estradiol and spironolactone may improve HS. Patients with HS who initiate testosterone warrant close follow-up with dermatology to evaluate for worsening disease activity. Limitations to this study include the small sample size, disproportionately Caucasian sample, and difficulty uncoupling estradiol from spironolactone as patients were on these concomitantly. None disclosed.