Barriers to Care in Patients With Skin of Colour Who Have Hidradenitis Suppurativa: A Systematic Review

To the Editor:

Hidradenitis suppurativa (HS), a chronic inflammatory skin condition, has a prevalence of 0.1%–0.4% in the United States. ¹ Racial disparities are evident in dermatology, with racial and ethnic minority groups consistently being undertreated as well as facing barriers in access and quality of healthcare. ² The prevalence of HS is two to three times higher and of greater disease severity in Black compared to White individuals. ¹ This systematic review (SR) aims to identify the existing literature regarding barriers associated with access to care, diagnosis, and treatment for patients with skin of colour (SoC) who have HS to inform clinicians and policymakers.

An electronic search of Medline, Embase, and Scopus (from inception to March 23, 2024) was completed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Supplemental Table 1). Full details of inclusion/exclusion criteria and methodology are included in the PROSPERO protocol (CRD42023491979). Risk of bias assessment was completed using adaptations of the Newcastle-Ottawa Scale (Supplemental Table 2). Citation chaining analysis was performed on all included articles, and relevant review articles prior to their exclusion.

A total of 483 studies potentially met the inclusion criteria, with 12 ultimately included after screening (Supplemental Table 3 and Supplemental Figure 1). The risk of bias assessment showed heterogeneous risk of biases; themes of barriers to diagnosis and treatment emerged.

Studies reporting on barriers to diagnosis found patients with SoC and HS are less likely to access care and may present later in the disease process compared to White patients. ¹ A study found the mean delay in diagnosis for HS was 1.62 times greater in Black than White patients. ³ Black patients were more likely to see a surgeon before a dermatologist in comparison to White patients (P ≤ .001). ³ Delayed diagnosis may occur due to a lack of disease recognition of HS in individuals with SoC compared to those with lighter skin tones.

Patients with SoC are 2.86 times more likely to require emergency department visits for HS (P < .001), ¹ and are less likely to receive a skin examination (P = .0267) and scheduled for a dermatology follow-up (P = .0017). ⁴ Inadequate pain management was reported in Black patients, with the finding that Black patients are less likely to be prescribed pain medications for HS than White patients (81.3% vs 78.9%, P < .001), ² and are less likely to be initiated on biological therapies. ¹

Disparities in HS treatment outcomes have been linked to variations in race, socioeconomic status, comorbidities, provider/patient education, and underrepresentation in clinical trials, ⁴ leading to insufficient evidence-based guidelines for treating patients with SoC and HS, variations in treatment approaches, and potential disparities in outcomes.

There is an urgent need to develop and utilize methodologies that do not rely solely on parameters typically associated with White populations to reduce barriers to providing culturally competent care. Diversifying patients in clinical trials will lead to a better understanding of genetic involvement in HS disease severity among populations with SoC. This SR highlights significant disparities and calls for urgent action to overcome these barriers to care for patients with SoC who have HS.

Supplemental Material

sj-docx-1-cms-10.1177_12034754241269125 – Supplemental material for Barriers to Care in Patients With Skin of Colour Who Have Hidradenitis Suppurativa: A Systematic Review

Supplemental material, sj-docx-1-cms-10.1177_12034754241269125 for Barriers to Care in Patients With Skin of Colour Who Have Hidradenitis Suppurativa: A Systematic Review by Eric McMullen, Dea Metko, Shanti Mehta, Mahan Maazi, Rajan Grewal, Marissa Joseph and Vincent Piguet in Journal of Cutaneous Medicine and Surgery