Research

JAMA Dermatology | Original Investigation

Differences Between Children and Adults With Hidradenitis Suppurativa

Katherine K. Hallock, MD; Marylena R. Mizerak, BS; Alison Dempsey, MD; Steven Maczuga, BS, MS; Joslyn S. Kirby, MD, MS, Med

Multimedia
IMPORTANCE Up to 50% of patients may have hidradenitis suppurativa (HS) onset between Supplemental content
age 10 and 21 years. To our knowledge, little is known about how adolescents with HS utilize
health care during their journey to receiving a diagnosis.

OBJECTIVE To assess the clinical characteristics and health care utilization patterns of
pediatric vs adult patients with HS.

DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included adult and
pediatric patients with HS claims from the MarketScan medical claims database during the
study period, January 1, 2012, to December 31, 2016. The data were analyzed between March
1 and March 31, 2021.

EXPOSURES Clinical characteristics and health care utilization patterns of pediatric vs adult
patients with HS.

MAIN OUTCOMES AND MEASURES Health care utilization patterns were examined and included
concurrent diagnoses, outpatient care by discipline, and emergency/urgent care and
inpatient claims.

RESULTS This study included 8727 members, comprising 1094 pediatric (155 male [14.2%]
and 939 female patients [85.8%]; mean [SD] age, 14.3 [2.47] years) and 7633 adult patients
(1748 men [22.9%] and 5885 women [77.1%]; mean [SD] age, 37.2 [12.99] years). Pediatric
patients were likely to see pediatricians, dermatologists, emergency department (ED) staff,
and family physicians before diagnosis and commonly received diagnoses of folliculitis and
comedones. Pediatric patients with HS had high rates of comorbid skin and general medical
conditions, including acne vulgaris (558 [51.0%]), acne conglobata (503 [45.9%]), obesity
(369 [33.7%]), and anxiety disorders (367 [33.6%]). A higher percentage of pediatric than
adult patients had HS-specific claims for services rendered by emergency and urgent care
physicians (35.6% vs 28.2%; P < .001; and 18.1% vs 13.4%; P < .001; respectively). However,
adult patients were more likely to have inpatient stays (2.38% vs 4.22%; P = .002). Pediatric
patients had 2.24 ED claims per person, while adults had 3.5 claims per person. The mean
cost per ED claim was similar between groups ($413.27 vs $682.54; P = .18). The largest
component of the total 5-year disease-specific cost was the cost of inpatient visits for
pediatric and adult patients with HS.

CONCLUSIONS AND RELEVANCE This cohort study suggests that pediatric patients utilize
high-cost ED care when HS can often be treated as an outpatient. These data suggest that
there are opportunities to improve recognition of HS in pediatric patients by
nondermatologists and dermatologists.

Author Affiliations: Department of

Dermatology, Penn State Hershey
Medical Center, Penn State
University, Hershey, Pennsylvania
(Hallock, Maczuga, Kirby); Penn State
College of Medicine, Hershey,
Pennsylvania (Mizerak); Department
of Internal Medicine, NYU Langone
Health, Brooklyn, New York
(Dempsey).
Corresponding Author: Joslyn S
Kirby, MD, MS, MEd, Penn State
Milton S Hershey Medical Center,
JAMA Dermatol. 2021;157(9):1095-1101. doi:10.1001/jamadermatol.2021.2865 500 University Dr, Hershey, PA 17036
Published online August 11, 2021. (jkirby1@pennstatehealth.psu.edu).

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 Research Original Investigation Differences Between Children and Adults With Hidradenitis Suppurativa

H
idradenitis suppurativa (HS) is a chronic, inflamma-
tory, follicular occlusive disease.1 It has an average on-
set at age 23 years and is reportedly rare in children, with
an estimate that fewer than 2% of cases occur before age 11 years.2
Despite this, up to 50% of patients show symptoms between ages
10 and 21 years.3-5 Thus, HS is likely not rare in pediatric pa-
tients, but the estimates may reflect delays in seeking care, po-
tential for misdiagnosis, or underdiagnosing.6-9 Small studies and
case reports reveal that pediatric patients with HS present to en-
docrinology, pediatrics or other primary care, or gastroenterol-
ogy departments.10-14 Prompt diagnosis by all clinicians with
prompt referral for treatment is important, as it may also miti-
gate the need for care in high-cost settings, such as the emer-
gency department (ED) or inpatient hospitalization.15 How-
ever, to our knowledge, specific data are unavailable on how
pediatric patients with HS utilize health care.
In addition, HS can be associated with other comorbid con-
ditions; however, these associations have been primarily stud-
ied in adults with HS.16 Based on previous studies, pediatric
patients with HS have been reported to have comorbid endo-
crine dysfunction, particularly precocious puberty, prema-
ture adrenarche, metabolic syndrome, hypothyroidism, poly-
cystic ovary syndrome (PCOS), or androgen excess.12,14,17,18
However, these studies are generally small, and comorbid con-
ditions in pediatric patients with HS need to be further eluci-
dated. Overall, little is known about how the presentation and
manifestations of HS compare between the pediatric and adult
populations. Therefore, in this study, we sought to assess and
compare (1) demographic characteristics, (2) comorbidities, and
(3) health care utilization patterns, including high-cost inpa-
tient and ED settings.
Methods
This retrospective claims analysis utilized data from the IBM
MarketScan commercial database. These data include health
Key Points
Question What are the similarities and differences in between
pediatric and adult patients with hidradenitis suppurativa (HS)
before diagnosis?
Findings In this cohort study of 1094 pediatric patients and 7633
adults, pediatric patients with HS were likely to see pediatricians,
emergency department staff, and family physicians and receive
diagnoses of folliculitis and comedones before HS diagnosis.
Pediatric patients with HS had high rates of comorbid acne
vulgaris, acne conglobata, obesity, and anxiety.
Meaning The findings of this study suggest that HS may be
underdiagnosed in pediatric patients; education directed at
primary care clinicians may aid in early recognition of HS and
facilitate specialist referrals for outpatient treatment.
insurance claims across the continuum of care (eg, inpatient,
outpatient, and emergency/urgent care) as well as enroll-
ment data from large employers and health plans across the
US that provide private health care coverage for more than 92
million people. These data have Penn State Hershey institu-
tional review board approval under expedited review. In-
formed consent was waived because it was a retrospective
study that used deidentified data. As a claims database, clini-
cal outcomes are not included.
A 5-year study period was used (January 1, 2012, to De-
cember 31, 2016). The study sample included only continu-
ously enrolled individuals during the 5-year period. Patients
with HS were defined by 2 or more claims for HS within 18
months as defined by International Classification of Diseases,
Ninth Revision (ICD-9) or ICD-10 codes 705.8 or L73.2, respec-
tively. The date of the first claim for HS was taken as the date
of HS diagnosis. Patients were classified in the pediatric HS
group if HS diagnosis occurred before age 18 years, whereas
patients with an HS diagnosis at or after turning age 18 years
were considered adults with HS. Hidradenitis suppurativa on-
set was based on the first claim for an HS-related diagnosis

Table 1. Characteristics of Pediatric and Adult Patients With Hidradenitis Suppurativa

Participants, No. (%)

Participant characteristics Pediatric Adult P value
Sample size, No. 1094 7633
Mean (SD) age, y 14.34 (2.47) 37.16 (12.99)
Sex
Male 155 (14.2) 1748 (22.9)
Female 939 (85.8) 5885 (77.1) NA
Age of HS, median (range), y
Onset 15 (6-17) 37 (14-64)
Diagnosis 15 (6-17) 40 (18-64)
Potential HS manifestations
Cutaneous abscess of limb 83 (7.59) 671 (8.79) .19
Carbuncle, unspecified 91 (8.32) 581 (7.61) .41
Furuncle, unspecified 96 (8.77) 656 (8.59) .84
Cellulitis, unspecified 332 (30.35) 2177 (28.52) .21
Folliculitis 297 (27.15) 1401 (13.64) <.001
Abbreviations: HS, hidradenitis
Comedones (other acne) 558 (51.00) 1888 (24.73) <.001
suppurativa; NA, not applicable.

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 Differences Between Children and Adults With Hidradenitis Suppurativa Original Investigation Research

(Table 1). Delay from HS onset to diagnosis was calculated by

Figure. Physician Specialty Seen Before Hidradenitis Suppurativa
taking the difference from claims for an HS-related diagnosis Diagnosis
to the first claim for HS. Patient characteristics, including age
and sex, were extracted, and comorbid conditions were ab- Physician specialty

stracted based on ICD-9 or ICD-10 documentation on claims Pediatrician

Pediatric
(eTable in the Supplement). The authors extracted comorbidi-
Adult
ties to be included in the study based on prior case reports and
Family medicine
case series involving pediatric patients with HS. The utiliza- Pediatric
tion and cost variables for outpatient, ED or urgent care, and Adult
inpatient care were extracted for claims that included a diag- Dermatologist
nosis of HS. Claims without an HS diagnosis were excluded for Pediatric
urgent care/ED visits and inpatient stays. The cost of care was Adult
ED physician
calculated from the health system perspective and was the
Pediatric
sum of payments by the insurer and the patient. Costs were
Adult
adjusted for inflation throughout the study period and are re- Gynecologist
ported in 2020 dollars. Pediatric
Descriptive statistics were used to describe the demo- Adult
graphic information, comorbid conditions, and the health care Internal medicine
utilization and cost data for the cohorts. Calculations in- Pediatric
Adult
cluded only those members with claims. Differences be-
Urgent care
tween cohorts were explored; comparisons of categorical
Pediatric
outcomes were made using the χ2 test. Comparisons of con- Adult
tinuous outcome variables were made using the t test. Statis- Surgeon
tical software (SAS, version 9.4; SAS Institute) was used for all Pediatric
analyses. P value less than .05 was considered statistically Adult
significant. Pediatric ED physician
Pediatric
Adult
Gastroenterologist
Results Pediatric
Adult
This study included 8727 members, comprising pediatric (1094 Endocrinologist
[12.5%]) and adult (7633 [87.5%]) patients; their characteris- Pediatric
tics are shown in Table 1. Most patients were female in the pe- Adult
diatric and adult populations, although a higher percentage of Rheumatologist
Pediatric
patients were female in the pediatric cohort (85.83% vs 77.10%).
Adult
The mean (SD) age of HS onset, which was based on first claim
for HS sign/symptoms, was 14.3 (2.5) years in the pediatric co-
hort and 37 (13) years in the adult cohort. The mean (SD) age 0 20 40 60 80 100
Patients, %
of HS diagnosis was 15 (2) years in the pediatric population and
40 (14) years in the adult population, with a mean delay of 0
All specialties were significantly statistically different between pediatric and
and 3 years (P < .001) from symptom onset to diagnosis in the adult cohorts. ED indicates emergency department.
pediatric and adult populations, respectively. Pediatric pa-
tients were more likely than adults to receive a diagnosis of
comedones (51.00% vs 24.73%; P < .001) and folliculitis (27.15% vs 28.2%; P < .001 and 18.1% vs 13.4%; P < .001, respec-
vs 13.64%, P < .001) while other diagnoses, such as cellulitis, tively). Overall, pediatric patients were less likely to see any
abscesses, and furuncles, were not significantly different be- surgeon than adults (8.1% vs 16.7%; P < .01). This number was
tween the 2 groups. not stratified by surgeon type. However, a total of 373 pediat-
Before HS diagnosis, pediatric and adult patients with HS ric patients with HS (34.1%) had incision and drainage claims,
were most likely to be seen by primary care clinicians. Pedi- while 151 (13.8%) had an excision for HS.
atric patients with HS obtained care from multiple types of cli- There were similarities and differences in the comorbidi-
nicians (Figure). They were most likely to have been seen by ties associated with HS among the adult and pediatric groups
a pediatric clinician (894 [81.7%]), family medicine (727 (Table 2). In the pediatric population, acne vulgaris (558
[66.5%]), and dermatology department (435 [39.8%]) before [51.0%]), acne conglobata (503 [45.9%]), obesity (369
HS diagnosis. Comparatively, adult patients with HS pre- [33.7%]), and anxiety disorder (367 [33.6%]) were the most
sented to family medicine (4634 [60.7%]), internal medicine common comorbidities. In the adult HS population, obesity
(3017 [39.5%]), and gynecology departments (2951 [38.7%]). (3343 [43.8%]), anxiety disorder (3216 [42.1%]), hyperlipid-
A higher percentage of pediatric than adult patients had care emia (2530 [33.1%]), and acne vulgaris (1888 [24.7%]) were
from the ED and urgent care physicians before diagnosis (35.6% the most common comorbidities.

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 Research Original Investigation Differences Between Children and Adults With Hidradenitis Suppurativa

Table 2. Comorbidities of Pediatric and Adult Patients With Hidradenitis Suppurativa

Participants, No. (%)

Comorbidities Pediatric Adult P value
Cutaneous
Acne vulgaris 558 (51.00) 1888 (24.73) <.001
Pyoderma gangrenosum 6 (0.55) 54 (0.71) .55
Pilonidal cyst 73 (6.67) 385 (5.04) .02
Acne conglobata 503 (45.98) 1610 (21.09) <.001
Endocrinologic
Diabetes
Type 1 20 (1.83) 215 (2.82) .06
Type 2 50 (4.57) 1665 (21.81) <.001
Hypothyroidism 64 (5.85) 1164 (15.25) <.001
Polycystic ovary syndrome 76 (6.95) 490 (6.03) .24
Precocious puberty 15 (1.37) 0 <.001
Obesity, unspecified 369 (33.73) 3343 (43.80) <.001
Metabolic syndrome 47 (4.30) 313 (4.1) .76
Psychiatric
MDD, recurrent, unspecified 59 (5.39) 566 (7.41) .02
Anxiety disorder, unspecified 367 (33.55) 3216 (42.13) <.001
Tobacco use 10 (0.91) 1394 (18.26) <.001
Other psychoactive abuse, uncomplicated 9 (0.82) 45 (0.59) .26
Cardiovascular
Essential (primary) hypertension 22 (2.01) 3018 (39.54) <.001
Hyperlipidemia, unspecified 47 (4.30) 2530 (33.14) <.001
Autoimmune
Crohn disease 19 (1.74) 139 (1.82) .85
Arthropathy, unspecified 11 (1.00) 440 (5.76) <.001
Abbreviation: MDD, major depressive
Spondyloarthropathy 0 0 >.99
disorder.

The total 5-year disease-specific ED/urgent care cost for the
pediatric and adult HS cohorts after HS diagnosis totaled
$61 163.74 and $1 324 130.59, respectively, with 148 claims for
66 patients in the pediatric cohort and 1940 claims for 553 pa-
tients in the adult cohort. Pediatric patients had a mean (SD)
of 2.24 (1.69) ED claims per person, while adults had 3.5 (4.99)
claims per person. The proportion of pediatric and adult
patients with HS with ED claims was similar (6.03% vs 6.97%;
P = .28), as was the mean cost per ED claim given the large stan-
dard deviation ($413.27 vs $682.54; P = .18). The largest com-
ponent of the total 5-year disease-specific cost was the cost of
inpatient visits for adult and pediatric patients with HS, with
30 hospitalizations totaling $811 235 in the pediatric cohort and
541 hospitalizations totaling $12 854 273 in the adult cohort
(Table 3). The proportion of pediatric and adult patients with
HS with inpatient stays was significantly different (2.38% vs
4.22%; P = .002); however, the mean hospital days per stay was
similar (4.9 vs 6.5 days; P = .49).
Discussion
This study included 8727 patients with HS, including 1094 pe-
diatric patients, making this one of the largest studies of chil-
dren with HS. To our knowledge, the largest published study
to date included 481 children.19 The findings of the present
study confirmed that most children with HS are female
(85.83%), with the mean age of symptom onset at 15 years,
which are similar findings to the recent study by Liy-Wong
et al19 that found that 80% were female and the mean age of
diagnosis of 14.4 years. The female to male ratio for pediatric
patients in our study was 6:1. This value is higher than obser-
vations in adult populations, which are typically 3:1.17,18 This
may be secondary to an earlier age of onset of HS symptom-
atology in female pediatric patients or health care–seeking
behaviors in pediatric female patients.
This study also highlights the importance of disciplines,
such as pediatrics, family medicine, and emergency medi-
cine, in HS diagnosis and management. Critically, pediatric and
adult patients with HS were likely to receive care by primary
care clinicians before diagnosis. These disciplines have the op-
portunity to promptly and accurately recognize and diagnose
HS to initiate first-line management and referral to a derma-
tologist or other clinician who is experienced with HS. It has
been shown that there is a discrepancy between nonderma-
tologists and dermatologists for the diagnosis of skin condi-
tions, which may partially explain the underdiagnosis of
HS.20,21 Given that pediatric patients in this study and a prior

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 Differences Between Children and Adults With Hidradenitis Suppurativa Original Investigation Research

Table 3. Emergency Department and Inpatient Costs for Pediatric and Adult Patients
With Hidradenitis Suppurativa

Participants
Characteristic Pediatric Adult P value
Patients with HS 1094 7933
Patients with an ED claim for 66 (6.03) 553 (6.97) .28
HS, No. (%)
HS ED claims
Claims, total 148 1940
NA
Claims per person 2.24 3.5
Cost per claim, mean (SD), $ 413.27 (474.73) 682.54 (2451.43) .18
Cost per claim, median 227.63 (0.50-3129.69) 173.42 (0.13-23 080.40) NA
(range), $
Total ED costs, $ 61 163.75 1 324 130.59 .18
Patients with an HS inpatient 26 (2.38) 335 (4.22) <.05
claim, No. (%)
HS inpatient claims
Total 30 541
NA
Per person 1.15 1.61
Total inpatient days 147 3523 NA
Hospital length of stay, mean 4.9 (4.5) 6.5 (12.7) .49
(SD), d
HS inpatient costs per visit, 27 041 (29 414.9) 23 760 (35 862.99) .58
mean (SD), $ Abbreviations: ED, emergency
department; HS, hidradenitis
Total inpatient costs, $ 811 234.92 12 854 273.01 .58
suppurativa; NA, not applicable.

study received diagnoses of comedones and folliculitis
before HS diagnosis, these features may be critical in helping
clinicians recognize HS.17 It is possible that pediatric patients
with HS present with less severe disease than adults given
early HS findings, along with decreased evaluation by surgi-
cal specialists. Increased clinician education, improved
screening measures for HS, and coordination of care could
lead to decreased diagnostic delay and more effective man-
agement of HS.
In the pediatric cohort, patients with HS had high rates of
comorbid skin and general medical conditions, including acne
vulgaris (51.0%), acne conglobata (45.9%), obesity (33.7%), and
anxiety disorders (33.6%). Previous studies have shown that
pediatric HS is associated with endocrine dysfunction and in-
flammatory bowel disease.12,14,17,18,22,23 Similarly, this study
showed the prevalence of endocrine disorders, such as type 1
diabetes (1.83%), type 2 diabetes (4.57%), hypothyroidism
(5.85%), PCOS (6.95%), precocious puberty (1.37%), and Crohn
disease (1.74%). These rates are similar to comorbidity rates in
prior studies that showed rates of type 1 diabetes (2.6%-5%),
type 2 diabetes (1-2%-2.6%), thyroid dysfunction (2.9%-5%),
PCOS (0.2%-3.6%), precocious puberty (0.2%-3.6%), and in-
flammatory bowel disease (1%-3.3%) in pediatric patients with
HS.19,24 Obesity was less prevalent in the pediatric (33.7%) co-
hort compared with the adult cohort (43.8%) in this study; how-
ever, it is important to recognize that obesity in the pediatric
HS cohort was higher than the US national average of 18.5%.25
Similarly, while anxiety in the pediatric HS cohort was less than
the adult cohort, it was higher than the 10.5% reported by the
US Centers for Disease Control for individuals aged 12 to 17
years.26 Moreover, the rate of anxiety in our study was higher
than that reported in a study by Tiri et al27 in which psychiat-
ric disorders were the single most common comorbidity in pe-
diatric patients with HS (15.7%), and 5.9% of those were anxi-
ety disorders. Early recognition of these comorbid conditions
is crucial to the holistic treatment of patients with HS.28,29
Adults with HS have an increased utilization of high-cost care
settings, such as the ED and inpatient hospitalization.23,30,31 In
this study, pediatric patients with HS had a comparable num-
ber of ED utilization claims per person compared with adult
patients with HS. Pediatric patients with HS may seek care from
high-cost settings, such as the ED or urgent care, if their out-
patient clinician is unable to diagnose or manage their dis-
ease. Because of geographic location, finances, or specialist
appointment scarcity, many patients with HS do not receive a
diagnosis or are unable to receive timely care; therefore, they
turn to the ED for diagnosis or symptom relief. In terms of in-
patient care, pediatric patients with HS had significantly fewer
inpatient hospitalization claims than adult patients; how-
ever, they did not differ in the mean cost nor days per stay be-
tween cohorts. This difference may be because of the higher
occurrence of any comorbid condition in adult patients. The
ICD-9 and ICD-10 codes extracted for this study were those
that listed HS on the admission chart but not necessarily as the
primary reason for admission. In addition, HS may be prefer-
entially underrecognized in the pediatric population, so it is
possible that the diagnosis of HS was not included on inpa-
tient claims.
Limitations
The findings of this study should be understood in the con-
text of its limitations. The MarketScan database may not be

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 Research Original Investigation Differences Between Children and Adults With Hidradenitis Suppurativa

representative of nor generalizable to other patient popula-
tions as it represents those with private insurance, and so
may not apply to patients without insurance. Given that
patients were identified by HS-specific ICD-9 and ICD-10
codes, the study may favor those with more severe disease.
Moreover, the data set only includes patients with a correct
diagnosis, while HS is frequently misdiagnosed or undiag-
nosed. Therefore, the number of cases in this data set likely
underrepresents the true number of HS cases. The data set
does not contain information on race and ethnicity, clinical
findings, or disease severity, so these could not be evaluated
in our study and, as such, it may underestimate the delay
in diagnosis because of differences in clinical notes and
charges on claims. In addition, it is not known whether the
HS-related diagnoses extracted in our study were associated
with the subsequent HS diagnosis; therefore, reported diag-
nostic delay may not represent the true timing of care
received. Finally, the costs described are all-cause and not
just those specific to HS.
Early recognition, prompt intervention, and referral to a
dermatologist may be the key to managing the complica-
tions and comorbidities of pediatric HS. Ultimately, this may
prevent the utilization of high-cost care settings, such as the
ED or inpatient hospitalization. Given that pediatric HS
populations may present with endocrine abnormalities,
higher than average obesity rates, and higher than average
anxiety disorder rates compared with their peers, it is impor-
tant to emphasize patient and clinician education as well as
coordination of care among clinicians. Addressing these
potential issues may prove to be highly beneficial in control-
ling patient symptoms, preventing unnecessary health care
costs, and, ultimately, getting patients the timely and effec-
tive care they require. Given that pediatric and adult patients
with HS were most likely to present to primary care special-
ties before diagnosis, targeted education regarding early
manifestations of HS for these clinicians may facilitate early
dermatology referral.
Conclusions
Pediatric patients utilize high-cost ED care when HS in chil-
dren and adults can often be treated as an outpatient if re-
ferred to the proper specialist. These data suggest that there
are opportunities to improve recognition of HS in pediatrics
by nondermatologists and dermatologists.

ARTICLE INFORMATION
Accepted for Publication: June 17, 2021.
Published Online: August 11, 2021.
doi:10.1001/jamadermatol.2021.2865
Author Contributions: Drs Hallock and Kirby had
full access to all of the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: Hallock, Kirby.
Acquisition, analysis, or interpretation of data:
All authors.
Drafting of the manuscript: Hallock, Mizerak,
Maczuga, Kirby.
Critical revision of the manuscript for important
intellectual content: Hallock, Mizerak, Dempsey,
Kirby.
Statistical analysis: Hallock, Maczuga.
Administrative, technical, or material support:
Maczuga, Kirby.
Supervision: Kirby.
Conflict of Interest Disclosures: Dr Kirby reported
personal fees from AbbVie, ChemoCentryx, Incyte,
Janssen, Novartis, and UCB Pharma outside the
submitted work. No other disclosures were
reported.
REFERENCES
1. Jemec GBE. Clinical practice: hidradenitis
suppurativa. N Engl J Med. 2012;366(2):158-164.
doi:10.1056/NEJMcp1014163
2. Scheinfeld N. Hidradenitis suppurativa in
prepubescent and pubescent children. Clin Dermatol.
2015;33(3):316-319. doi:10.1016/j.clindermatol.2014.
12.007
3. Molina-Leyva A, Cuenca-Barrales C.
Adolescent-onset hidradenitis suppurativa:
prevalence, risk factors and disease features.
Dermatology. 2019;235(1):45-50. doi:10.1159/
000493465
4. von der Werth JM, Williams HC. The natural
history of hidradenitis suppurativa. J Eur Acad
Dermatol Venereol. 2000;14(5):389-392. doi:10.
1046/j.1468-3083.2000.00087.x
5. Jemec GB. The symptomatology of hidradenitis
suppurativa in women. Br J Dermatol. 1988;119(3):
345-350. doi:10.1111/j.1365-2133.1988.tb03227.x
6. Garg A, Wertenteil S, Baltz R, Strunk A, Finelt N.
Prevalence estimates for hidradenitis suppurativa
among children and adolescents in the United
States: a gender- and age-adjusted population
analysis. J Invest Dermatol. 2018;138(10):2152-2156.
doi:10.1016/j.jid.2018.04.001
7. Micheletti RG. Hidradenitis suppurativa: current
views on epidemiology, pathogenesis, and
pathophysiology. Semin Cutan Med Surg. 2014;33
(3)(suppl):S48-S50. doi:10.12788/j.sder.0091
8. Dessinioti C, Tzanetakou V, Zisimou C,
Kontochristopoulos G, Antoniou C. A Retrospective
Study of the Characteristics of Patients with
Early-Onset Compared to Adult-Onset Hidradenitis
Suppurativa. Vol 57. Blackwell Publishing Ltd; 2018.
9. Bettoli V, Ricci M, Zauli S, Virgili A. Hidradenitis
suppurativa-acne inversa: a relevant dermatosis in
paediatric patients. Br J Dermatol. 2015;173(5):
1328-1330. doi:10.1111/bjd.13951
10. Wortsman X, Rodriguez C, Lobos C, Eguiguren
G, Molina MT. Ultrasound diagnosis and staging in
pediatric hidradenitis suppurativa. Pediatr Dermatol.
2016;33(4):e260-e264. doi:10.1111/pde.12895
11. Krakowski AC, Admani S, Uebelhoer NS,
Eichenfield LF, Shumaker PR. Residual scarring from
hidradenitis suppurativa: fractionated CO2 laser as
a novel and noninvasive approach. Pediatrics. 2014;
133(1):e248-e251. doi:10.1542/peds.2012-3356
12. Palmer RA, Keefe M. Early-onset hidradenitis
suppurativa. Clin Exp Dermatol. 2001;26(6):501-503.
doi:10.1046/j.1365-2230.2001.00876.x
13. Prabhu G, Laddha P, Manglani M, Phiske M.
Hidradenitis suppurativa in a HIV-infected child.
J Postgrad Med. 2012;58(3):207-209. doi:10.4103/
0022-3859.101403
14. Randhawa HK, Hamilton J, Pope E. Finasteride
for the treatment of hidradenitis suppurativa in
children and adolescents. JAMA Dermatol. 2013;149
(6):732-735. doi:10.1001/jamadermatol.2013.2874
15. Khalsa A, Liu G, Kirby JS. Increased utilization of
emergency department and inpatient care by
patients with hidradenitis suppurativa. J Am Acad
Dermatol. 2015;73(4):609-614. doi:10.1016/
j.jaad.2015.06.053
16. Shlyankevich J, Chen AJ, Kim GE, Kimball AB.
Hidradenitis suppurativa is a systemic disease with
substantial comorbidity burden: a chart-verified
case-control analysis. J Am Acad Dermatol. 2014;71
(6):1144-1150. doi:10.1016/j.jaad.2014.09.012
17. Liy-Wong C, Pope E, Lara-Corrales I.
Hidradenitis suppurativa in the pediatric
population. J Am Acad Dermatol. 2015;73(5)(suppl
1):S36-S41. doi:10.1016/j.jaad.2015.07.051
18. Mengesha YM, Holcombe TC, Hansen RC.
Prepubertal hidradenitis suppurativa: two case
reports and review of the literature. Pediatr Dermatol.
1999;16(4):292-296. doi:10.1046/
j.1525-1470.1999.00077.x
19. Liy-Wong C, Kim M, Kirkorian AY, et al.
Hidradenitis Suppurativa in the pediatric
population: an international, multicenter,
retrospective, cross-sectional study of 481 pediatric
patients. JAMA Dermatol. 2021;157(4):385-391. doi:
10.1001/jamadermatol.2020.5435
20. Tran H, Chen K, Lim AC, Jabbour J, Shumack S.
Assessing diagnostic skill in dermatology:
a comparison between general practitioners and
dermatologists. Australas J Dermatol. 2005;46(4):
230-234. doi:10.1111/j.1440-0960.2005.00189.x

1100 JAMA Dermatology September 2021 Volume 157, Number 9 (Reprinted) jamadermatology.com

© 2021 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ by a Dominican Republic | Access Provided by JAMA User on 05/06/2023
 Differences Between Children and Adults With Hidradenitis Suppurativa
21. Gerbert B, Maurer T, Berger T, et al. Primary
care physicians as gatekeepers in managed care:
primary care physicians’ and dermatologists’ skills
at secondary prevention of skin cancer. Arch
Dermatol. 1996;132(9):1030-1038. doi:10.1001/
archderm.1996.03890330044008
22. Lewis F, Messenger AG, Wales JKH.
Hidradenitis suppurativa as a presenting feature of
premature adrenarche. Br J Dermatol. 1993;129(4):
447-448. doi:10.1111/j.1365-2133.1993.tb03174.x
23. Iskandar H, Greer JB, Krasinskas AM, et al. IBD
LIVE series—case 8: treatment options for
refractory esophageal Crohn’s disease and
hidradenitis suppurativa. Inflamm Bowel Dis. 2017;
23(10):1667-1677. doi:10.1097/
MIB.0000000000001266
24. Riis PT, Saunte DM, Sigsgaard V, et al. Clinical
characteristics of pediatric hidradenitis suppurativa:
a cross-sectional multicenter study of 140 patients.
Arch Dermatol Res. 2020;312(10):715-724. doi:10.
1007/s00403-020-02053-6
jamadermatology.com
© 2021 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ by a Dominican Republic | Access Provided by JAMA User on 05/06/2023
Original Investigation Research
25. Hales CM, Carroll MD, Fryar CD, Ogden CL. Healthcare Needs (VOICE) Project. J Am Acad
Prevalence of obesity among adults and youth: Dermatol. 2020;82(2):366-376. doi:10.1016/
United States, 2015-2016 key findings data from j.jaad.2019.06.1301
the National Health and Nutrition Examination
29. Thorlacius L, Cohen AD, Gislason GH, Jemec
Survey. Accessed December 22, 2020. https://
GBE, Egeberg A. Increased suicide risk in patients
www.cdc.gov/nchs/data/databriefs/
with hidradenitis suppurativa. J Invest Dermatol.
db288_table.pdf#1
2018;138(1):52-57. doi:10.1016/j.jid.2017.09.008
26. US Centers for Disease Control and Prevention.
30. Braunberger TL, Nicholson CL, Gold L, et al.
Data and statistics on children’s mental health.
Hidradenitis suppurativa in children: the Henry Ford
Accessed December 22, 2022. https://www.cdc.
experience. Pediatr Dermatol. 2018;35(3):370-373.
gov/childrensmentalhealth/data.html#ref/
doi:10.1111/pde.13466
27. Tiri H, Jokelainen J, Timonen M, Tasanen K,
31. Alavi A, Lynde C, Alhusayen R, et al. Approach
Huilaja L. Somatic and psychiatric comorbidities of
to the management of patients with hidradenitis
hidradenitis suppurativa in children and
suppurativa: a consensus document. J Cutan Med
adolescents. J Am Acad Dermatol. 2018;79(3):514-
Surg. 2017;21(6):513-524. doi:10.1177/
519. doi:10.1016/j.jaad.2018.02.067
1203475417716117
28. Garg A, Neuren E, Cha D, et al. Evaluating
patients’ unmet needs in hidradenitis suppurativa:
results from the Global Survey Of Impact and
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