Sexual and gender minority patients are disproportionately at risk for infections, including HIV, that can significantly alter the clinical course and presentation of hidradenitis suppurativa (HS), according to a review published in the Journal of the American Academy of Dermatology.
Jason Gomez and colleagues at the Stanford School of Medicine explored critical factors for dermatologists to consider when managing the physical and behavioral care needs of LGBTQAI patients with HS.
According to the researchers, dermatologists should consider comorbidities, infections in HIV-positive individuals, and creating a welcoming environment when managing sexual and gender minority (SGM) patients with HS.
Current management guidelines for HS recommend screening for depression, anxiety, and substance abuse, which LGBTQAI-identifying patients are at high risk of experiencing. Diagnosing HS might worsen discrimination and shame.
“Mental health screening and support are important aspects of care for SGM patients with HS. Dermatologists can contribute to normalization by openly discussing anxiety, depression, chronic pain in HS, sexual orientation, gender identity issues, and diverse sexual behaviors in a supportive manner,” the researchers said. “Further, a multidisciplinary approach with pain management and psychiatry or therapy may be helpful when appropriate.”
The researchers also found that comorbidities associated with HS, such as acne, may exacerbate behavioral health issues and precipitate gender dysphoria in transgender youth. According to the researchers, dermatologists should recognize gender dysphoria in transgender patients when treating acne and HS.
“Furthermore, gender-affirming hormonal therapy (GAHT) can influence the course of acne. Testosterone can trigger or worsen acne, while estrogen and antiandrogen hormonal therapy may improve it,” they added.
According to the researchers, GAHT is associated with worsening cardiovascular disease, increased thromboembolic risk, and sex-specific metabolic syndrome abnormalities in transgender patients. In addition, they observed that sexual minority women have higher baseline metabolic syndrome and risk factor risks (obesity, smoking, heavy drinking, and depression) than heterosexual women.
“Routine screening in patients with HS for these systemic conditions is essential and even more critical to address if those patients are on GAHT…. Dermatologists may find it useful to partner with gender-affirming endocrinologists (if available) or whoever is managing their patients’ hormonal treatments in these cases to optimize GAHT with HS therapy.”
The researchers also advised dermatologists to consider potentially serious consequences in SGM patients with HS, such as squamous cell carcinoma (SCC) and HIV infections. SGM individuals are less likely to receive cancer-preventative services despite a higher self-reported lifetime prevalence of skin cancer and a higher risk of human papillomavirus infection, which may increase SCC incidence.
As a result of these risks, the researchers recommended that SGM patients with HS routinely follow up with a dermatologist for full-body skin examinations, even in cases of well-controlled disease. They also recommended against using anal Pap smears for men who have sex with men.
The authors provided several other unique considerations for providers when managing transgender patients, such as discussing medical exams and procedures in advance to reduce anxiety and enable SGM patients to voice concerns and using patients’ preferred terms when explaining each step of the exam.