Does HS cause depression?

Research consistently shows that 30-40% of HS patients meet criteria for clinical depression - a rate 2-3 times higher than the general population. The relationship is bidirectional: HS causes depression through chronic pain, disfigurement, and social isolation, while depression worsens HS through stress-induced inflammation and reduced treatment adherence.

How common is anxiety in HS patients?

Anxiety disorders affect approximately 20-30% of HS patients. The unpredictability of flares, fear of odor or visible lesions in social situations, and the cumulative psychological burden of living with a chronic, painful, and often misunderstood condition are the primary drivers of anxiety in HS.

Can treating HS improve depression and anxiety?

Yes. Multiple studies show that effective HS treatment - particularly with biologics such as adalimumab - significantly reduces depression and anxiety scores alongside physical disease improvement. Treating the underlying inflammation appears to have direct benefits for mental health, supporting the bidirectional inflammatory hypothesis.

What mental health treatments work best for HS patients?

Cognitive behavioral therapy (CBT) has the strongest evidence for chronic illness-related depression and anxiety. Acceptance and commitment therapy (ACT) is also effective for pain-related psychological distress. Antidepressants (SSRIs/SNRIs) may be appropriate when depression is moderate to severe. Peer support through HS communities provides additional benefit beyond formal therapy.

Should I tell my dermatologist about my depression or anxiety?

Absolutely. Mental health status directly affects HS treatment outcomes - depression reduces treatment adherence and worsens inflammatory markers. Leading HS guidelines recommend routine mental health screening at every dermatology visit. Your dermatologist can refer you to a mental health professional experienced with chronic illness, and may factor your mental health into treatment decisions.

Is suicidal ideation more common in HS patients?

Studies have found elevated rates of suicidal ideation in HS patients compared to the general population and to patients with other chronic skin conditions. If you are experiencing thoughts of self-harm, please contact the 988 Suicide and Crisis Lifeline (call or text 988 in the US) immediately. You are not alone, and effective help is available.

Comorbidity Deep-Dive

HS and Depression & Anxiety

Hidradenitis suppurativa carries one of the highest psychiatric comorbidity burdens of any chronic skin disease. Understanding the bidirectional relationship between HS and mental health is essential for effective, whole-person care.

30-40%

of HS patients have clinical depression

20-30%

of HS patients have an anxiety disorder

2-3x

higher depression rate vs. general population

Bidirectional

HS worsens mental health; mental health worsens HS

If you are experiencing thoughts of self-harm, please reach out immediately.

Call or Text 988 (US Crisis Line)

The Core Relationship

Why HS and Mental Health Are Inseparable

HS is not just a skin disease. It is a chronic, painful, and often disfiguring condition that affects every dimension of a patient's life. The psychiatric burden of HS is among the highest of any dermatological condition - higher than psoriasis, atopic dermatitis, and acne. A landmark 2020 meta-analysis found that HS patients have 2.78 times the odds of depression compared to the general population.^[6]

Critically, the relationship is bidirectional. HS causes depression and anxiety through pain, stigma, and social isolation. But depression and anxiety also worsen HS - through stress-induced inflammation, reduced treatment adherence, and avoidance of medical care. Breaking this cycle requires treating both the skin disease and the mental health condition simultaneously.^[5]

Clinical Guideline Recommendation

Both the North American and European HS clinical guidelines recommend routine screening for depression and anxiety at every dermatology visit using validated tools such as the PHQ-9 and GAD-7.^[7][9]

Six Pathways from HS to Mental Health Conditions

Depression and anxiety in HS are not simply reactions to having a chronic illness. They arise through specific, well-documented biological and psychosocial mechanisms.

Chronic Pain and Sleep Disruption

Persistent pain from HS lesions disrupts sleep architecture, reduces daily functioning, and is one of the strongest independent predictors of depression in chronic disease. HS patients report pain scores comparable to those seen in rheumatoid arthritis and inflammatory bowel disease.

Shame, Stigma, and Social Withdrawal

Visible lesions, drainage, and odor from HS cause profound shame and social withdrawal. Many patients avoid swimming, gyms, intimate relationships, and workplace interactions. This isolation is a direct pathway to both depression and anxiety.

Systemic Inflammation and Brain Chemistry

Elevated pro-inflammatory cytokines (TNF-alpha, IL-1beta, IL-6) in HS directly affect brain chemistry. These same cytokines reduce serotonin synthesis, impair neuroplasticity, and activate the hypothalamic-pituitary-adrenal (HPA) stress axis - all established mechanisms of depression.

Grief, Identity, and Loss

HS forces patients to grieve activities, careers, relationships, and body image that the disease has taken from them. This grief process, when unaddressed, becomes a major driver of clinical depression. Acceptance-based therapies are specifically designed to address this dimension.

Unpredictability and Loss of Control

The unpredictable nature of HS flares - which can be triggered by heat, stress, friction, or for no apparent reason - creates chronic anticipatory anxiety. Patients often restructure their entire lives around avoiding triggers, which itself becomes a source of anxiety and reduced quality of life.

Bidirectional Amplification

Depression and anxiety worsen HS through multiple pathways: stress elevates cortisol and inflammatory cytokines; depression reduces treatment adherence; anxiety leads to avoidance of medical care. This creates a self-reinforcing cycle where untreated mental health worsens physical disease.

Warning Signs to Discuss With Your Doctor

Signs of Depression

-Persistent low mood lasting more than two weeks
-Loss of interest in activities you previously enjoyed
-Significant changes in sleep (too much or too little)
-Fatigue or loss of energy most days
-Feelings of worthlessness or excessive guilt
-Difficulty concentrating or making decisions
-Withdrawing from friends, family, or social activities
-Thoughts of death or self-harm

Signs of Anxiety

-Excessive worry about HS flares that is difficult to control
-Avoiding social situations, work, or activities due to HS
-Physical symptoms: racing heart, sweating, trembling
-Difficulty sleeping due to worry or anticipation of pain
-Irritability or feeling on edge most of the time
-Panic attacks related to HS symptoms or social exposure
-Compulsive checking of lesions or avoidance rituals

If you are experiencing four or more of these symptoms most days for two or more weeks, speak with your dermatologist or primary care physician. You do not need to wait until your next scheduled appointment.

Validated Screening Tools Used in HS Care

These questionnaires are used by dermatologists and mental health professionals to assess the psychological burden of HS. You can complete them before your appointment and share the results with your care team.

Tool	Measures	Questions	Time	Scoring	Guideline Rec.
PHQ-9 Patient Health Questionnaire-9	Depression severity	9	2-3 min	0-27; score >=10 suggests moderate depression	Recommended
GAD-7 Generalized Anxiety Disorder-7	Anxiety severity	7	2 min	0-21; score >=10 suggests moderate anxiety	Recommended
DLQI Dermatology Life Quality Index	Skin disease quality of life impact	10	2-3 min	0-30; score >=10 indicates very large effect on life	Recommended
HiSQOL HS Quality of Life Scale	HS-specific quality of life	17	5 min	0-68; higher scores indicate worse quality of life	Optional

Evidence-Based Treatment Approaches

Effective treatment of HS-related depression and anxiety requires a combined approach addressing both the physical disease and the psychological burden.

Psychotherapy

Cognitive Behavioral Therapy (CBT)Strong Evidence

Strongest evidence for chronic illness-related depression and anxiety. Addresses negative thought patterns, pain catastrophizing, and avoidance behaviors.

Acceptance and Commitment Therapy (ACT)Strong Evidence

Particularly effective for pain-related psychological distress and grief over lost functioning. Helps patients build a meaningful life alongside chronic illness.

Mindfulness-Based Stress Reduction (MBSR)Moderate Evidence

Reduces pain catastrophizing and anxiety. Useful as an adjunct to CBT or ACT, particularly for patients with high stress-triggered flare patterns.

Medication

SSRIs / SNRIsStrong Evidence

First-line pharmacotherapy for moderate-to-severe depression and anxiety. Some SSRIs (e.g., sertraline, escitalopram) also have mild anti-inflammatory properties.

Biologics (Adalimumab, Secukinumab)Strong Evidence

Treating HS with biologics significantly reduces depression and anxiety scores. Reducing systemic inflammation directly improves mental health outcomes.

BupropionModerate Evidence

Useful when depression co-occurs with fatigue or weight gain. Also aids smoking cessation, which is relevant as smoking worsens HS.

Peer & Community Support

HS Online CommunitiesModerate Evidence

Peer support reduces isolation and provides practical coping strategies. HS Foundation, Reddit r/Hidradenitis, and Facebook groups are widely used.

In-Person Support GroupsModerate Evidence

Particularly valuable for reducing shame and social isolation. Some academic medical centers offer HS-specific patient support groups.

Chronic Illness CoachingEmerging Evidence

Health coaching focused on chronic illness management, goal-setting, and self-efficacy. Complements formal therapy and medical treatment.

Frequently Asked Questions

Mental Health

HS Mental Health: You Are Not Alone

Comorbidities

HS Comorbidities Hub

Sleep

HS and Sleep Apnea

Relationships

Intimacy & Relationships

Daily Life

Living With HS

Comorbidity

HS and Thyroid Disorders

References & Citations

[1]Kurek A, et al. A prospective cohort study on psychiatric morbidity in patients with hidradenitis suppurativa. Acta Derm Venereol. 2013;93(3):342-345. PubMed
[2]Onderdijk AJ, et al. Depression in patients with hidradenitis suppurativa. J Eur Acad Dermatol Venereol. 2013;27(4):473-478. PubMed
[3]Shlyankevich J, et al. 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. PubMed
[4]Kimball AB, et al. Adalimumab for the treatment of moderate to severe hidradenitis suppurativa. N Engl J Med. 2016;375(5):422-434. PubMed
[5]Thorlacius L, et al. Bidirectional association between hidradenitis suppurativa and depression: a population-based cohort study. Br J Dermatol. 2020;182(3):686-692. PubMed
[6]Patel KR, et al. Psychiatric comorbidities in hidradenitis suppurativa: a systematic review and meta-analysis. J Am Acad Dermatol. 2020;82(2):366-373. PubMed
[7]Alikhan A, et al. North American clinical management guidelines for hidradenitis suppurativa. J Am Acad Dermatol. 2019;81(1):76-90. PubMed
[8]Matusiak L, et al. Psychophysical aspects of hidradenitis suppurativa. Acta Derm Venereol. 2010;90(3):264-268. PubMed
[9]Zouboulis CC, et al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol. 2015;29(4):619-644. PubMed

This article is for educational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider for diagnosis and treatment decisions. If you are experiencing a mental health crisis, contact the 988 Suicide and Crisis Lifeline (call or text 988).

Back to HS Comorbidities Hub