Profound disturbances of sexual health in patients

with acne inversa

Agata Kurek,a Eva M. J. Peters, MD,a,b,e Akewit Chanwangpong, MD,a Robert Sabat, MD,c,d
Wolfram Sterry, MD,a and Sylke Schneider-Burrus, MDa
Berlin and Giessen, Germany

Background: Acne inversa (AI) leads chronically to painful eruptions and extensive scarring in
predominantly intimate areas. We hypothesized an impairment of sexual life caused by the disease.

Objectives: By means of validated questionnaires, sexual health and quality of life were assessed in
patients with AI and in healthy control subjects.

Methods: A self-administered questionnaire was given to 85 voluntary study participants. In all, 45 women (24
patients vs 21 control subjects) and 40 men (20 patients vs 20 control subjects) were enrolled in the study. The
Female Sexual Function Index, the International Index of Erectile Function, and the Frankfurt Self-Concept Scale
for Sexuality were used to assess sexual health. Quality of life was measured with the Dermatology Life Quality
Index.

Results: This study demonstrated, for the first time to our knowledge, that patients with AI have sexual
dysfunctions and sexual distress in comparison with matched control subjects. Sexual distress was
particularly higher in female than in male patients with AI. Surprisingly, severity of cutaneous alterations
correlated neither with sexual dysfunctions nor with sexual distress. However, the sexual dysfunction and
sexual distress negatively correlated with the quality of life in female patients with AI who had a lower
quality of life compared with gender-matched control subjects and male patients.

Limitations: Small sample size is the main limitation of this study.

Conclusions: Sexual health is diminished in patients with AI. We underscore the need for physicians to
implement attention on the impact of AI on sexual health and quality of life when treating patients for this
disease. ( J Am Acad Dermatol 2012;67:422-8.)

Key words: Dermatology Life Quality Index; Female Sexual Function Index; Frankfurt Self-Concept Scale
for Sexuality; hidradenitis suppurativa; International Index of Erectile Function; sexual dysfunction; sexual
health.

A cne inversa (AI), also referred to as ‘‘hidrad-

enitis suppurativa,’’ is a chronic inflamma-
tory disease of terminal hair follicles, which
affects the intertriginous skin of axillary, perianal,
Abbreviations used:
AI:
BMI:
DLQI:
acne inversa
body mass index
Dermatology Life Quality Index
and inguinal sites.1,2 It is estimated that AI affects 1% FKKS SSEX: Frankfurt Self-Concept Scale for
to 4% of the general population.3,4 Apart from the Sexuality
FSFI: Female Sexual Function Index
clinical symptoms such as pain, swelling, and oozing, IIEF: International Index of Erectile
AI has a profound impact on the patient’s quality of Function
life.5-9 Matusiak et al,7 von der Werth5 and Jemec3

From the Department of Dermatology and Allergya; Psoriasis Accepted for publication October 20, 2011.
Research and Treatment Centerc; and Interdisciplinary Group of Reprint requests: Agata Kurek, Department of Dermatology,
Molecular Immunopathology, Dermatology/Medical Immunolo- University Hospital Charite, Chariteplatz 1, 10117 Berlin,
gyd at University Hospital Charite, Berlin; and the Psychoneuro- Germany. E-mail: agata.kurek@charite.de.
immunology, Departments of Psychosomatics and Published online December 19, 2011.
Psychotherapyb; and Justus-Liebig University,e Giessen. 0190-9622/$36.00
Funding sources: None. Ó 2011 by the American Academy of Dermatology, Inc.
Conflicts of interest: None declared. doi:10.1016/j.jaad.2011.10.024

422
J AM ACAD DERMATOL Kurek et al 423
VOLUME 67, NUMBER 3

showed that patients with AI have a significantly Sartorius score.22,23 A higher score indicates greater
lower quality of life, compared with patients with severity of the disease.
other chronic skin diseases, such as acne vulgaris,10
psoriasis,11,12 atopic dermatitis,13 alopecia,14 Darier Control group
disease,15 and morbus Hailey-Hailey.15 The patients were compared with control subjects
Although the affected body regions are intimate, without AI matched for age, sex, and body mass
the effect of AI on sexual health, as an integral part of index (BMI) (matched pairs), who were selected
quality of life, is an underex- randomly as healthy volun-
plored area. teers from the population.
In dermatology, only a CAPSULE SUMMARY Control subjects aged 18
few studies on sexual func- years or older were eligible
tion and chronic skin dis-
d Acne inversa has a detrimental impact
for inclusion. They were in-
eases have been carried out. on quality of life. To our knowledge,
formed about the purpose
Examples are psoriasis vul- sexual health has never been analyzed in
and anonymity of the study
garis,16-18 atopic dermatitis,13 these patients.
and signed the informed
chronic hand eczema,19 viti- d Patients with acne inversa experience a consent, as well. We re-
ligo, and chronic urticaria.20 high level of sexual dysfunction. cruited 41 control subjects
To our knowledge, the de- d Counseling for sexual health should be (21 women, 20 men).
gree of sexual dysfunction in established for these patients to improve
patients with AI is unknown, their general health and quality of life. Questionnaires
until today. Subsequent to the clinical
The aim of the study was evaluation, the following 4
to explore the impairment of quality of life in our self-administered questionnaires were given to the
German population of patients with AI and, for the patients and control subjects to measure their sexual
first time to our knowledge, investigate sexual health health and quality of life (Supplemental Table SI;
in patients given a diagnosis of AI. available at http://www.jaad.org):
Female Sexual Function Index. The Female
Sexual Function Index (FSFI)24 contains 19 questions
METHODS
that describe the female sexual function in 6 do-
We conducted a case-control study with a pro-
mains. The domains are: desire, arousal, lubrication,
spective observational cross-sectional design.
orgasm, satisfaction, and pain, which can both be
Approval for this study was obtained from the
evaluated individually and in their entirety.
Charit e Ethics Committee (EA1/271/09).
Calculations were performed as previously de-
scribed by Rosen et al.24 Any missing response
Patients resulted in the questionnaire being excluded from
In all, 44 patients (24 women, 20 men) given a the final calculation of the questionnaire, according
diagnosis of AI were included in our study. All to the FSFI manual. Higher scores indicate a good
patients with AI enrolled in the study: (1) visited sexual function (range 2-36).24
the Department of Dermatology, University Hospital International Index of Erectile Function
Charit e, Berlin, Germany, from August 2009 to 15. The International Index of Erectile Function
August 2010; (2) gave written informed consent; (IIEF)25 contains 15 questions that were assigned in
and (3) fulfilled the following inclusion criteria: age 5 domains of male sexuality: erectile function, orgas-
of at least 18 years, a diagnosis of AI, and absence mic function, sexual desire, intercourse satisfaction,
of any malignant, psychiatric, and/or hormonal and overall satisfaction. The 5 domains are each set
disorders. up by a different cluster of items and summing the
The diagnosis of AI was primarily made on the scores for individual items computes domain scores.25
basis of the characteristic clinical presentation and Any missing response resulted in the questionnaire
had to meet the diagnostic criteria adopted by the being excluded from the final calculation of the
Second International Conference on hidradenitis questionnaire, according to the IIEF manual. Higher
suppurativa, March 5, 2009, San Francisco, CA.21 A scores indicate a good sexual function (range 5-75).
standardized data form was used for each patient to Frankfurt Self-Concept Scale for Sexuality.
record demographic characteristics, details of the Frankfurt Self-Concept Scale for Sexuality (FKKS
course of the disease (eg, age at onset, region at SSEX)26 measures to what extend the individual has
onset, duration of the disease), and details of the difficulties with their sexuality, how much the indi-
lesions. Disease severity was assessed by the vidual is concerned about their sexuality, if one feels
424 Kurek et al
attractive, and how one is able to show affection.
Lower scores indicate sexual distress (range 1-36).26
Dermatology Life Quality Index. The Derma-
tology Life Quality Index (DLQI)27 was developed to
assess the quality of life in skin diseases. The ques-
tionnaire consists of 10 items covering 6 different
scales of quality of life: symptoms and feelings, daily
activities, leisure, job and school, personal relation-
ships, and treatment of the disease. In case of missing
answers, we calculated the scores according to the
manual. The higher the DLQI score, the more quality
of life is impaired. (range 0-30).27
Statistical analysis
Statistical calculations were performed using soft-
ware (Statistical Package for Social Science, Version
18.0, SPSS Inc, Chicago, IL). Continuous variables
were described as means (6SD). Discontinuous
variables were described by the total frequencies
and percentages of each modality. Missing values
were processed as described in the section
‘‘Questionnaires’’; for other variables the missing
data were not included in the analysis. Mann-
Whitey U test was used for comparing means. The
x2 test was used to compare nominal variables. The
relationship among DLQI, Sartorius, FSFI/IIEF, and
FKKS SSEX scores was analyzed by the Spearman
rank order correlation test. The partial correlation
test was used, controlling for associations between
the variables. Statistical significance was achieved if
P values were less than .05.
RESULTS
Baseline
Of 90 distributed questionnaires, a total of 85
questionnaires were evaluated, resulting in a re-
sponse rate of 94%. One patient and 4 control
subjects returned the questionnaires incompletely
and were excluded from the study.
In total, 45 women (24 patients, 21 control
subjects) and 40 men (20 patients, 20 control sub-
jects) were included in our study. As a prerequisite
for these analyses, there were no significant differ-
ences in age or BMI between those two groups
(Supplemental Table SII; available online at http://
www.jaad.org). Disease-related characteristics (eg,
age at onset, region at onset, duration of the disease)
are shown in Supplemental Table SIII (available
online at http://www.jaad.org).
Sexual health
In the next step, the sexual health among patients
with AI and control subjects was evaluated. Firstly,
female sexual function was analyzed. The mean 6
SD FSFI score for female sexual functioning was
J AM ACAD DERMATOL
SEPTEMBER 2012
significantly lower in female patients with AI than in
female control subjects without AI (22.1 6 10.2 vs
29.0 6 8.2, P = .01), demonstrating significant sexual
dysfunction in female patients with AI (Fig 1, A, and
Table I).
Secondly, male sexual function was analyzed. The
mean 6 SD IIEF score for male sexual functioning
was significantly lower compared with the male
control subjects (42.6 6 27.1 vs 62.6 6 10.8, P =
.01), demonstrating a higher sexual dysfunction in
male patients compared with control subjects (Fig 1,
B, and Table II).
After analyzing the sexual function for both sexes
individually, the FKKS SSEX questionnaire for sexual
distress was evaluated. The FKKS SSEX score, which
can be used for both sexes, showed significantly
lower values for patients with AI compared with
control subjects without AI (mean 6 SD 21.4 6 5.7
vs 27.7 6 4.6, P \ .01), suggesting higher sexual
distress within the patient group compared with
healthy control subjects (Fig 1, C). Comparing female
and male patients with AI, a significantly lower FKKS
SSEX score was detected in the female patients,
indicating higher sexual distress in female patients
compared with male patients (mean 6 SD 19.5 6 5.1
vs 23.5 6 5.8, P =. 02) (Fig 1, C, and Table III).
To investigate if the region affected by AI has an
impact on the sexual health, we separated male
patients into two subgroups: those with (n = 18) and
without (n = 2) lesions of the lower abdomen (eg,
anogenital, inguinal, and gluteal lesions). Patients
without lesions of the lower abdomen presented IIEF
and FKKS SSEX scores comparable with healthy
control subjects (IIEF 64.5 6 9.2 vs 62.6 6 10.8;
FKKS SSEX 30.5 6 2.1 vs 28.0 6 4.8).
Quality of Life
The mean 6 SD DLQI score for female patients
with AI was significantly higher than for male
patients with AI (14.4 6 6.6 vs 9.6 6 6.9, P = .03),
indicating a significantly lower quality of life in
female compared with male patients with AI (Fig 1,
D, and Table III).
Severity of AI and quality of life
The Sartorius score measuring the severity of the
disease showed a mean 6 SD of 52.9 6 31.7 for
patients with AI. There was no significant difference
between the Sartorius score of female and male
patients (P = .7) (Table III). The Sartorius score
correlated significantly with the DLQI score (r = 0.38,
P = .01), indicating that the severity of AI has an impact
on the quality of life in patients with AI. Taking patient
gender into consideration, this correlation was still
significant in female patients with AI (r = 0.44, P = .03)
J AM ACAD DERMATOL Kurek et al 425
VOLUME 67, NUMBER 3

Fig 1. A, Female Sexual Function Index (FSFI ) in female patients with AI and female control
subjects. Female patients with AI reported significantly lower FSFI score (P = .01). (Table I.) B,
International Index of Erectile Function (IIEF ) scores in male patients with AI and male control
subjects. Male patients with AI reported significantly lower IIEF score. (P = .01) (Table II.) C,
Frankfurt Self-Concept Scale for Sexuality (FKKS SSEX ) scores in patients with AI and control
subjects. Female patients with AI reported significantly lower FKKS SSEX scores than female
control subjects (P \ .01). (Table I.) Male patients reported significantly lower FKKS SSEX
scores than male control subjects (P = .02). (Table II.) Furthermore, female patients with AI
reported significantly lower FKKS SSEX scores than male patients with AI (P = .02). (Table III.)
D, Dermatology Life Quality Index (DLQI ) scores in patients with acne inversa (AI ). Female
patients with AI reported significantly lower DLQI score than did male patients with AI (P =
.03). (Table III.) Average DLQI, FSFI, IIEF, and FKKS SSEX scores are demonstrated as mean 6
SEM. A to D, Significance of differences was assessed by Mann-Whitney U test (*P \.05; **P
\.01). A and B, Patients with AI are shown in boldface. (*P \0.05; **P \0.01)

(Table IV). The correlation in male patients with AI is
almost significant (r = 0.42, P = .06) (Table IV).
Severity of AI and sexual health
The fact that the severity of AI correlates with
the quality of life raised the question of whether the
impairment of sexual health is connected with the
severity of AI. There was no significant correlation
between FSFI and the Sartorius score in our female
patients (r = 0.22, P = .34). Furthermore, the IIEF and
Sartorius scores were also not significantly correlated
(r = 0.13, P = .31). The FKKS SSEX score did not
correlate significantly in either sex with the Sartorius
score (r = 0.18, P = .25) (Table IV).
Sexual health and quality of life
In addition, the association between sexual health
and quality of life was evaluated. Statistical analysis
showed a significant correlation between the FSFI
score of female patients with AI and the DLQI score
(r = 0.52, P = .02). There was no significant correla-
tion between the IIEF and the DLQI scores (r = 0.24,
P = .31) (Table IV).
In female patients with AI, the FKKS SSEX score
correlated with the DLQI score (r = 0.60, P \ .01).
The correlation between the FKKS SSEX and the
DLQI scores for male patients with AI was not
significant (r = 0.07, P = .76) (Table IV).
The univariant regression analysis showed that
high sexual distress (FKKS SSEX) influences the
quality of life (DLQI) in female patients with AI
(r2 = 0.5, P \ .01). In contrast, a high FKKS SSEX
score did not influence the IIEF score in male
patients with AI (r2 \ 0.01, P = .8).
Using the univariant regression analysis, all mea-
sured data were also controlled for age, duration of
the disease, age at onset, region at onset, and
affected areas. None of them showed a significant
association considering quality of life or sexual
health (r2 \ 0.2, P [.05).
426 Kurek et al J AM ACAD DERMATOL
SEPTEMBER 2012

Table I. Female Sexual Function Index and Frankfurt Self-Concept Scale for Sexuality scores in female patients
with acne inversa and female control subjects
Female patients Female control subjects P value
FSFI total, mean 6 SD (range) 22.1 6 10.2 (1.8-34.3) 29.0 6 8.2 (4.7-36.0) .01*
FKKS SSEX, mean 6 SD (range) 19.5 6 5.1 (12-32) 27.4 6 4.5 (19-36) \.01*

Mean 6 SD data of analyzed parameters are shown. P values calculated by Mann-Whitney U test are indicated.
FKKS SSEX, Frankfurt Self-Concept Scale for Sexuality; FSFI, Female Sexual Function Index.
*Significant (\.05).

Table II. International Index of Erectile Function and Frankfurt Self-Concept Scale for Sexuality scores in male
patients with acne inversa and male control subjects
Male patients Male control subjects P value
IIEF total, mean 6 SD (range) 42.6 6 27.1 (0-71) 62.6 6 10.8 (39-75) .01*
FKKS SSEX, mean 6 SD (range) 23.5 6 5.8 (13-32) 28.0 6 4.8 (18-34) .02*

FKKS SSEX, Frankfurt Self-Concept Scale for Sexuality; IIEF, International Index of Erectile Function.
*Significant (\.05).

Table III. Dermatology Life Quality Index, Frankfurt Self-Concept Scale for Sexuality, and Sartorius scores in
female and male patients with acne inversa
Female patients Male patients P value
DLQI, mean 6 SD (range) 14.4 6 6.6 (1-26) 9.6 6 6.9 (1-21) .03*
FKKS SSEX, mean 6 SD (range) 19.5 6 5.1 (12-32) 23.5 6 5.8 (13-32) .02*
Sartorius score, mean 6 SD (range) 52.9 6 35.5 (7-138) 52.8 6 27.3 (17-114) .72

Mean 6 SD data of analyzed parameters are shown. P values calculated by Mann-Whitney U test are indicated.
DLQI, Dermatology Life Quality Index; FKKS SSEX, Frankfurt Self-Concept Scale for Sexuality.
*Significant (\.05).

DISCUSSION scaring in predominantly intimate areas, it seemed

In this study we investigated sexual health and
quality of life in patients with AI and, to our knowl-
edge, demonstrated for the first time a significantly
higher impairment of sexual health in patients with
AI compared with age-, sex-, and BMI-matched
control subjects.
It has been published previously that AI has a
substantial impact on the quality of life.5-9 The mean
6 SD DLQI score of 12.2 6 7.0 in our investigation is
in agreement with an earlier study by Matusiak et al7
(DLQI 12.7 6 7.7), showing that patients with AI
have a significantly higher impairment of quality of
life compared with patients with chronic dermato-
logic diseases including psoriasis11,12 (DLQI 9.8-
11.7), atopic eczema13 (DLQI 11.95), acne vulgaris10
(DLQI 9.2), alopecia14 (DLQI 8.3), Darier disease15
(DLQI 5.9), or morbus Hailey Hailey15 (DLQI 6.1).
Former studies investigating patients with AI have
already demonstrated a significant correlation be-
tween the severity of the disease and the quality of
life.5,7,23 Sexual health, as an integral part of quality
of life, has never, to our knowledge, been analyzed
in patients with AI. As AI leads to chronic painful
eruptions, malodorous discharge, and extensive
likely that patients with AI could experience impair-
ment of sexual life.
In accordance with our hypothesis, we found that
female and male patients who are affected by AI
experienced significantly higher sexual dysfunction
and sexual distress than the age-, sex-, and BMI-
matched control subjects; however, this did not
correlate with the severity of the disease.
Interestingly, female patients with AI reported
significantly higher sexual distress and a lower
quality of life than male patients with AI, even
though they had comparable disease severity mea-
sured by the Sartorius score.
In addition, sexual function, sexual distress, and
quality of life were strongly correlated in female
patients with AI and did not correlate significantly in
male patients.
An explanation for this gender difference may
include that lesions of the lower abdomen are
significantly more frequent in women than in men,
whereas axillary lesions are equally frequent in both
genders.3 Moreover, in the current study, women
with AI reported age at disease onset approximately
6 years younger compared with male patients, which
J AM ACAD DERMATOL
VOLUME 67, NUMBER 3
Table IV. Correlation of Female Sexual Function
Index, International Index of Erectile Function,
Frankfurt Self-Concept Scale for Sexuality,
Dermatology Life Quality Index, and Sartorius
scores in female and male patients with acne
inversa
Sartorius
FSFI FKKS SSEX DLQI score
IIEF 1.000 .37 (.12) .24 (.31) .13 (.58)
FKKS SSEX .53 (.02)* 1.000 .07 (.77) .26 (.27)
DLQI .52 (.02)* .60 (\.01)* 1.000 .42 (.06)
Sartorius .22 (.34) .22 (.30) .44 (.03)* 1.000
score
Correlation was investigated by Spearman rank correlation
analysis. Shaded fields represent correlations in male patients
with acne inversa; white fields indicate correlations in female
patients with acne inversa. For each field, Spearman rank
correlation coefficient and, in parenthesis, P values are indicated.
DLQI, Dermatology Life Quality Index; FKKS SSEX, Frankfurt Self-
Concept Scale for Sexuality; FSFI, Female Sexual Function Index;
IIEF, International Index of Erectile Function.
*Significant (\.05).
may explain the higher impairment of quality of life
and the increased sexual distress among female
patients with AI. However, it may also reflect differ-
ent cultural connotations of disfigurement in men
and women and a higher emotional and neuroen-
docrine responsiveness in the female population.
Compared with patients who have psoriasis, pa-
tients who have AI show a higher sexual dysfunction
(FSFI 22.1 and IIEF 42.6 vs FSFI 23.6-24.3 and IIEF
52.0-56.1),16,18 even when compared with those
patients who have psoriasis with genital involve-
ment18 or underlying depression.16 Interestingly, the
sexual dysfunction in female patients with AI was
comparable to female patients with atopic dermatitis
(FSFI 22.8).13
This finding underlines the burden of patients
with AI. Psoriasis and atopic dermatitis are accepted
as highly stigmatizing and distressing conditions in
research and clinical practice.28-31 In contrast, AI is
often not recognized by dermatologists until today,
although it affects 1% to 4% of the population.3,4
The fact that the severity of AI has an impact on
the quality of life plays an important role in the
treatment of these patients. In minimizing the af-
fected areas by medical or surgical means, one can
assume that patients’ quality of life will improve.5
In contrast, the severity of the disease did not
correlate significantly with sexual functioning (FSFI,
IIEF, FKKS SSEX). Similar results have been reported
for patients with psoriasis, comparing the severity of
the disease (Psoriasis Area and Severity Index) with
the level of sexual dysfunction (FSFI, IIEF).16,17
Kurek et al 427
Hence, the severity of the disease has an impact on
the quality of life, but does not correlate significantly
with the level of sexual dysfunction. As expected, the
only two patients without genital lesions had levels
of sexual function similar to that of healthy control
subjects, potentially indicating that sexual dysfunc-
tion should be expected if any areas of the lower
abdomen are affected.
Consequently, sexuality-specific questionnaires
such as the FSFI/IIEF should be used regularly to
detect possible sexual dysfunction, especially in pa-
tients with genital involvement of AI. Furthermore, a
simple question regarding the sexual satisfaction often
opens a door for patients to relieve their burden and
helps physicians better understand patient needs and
pain.
Psychological care for patients with sexual dys-
function is provided by many hospitals in the context
of specialized consultations offered, for example, by
the departments of gynecology, urology, and inter-
nal medicine. The findings of this study led us to
routinely screen patients with AI for the need of
psychological guidance and offer patients with AI a
consultation with a psychologist specializing in sex-
ual dysfunction.
The motivation to participate in this study shows
that patients with AI want to talk about their sexuality
and impairment of quality of life. We believe that
better communication and counseling about sexual-
ity and quality of life may help to improve accep-
tance of the skin disease and ameliorate therapeutic
results.
REFERENCES
1. Meixner D, Schneider S, Krause M, Sterry W. Acne inversa.
J Dtsch Dermatol Ges 2008;6:189-96.
2. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a
comprehensive review. J Am Acad Dermatol 2009;60:539-63.
3. Jemec GB, Heidenheim M, Nielsen NH. The prevalence of
hidradenitis suppurativa and its potential precursor lesions.
J Am Acad Dermatol 1996;35:191-4.
4. Revuz JE, Canoui-Poitrine F, Wolkenstein P, Viallette C,
Gabison G, Pouget F, et al. Prevalence and factors associated
with hidradenitis suppurativa: results from two case-control
studies. J Am Acad Dermatol 2008;59:596-601.
5. von der Werth JM, Jemec GB. Morbidity in patients with
hidradenitis suppurativa. Br J Dermatol 2001;144:809-13.
6. Wolkenstein P, Loundou A, Barrau K, Auquier P, Revuz J.
Quality of life impairment in hidradenitis suppurativa: a study
of 61 cases. J Am Acad Dermatol 2007;56:621-3.
7. Matusiak L, Bieniek A, Szepietowski JC. Psychophysical aspects
of hidradenitis suppurativa. Acta Derm Venereol 2010;90:
264-8.
8. Matusiak L, Bieniek A, Szepietowski JC. Hidradenitis suppu-
rativa markedly decreases quality of life and professional
activity. J Am Acad Dermatol 2010;62:706-708.e1.
9. Jemec GB, Heidenheim M, Nielsen NH. Hidradenitis suppu-
rativaecharacteristics and consequences. Clin Exp Dermatol
1996;21:419-23.
428 Kurek et al
10. Klassen AF, Newton JN, Mallon E. Measuring quality of life in
people referred for specialist care of acne: comparing generic
and disease-specific measures. J Am Acad Dermatol 2000;43:
229-33.
11. Gladman DD, Mease PJ, Cifaldi MA, Perdok RJ, Sasso E, Medich J.
Adalimumab improves joint-related and skin-related functional
impairment in patients with psoriatic arthritis: patient-reported
outcomes of the adalimumab effectiveness in psoriatic arthritis
trial. Ann Rheum Dis 2007;66:163-8.
12. Revicki D, Willian MK, Saurat JH, Papp KA, Ortonne JP, Sexton
C, et al. Impact of adalimumab treatment on health-related
quality of life and other patient-reported outcomes: results
from a 16-week randomized controlled trial in patients with
moderate to severe plaque psoriasis. Br J Dermatol 2008;158:
549-57.
13. Ermertcan AT, Gencoglan G, Temeltas G, Horasan GD, Deveci
A, Ozturk F. Sexual dysfunction in female patients with
neurodermatitis. J Androl 2011;32:165-9.
14. Williamson D, Gonzalez M, Finlay AY. The effect of hair loss on
quality of life. J Eur Acad Dermatol Venereol 2001;15:137-9.
15. Harris A, Burge SM, Dykes PJ, Finlay AY. Handicap in Darier’s
disease and Hailey-Hailey disease. Br J Dermatol 1996;135:
959-63.
16. Turel Ermertcan A, Temeltas G, Deveci A, Dinc G, Guler HB,
Ozturkcan S. Sexual dysfunction in patients with psoriasis.
J Dermatol 2006;33:772-8.
17. Sampogna F, Gisondi P, Tabolli S, Abeni D. Impairment of
sexual life in patients with psoriasis. Dermatology 2007;214:
144-50.
18. Meeuwis KA, de Hullu JA, van de Nieuwenhof HP, Evers AW,
Massuger LF, van de Kerkhof PC, et al. Quality of life and
sexual health in patients with genital psoriasis. Br J Dermatol
2011;164:1247-55.
19. Ergun M, Turel Ermertcan A, Ozturkcan S, Temeltas G,
Deveci A, Dinc G. Sexual dysfunction in patients with
chronic hand eczema in the Turkish population. J Sex Med
2007;4:1684-90.
20. Sukan M, Maner F. The problems in sexual functions of vitiligo
and chronic urticaria patients. J Sex Marital Ther 2007;33:
55-64.
J AM ACAD DERMATOL
SEPTEMBER 2012
21. Hidradentitis Suppurativa Foundation (HSF). Second Interna-
tional Conference on hidradenitis suppurativa, San Francisco,
CA, March 5, 2009. Available from: www.hs-foundation.org.
Accessed June 18, 2011.
22. Sartorius K, Lapins J, Emtestam L, Jemec GB. Suggestions for
uniform outcome variables when reporting treatment effects
in hidradenitis suppurativa. Br J Dermatol 2003;149:211-3.
23. Sartorius K, Emtestam L, Jemec GB, Lapins J. Objective scoring
of hidradenitis suppurativa reflecting the role of tobacco
smoking and obesity. Br J Dermatol 2009;161:831-9.
24. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R,
et al. The Female Sexual Function Index (FSFI): a multidimen-
sional self-report instrument for the assessment of female
sexual function. J Sex Marital Ther 2000;26:191-208.
25. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra
A. The International Index of Erectile Function (IIEF): a multi-
dimensional scale for assessment of erectile dysfunction.
Urology 1997;49:822-30.
26. Deusinger IM. Measurement of change in self-concept with
the Frankfurt self-concept scales [in German]. Z Gerontol 1982;
15:42-5.
27. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)ea
simple practical measure for routine clinical use. Clin Exp
Dermatol 1994;19:210-6.
28. Schmid-Ott G, Burchard R, Niederauer HH, Lamprecht F,
Kunsebeck HW. Stigmatization and quality of life of patients
with psoriasis and atopic dermatitis [in German]. Hautarzt
2003;54:852-7.
29. Schmid-Ott G, Kuensebeck HW, Jaeger B, Werfel T, Frahm K,
Ruitman J, et al. Validity study for the stigmatization experi-
ence in atopic dermatitis and psoriatic patients. Acta Derm
Venereol 1999;79:443-7.
30. Oh SH, Bae BG, Park CO, Noh JY, Park IH, Wu WH, et al.
Association of stress with symptoms of atopic dermatitis. Acta
Derm Venereol 2010;90:582-8.
31. Leibovici V, Canetti L, Yahalomi S, Cooper-Kazaz R, Bonne O,
Ingber A, et al. Well being, psychopathology and coping
strategies in psoriasis compared with atopic dermatitis: a
controlled study. J Eur Acad Dermatol Venereol 2010;24:
897-903.
J AM ACAD DERMATOL Kurek et al 428.e1
VOLUME 67, NUMBER 3

Supplemental Table SI. Acne inversa scoring system

Scoring system Measure Interpretation
Sartorius score Severity of acne inversa [ Score = [ severity
DLQI Dermatology-specific quality of life [ Score = Y quality of life
FSFI Female sexual function [ Score = better sexual function
IIEF Male sexual function [ Score = better sexual function
FKKS SSEX Sexual function [ Score = no sexual distress

Questionnaires/measures and proper interpretation are indicated.

DLQI, Dermatology Life Quality Index; FKKS SSEX, Frankfurt Self-Concept Scale for Sexuality; FSFI, Female Sexual Function Index; IIEF,
International Index of Erectile Function.

Supplemental Table SII. Demographic characteristics of patients with acne inversa and control subjects
Female patients Female control subjects P value Male patients Male control subjects P value
Gender 53.3% 46.7% .76 50.0% 50.0% .76
Age, mean 6 SD (range), y 32.8 6 10.0 (18-59) 38.14 6 10.80 (23-59) .12 36.1 6 11.4 (10-50) 36.05 6 11.27 (20-53) .98
BMI, mean 6 SD (range) 33.4 6 8.1 (19-50) 29.7 6 10.5 (19-54) .06 27.4 6 4.6 (22-39) 27.7 6 7.6 (20-49) .56

P values calculated by x2 test (sex distribution) or Mann-Whitney U test (age, BMI) are indicated.
BMI, Body mass index.

Supplemental Table SIII. Disease-related characteristics of patients with acne inversa

Total Female patients with AI Male patients with AI P value
Duration of AI, mean 6 SD (range), y 10.2 6 8.4 (1-31) 11.1 6 7.0 (1-24) 9.0 6 9.9 (2-31) .90
Age at onset, mean 6 SD (range), y 24.2 6 9.1 (9-49) 21.7 6 8.3 (9-49) 27.3 6 9.2 (13-47) .03*
BMI distribution
Normal weight 25.0% 16.7% 35.0% .16
Overweight 29.5% 16.7% 45.0% .09
Obese 45.5% 66.7% 20.0% \.01*
Region at onset
Axilla 31.8% 12.5% 55.0% \.01*
Lower abdomen 68.2% 87.5% 45.0% \.01*
Affected regions
Axilla 72.7% 62.5% 85.0% .10
Lower abdomen 95.5% 100.0% 90.0% .11
Smoking
Smoker 72.7% 70.8% 75.0% .80
Former smoker 20.5% 20.8% 20.0% .89
Nonsmoker 6.8% 8.4% 5.0% .91

Percentages of total, female, and male patients with AI, and mean 6 SD data of analyzed parameters are shown. P values calculated by x2
test (for BMI distribution, first localization, affected regions, and smoking) or Mann-Whitney U test (for duration of AI and age at onset) are
indicated.
AI, Acne inversa; BMI, Body mass index.
*Significant (\.05).