Accepted Manuscript. Overall and Subgroup Prevalence of Acne Vulgaris Among Patients with Hidradenitis Suppurativa

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1 Accepted Manuscript Overall and Subgroup Prevalence of Acne Vulgaris Among Patients with Hidradenitis Suppurativa Sara Wertenteil, BA, Andrew Strunk, MA, Amit Garg, MD PII: S (18) DOI: Reference: YMJD To appear in: Journal of the American Academy of Dermatology Received Date: 12 November 2018 Accepted Date: 14 November 2018 Please cite this article as: Wertenteil S, Strunk A, Garg A, Overall and Subgroup Prevalence of Acne Vulgaris Among Patients with Hidradenitis Suppurativa, Journal of the American Academy of Dermatology (2018), doi: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 1 1 2 Title: Overall and Subgroup Prevalence of Acne Vulgaris Among Patients with Hidradenitis Suppurativa Sara Wertenteil, BA, Andrew Strunk, MA, Amit Garg, MD Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra / Northwell, New Hyde Park, NY Word count: 401 Abstract word count: NA Capsule summary: NA Figures: 0 Tables: 1 References: 5 Corresponding Author: Amit Garg, MD Donald and Barbara Zucker School of Medicine at Hofstra / Northwell 1991 Marcus Avenue, Suite 300 New Hyde Park, NY, amgarg@northwell.edu Other Authors: Sara Wertenteil swertenteil@northwell.edu Andrew Strunk astrunk1@northwell.edu Funding Sources: This study was supported in part by an education grant from AbbVie. The sponsor has had no role in the design and conduct of the study; collection, management, analysis

3 and interpretation of data; preparation, review, or approval of the manuscript; decision to submit the manuscript for publication Conflict of Interest: Dr. Garg has served as an advisor for AbbVie, Pfizer, Janssen, UCB, Asana Biosciences, and has received honoraria. Role of Sponsor: NA Prior Presentation: There is no prior presentation of this work. IRB Statement: This investigation was approved by the IRB of the Feinstein Institute for Medical Research at the Northwell Health. Acknowledgements: None

4 To the Editor: We review with interest the analysis by Jørgensen et al comparing patients with hidradenitis suppurativa (HS) who have and do not have acne vulgaris (AV). This type of analysis may be useful in identifying the phenotype for HS patients having the comorbidity of interest. In the Danish cohort, the authors observed that patients with HS and AV had lower mean age than patients without AV, among other findings. Prevalence of AV was not significantly different between sexes, obese and nonobese, tobacco smokers and nonsmokers, or those who did and did not have polycystic ovarian syndrome (PCOS). While the authors noted that HS patients with AV had lower levels of plasma inflammatory markers, the analysis on markers was not adjusted for age or sex, which limits interpretation of this finding. Using the same HS population in which we identified the association between HS and AV, we further analyzed available corresponding variables of interest. Among 48,085 HS patients, we identified 7,315 who had AV. (Table I) A greater proportion of HS patients with AV was female (80.2% vs. 73.4%, p<0.001) and was in the lowest age group of 1844 years (71.9% vs. 57.9%, p<0.001), compared to HS patients who did not have AV. No significant differences in prevalences of obesity and smoking were noted between HS patients with and without AV. However, women with HS and AV had twice the prevalence of PCOS compared to women with HS who did not have AV (11.7% vs. 5.7%, p<0.001). In the adjusted analysis, HS patients with AV were more likely to be female [aor 1.32, 95% CI ], in the lowest age group [aor 1.66, 95% CI ], and have PCOS [aor 2.03, 95% CI ]. Different from the analysis by Jørgensen et al using their hospital based cohort, we observed a significant association of HS and AV with female sex and presence of PCOS in our HS population. The association between AV and PCOS is already well established. Our group recently demonstrated that approximately 1 in 11 women with HS also have PCOS. 1 The link among the three conditions is not yet clearly established, as circulating and end organ androgen expression appear to be normal among HS patients. 25

5 We thank the authors for their interest in our analysis on HS and AV, and for the opportunity to discuss the relevance of further characterizing the case cohort having the 64 comorbidity of interest.

6 References: 1. Garg A, Neuren E, Strunk A. Hidradenitis Suppurativa Is Associated with Polycystic Ovary Syndrome: A PopulationBased Analysis in the United States. J Invest Dermatol. 2018;138(6): Barth JH, Layton AM, Cunliffe WJ. Endocrine factors in pre and postmenopausal women with hidradenitis suppurativa. Br J Dermatol 1996;134: Jemec GB. The symptomatology of hidradenitis suppurativa in women. Br J Dermatol. 1988;119: Barth JH, Kealey T. Androgen metabolism by isolated human axillary apocrine glands in hidradenitis suppurativa. Br J Dermatol. 1991;125: Buimer MG, Wobbes T, Klinkenbijl JHG, Reijnen MM, Blokx WA. Immunohistochemical analysis of steroid hormone receptors in hidradenitis suppurativa. Am J Dermatopathol. 2015;37:

7 6 Table I: Characteristics of HS patients with and without Acne With Acne Without Acne With Acne vs. Without Acne (ref.) (n=7,315) (n=40,770) aor a (95% CI) pvalue Sex Female Male Age > 65 5,870 (80.2%) 1,445 (19.8%) 5,260 (71.9%) 1,780 (24.3%) 275 (3.8%) 29,920 (73.4%) 10,850 (26.6%) 23,610 (57.9%) 12,715 (31.2%) 4,445 (10.9%) 1.32 ( ) 1.66 ( ) 0.79 ( ) 0.35 ( ) Obese 5,430 (74.2%) 29,705 (72.9%) 0.98 ( ).55 Smoker Yes No Race White Nonwhite 4,150 (56.7%) 3,165 (43.3%) 4,195 (57.3%) 3,120 (42.7%) 24,000 (58.9%) 16,770 (41.1%) 26,065 (63.9%) 14,705 (36.1%) 0.95 ( ) 0.81 ( ).07 PCOS* 685 (11.7%) 1,700 (5.7%) 2.03 ( ) a Adjusted odds ratios compare the odds of each of the selected characteristics between HS patients with and without acne (reference group). Logistic regression models were adjusted for each of the other characteristics, with the exception of the model for gender (PCOS was omitted because it is a perfect predictor of gender). *PCOS prevalence and odds ratio among female patients.