Source: Xiong G, Ali M, Kakhki EG, et al. Prevalence, age of onset, age at diagnosis, and family history of hidradenitis suppurativa in pediatric populations: a systematic review and meta-analysis. Pediatr Dermatol. 2025;42(6):1142-1148; doi: 10.1111/pde.70022.Investigators from McMaster University, Hamilton, and the University of Toronto, Ontario, Canada, conducted a metaanalysis to estimate the prevalence of hidradenitis suppurativa (HS), a chronic skin condition characterized by nodules and abscesses, typically in intertriginous areas, and clinical characteristics of pediatric patients with the condition. A standardized process was used to identify observational studies assessing children <18 years old with HS. Data collected from the selected studies included number of participants, location of study, patient demographic and clinical characteristics, and family history. Severity of HS in the included studies was graded as mild to severe, using Hurley stages. Results from the included studies were pooled using random effects meta-analysis. Studies conducted in the US were used to estimate the prevalence of HS in children.A total of 37 articles that reported on 6,941 pediatric patients were included in the meta-analysis. After pooling data from 16 US studies, the prevalence of HS in children was estimated as 0.03% (95% confidence interval CI, 0.01%, 0.05%). The age of patients was reported in 13 studies. The mean age at onset of symptoms was 11.3 years (95% CI, 10.15, 12.39), and mean age at diagnosis was 14.0 years (95% CI, 12.65, 15.28). Among 5,931 children included in 36 studies, 78.0% were females. Severity was reported in 1,469 patients, with 625 (42.6%) classified with mild HS (Hurley stage I), 679 (46.2%) with moderate severity (Hurley stage II), and 165 (11.2%) categorized as having severe HS (Hurley stage III). Among children included in 27 studies, 38% (95% CI, 30%, 45%) had a positive family history of HS.The authors conclude that HS in children is uncommon and occurs predominantly in girls. The results suggest that the diagnosis is generally made more than 2 years after the onset of symptoms.Dr Raphael has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.HS is a chronic inflammatory disease that can have significant impact on quality of life (QOL). In a previous study of pediatric age patients, over 90% of those surveyed reported QOL impairment, including impact on daily activities such as decreased participation in sports and concerns about ability to shave, and nearly a third reported co-morbid psychiatric diagnosis.1,2Reassuringly, in the current meta-analysis, the prevalence of HS was low. Although the researchers likely provide the most precise estimate of prevalence currently available, the underlying literature remains limited. For the meta-analysis, much of the prevalence data were obtained from three US population-based studies, which relied on ICD-9 codes from claims and electronic medical record data. Despite the significant physical and psychological impact of HS, pediatric disease often is under-recognized. In an international cross-sectional study of 481 pediatric patients with HS seen at dermatology clinics, only 39% had HS listed as the referring diagnosis. For the remainder, HS was misdiagnosed as acne, cyst/abscess, and folliculitis prior to referral.3 Because HS commonly is missed in clinical practice, ICD9 coding may not capture all cases, as it depends entirely on provider recognition. The higher proportion of advanced disease symptoms (57.4% had moderate or severe disease) among the participants included in the meta-analysis also may reflect a referral bias and missed early cases. Hence, the true prevalence, particularly that of early disease, may remain underestimated.Consistent with prior research, the current meta-analysis also highlights diagnostic delay as a significant concern. Early identification is essential as HS is most aggressive during the first 6 years after onset.2 Besides surgery, there are multiple treatment options available, including topical and systemic antibiotics, biologic agents, immunomodulators, and hormonal therapies.2 Nearly half of pediatric patients with HS already have scarring at the time of diagnosis, and timely treatment may prevent permanent tissue damage.2,3 The current study findings suggest that among females with a family history of HS, pediatricians should maintain a heightened index of suspicion and consider early referral for HS if concerning symptoms are identified.Although the estimated prevalence of HS is low, it remains under-recognized, leading to frequent delays in diagnosis.It should be pointed out that HS may be associated with several genetic, inflammatory, and endocrine diseases (eg, diabetes, inflammatory bowel disease), as well as an increased risk of systemic lupus erythematosus.4
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