Cutaneous Body Image (CBI) in patients with hidradenitis suppurativa (HS): a hospital- based cross-sectional study.

doi:10.21203/rs.3.rs-1864512/v1

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Cutaneous Body Image (CBI) in patients with hidradenitis suppurativa (HS): a hospital- based cross-sectional study.

https://doi.org/10.21203/rs.3.rs-1864512/v1

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Introduction:

Hidradenitis suppurativa (HS) has been linked with body image (BI) impairment and reduced quality of life (QoLWe sought to evaluate the associations between Cutaneous Body Image (CBI) and disease severity in HS patients.

Materials and methods

Between July 2020 and January 2022, a cross-sectional study was carried out including consecutive HS patients above the age of 16 who attended the Dermatology Department of a University Hospital. Disease Severity was graded with Hurley stage, HS-Physician’s Global Assessment (HS-PGA) scale, the Modified Sartorius scale (MSS), and Hidradenitis Suppurativa Clinical Response (HiSCR) score. Patients completed ten survey instruments including Patients’ Severity of disease, pain and pruritus scale, CBI, BI, Dermatology Quality of Life Index (DLQI), Skindex-16, EQ5D 5L, EQ- visual analogue scale (VAS), PHQ9, and GAD7.

Results

In total, 70 HS patients above 16-year-old participated, mean [SD] age, 34.44 [11.64] years; 49/70 (70%) males and 21/70 (30%) females. Mean ± SD CBI, DLQI, Skindex-16 total, EQ-5D-5L, EQ VAS, PHQ9 and GAD7 were 5.59 ± 1.58, 11.70 ± 8.88, 52.90 ± 27.75, 0.75 ± 0.21, 62.48 ± 21.12, 7.64 ± 5.56, 7.87 ± 5.23 respectively. Moderate to severe CBI dissatisfaction was reported by 36/70 (51.42%) patients. CBI was correlated with educational level (p < 0.01, r = 0.306), BI appearance evaluation (AE) (p < 0.01, r = 0.544), body areas satisfaction (BASS) (p < 0.01, r = 0.481), and overweight preoccupation subscale (OWPS) (p < 0.01, r=-0.267), and Skindex-16 (p < 0.01, r=-0.288).

Conclusion

Our study found that the mean of CBI in HS patients was 5.59 ± SD 1.58 and this was correlated with AE, BASS, OWP, and Skindex-16.

Hidradenitis suppurativa

quality of life

Cutaneous Body Image

Body Image

Depression

Anxiety

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that affects the terminal hair follicles mainly of the intertriginous skin areas of the axillary, groin, perianal, perineal, and inframammary regions and is characterized by the presence of recurrent painful nodules on these areas [1]. HS patients are often negatively perceived and stigmatized [2], leading to impaired Quality of Life (QoL) [3, 4], poor Body Image (BI) [5, 6] and higher incidence of psychiatric disorders [7], anxiety, and depression [8,9 ]. Cutaneous body image (CBI) may be defined as the individuals’ mental perception of the appearance of their integumentary system, i.e., their skin, hair, and nails. ¹⁰ Cutaneous body image (CBI) is an important dermatologic construct—both in the wide range of cosmetically disfiguring skin disorders where cutaneous body image dissatisfaction can have a profound impact upon the quality of life (QoL) of the patient and in situations where the cutaneous body image (CBI) is distorted such as body dysmorphic disorder[10, 11]. Patient dissatisfaction with cutaneous body image is often the primary consideration in deciding whether or not to commence treatments for some skin disorders [11].

CBI has not yet been evaluated in HS patients. Because HS causes disfigurement mainly of the intertriginous skin areas of the axillary, groin, perianal, perineal, and inframammary regions, we expected impaired Cutaneous Body Image (CBI) in these patients. This study aims to evaluate CBI in HS patients and whether disease severity, the topography of lesions, age at onset, disease duration, obesity, general health, anxiety, and depression are linked to CBI impairment.

This was a prospective, non-interventional, observational cross-sectional study conducted at the Dermatology Department of the University Hospital of Heraklion, Heraklion, Crete, Greece. Consecutive patients with hidradenitis suppurativa (HS) above the age of 16, willing to participate in the study, after obtaining informed consent for subjects above the age of 18 or with parental consent for patients below the age of 18, were recruited from the Dermatology Department between July 2020 and January 2022. The inclusion criteria were i) age above 16, ii) willingness to participate together with parental consent for patients below the age of 18, iii) a clinical diagnosis of HS made by an experienced dermatologist, iv) capability of completing the QoL questionnaires that were administered. Ethics committee approval was obtained for this study and informed written consent was provided from all participants. Procedures followed were by the ethical standards of the responsible institutional ethics committee and with the Helsinki Declaration of 1975, as revised in 1983.

All participants were examined by the same dermatologist who provided information about clinical characteristics, affected body areas, past medical history, comorbidities, and treatments. Disease severity was assessed by the clinician with the following three measures: Hurley staging, Hidradenitis Suppurativa-Physician’s Global Assessment (HS-PGA) of disease, and Modified Sartorius Score (MSS) [12]. Patients were also asked to rate their a) HS disease severity using a scale from 0 to 10, where 0 indicated clear disease and 10 represented very severe disease [13], b) HS-related pain intensity on a scale from 0 to 10, where 0 indicated no pain at all and 10 pain as bad as it could be [14-16], and c) HS-related pruritus severity using a scale from 0 to 10, where 0 indicated no pruritus and 10 represented very severe pruritus because of HS lesions [16]. All participants completed seven paper-based questionnaires regarding Cutaneous Body Image (CBI), Body Image (BI), and quality of life (QoL).

Cutaneous Body Image Scale (CBIS)

Self-evaluation of cutaneous body image (CBI) was investigated using the validated CBI questionnaire, which is a seven-item scale (Table 1) [10]. The total CBIS score is derived from the mean ratings of the seven questions, where a high total count is suggestive of greater satisfaction with CBI (possible range, 0-9) [11].

Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS)

The 34-questionnaire version of the Multidimensional Body-Self Relations Questionnaire (MBSRQ) instrument, contains only the five appearance-related items: Appearance Evaluation (AE), Appearance Orientation (AO), Body Areas Satisfaction Scale (BASS), Overweight Preoccupation (OWP), and Self Classified Weight (SCW) items is the shortened version of the 69 questions MBSRQ attitudinal body image (BI) evaluation [18,19]. It is reinforced to use this version when investigators are mainly interested in appearance-based BI [19]. The questionnaire consists of a 5-point response format varying from 1 definitely disagree to 5 definitely agree. This study used the 34-questionnaire version of the MBSRQ-AS.

Appearance Evaluation (AE) is a 7-item measure of satisfaction with attractiveness, and positive or negative self-perceptions of physical appearance. High scores indicate positive and satisfied perceptions of physical appearance and attractiveness. Appearance orientation (AO) is a 12-item subscale measure of personal time and effort consuming on grooming and countenance. High scores express high levels of attention to appearance and extensive countenance. Overweight Preoccupation (OP) is a four-item subscale of fat concern, weight consideration, dieting, and eating restriction. High scores indicate high fat anxiety and high levels of dieting behavior. Self-Classified Weight (SCW) consists of two items that indicate the individual’s perception of their weight— “I think I am” and the label of their weight “others say I am”. The scale ranges from 1—very underweight to 5—very overweight. High scores indicate a high subjective and internalized perception of self as obese, whilst low scores indicate a high subjective and internalized view of self as thin. The BASS is a 9-item scale that measures the degree of dissatisfaction or satisfaction with specific body areas and attributes (e.g., face, weight, muscle tone, etc.), where high scores indicate overall satisfaction with subjective body appearance, whilst low scores indicate an overall dissatisfaction with subjective body appearance[19]. A validated Greek version was introduced by Argyrides M, et al. in 2013 [20]. The latter was used in our study.

Health-related quality of life measures

Dermatology Life Quality Index (DLQI)

For evaluating skin-specific HRQoL, we used the Dermatology Life Quality Index (DLQI). This is a 10-item questionnaire evaluating the impact of skin diseases on patients’ lives within the last week. Of the 10 questions, each scored 0 to 3, concern symptoms (itchy/sore/ painful/stinging), feelings (embarrassed/self-conscious), daily activities (shopping/home/garden), choice of clothes, social or leisure activities, sport, work/school, personal relationships, sexual difficulties, and the problem with taking a treatment. Every item of the questionnaire has 4 potential answers: “not at all,” “a little,” “a lot,” or “very much” which correspond to scores 0, 1, 2, and 3, respectively. The DLQI is measured by summing the score of each item, giving a maximum of 30 and a minimum of 0. The higher the score, the greater the impact of skin disorder on QoL [21].

Skindex‑16

The Skindex-16 is a health-related quality of life (HRQOL) instrument designed to measure the effects of skin disease on patients’ quality of life [22]. Skindex-16 is a questionnaire that specifically measures the effects of skin disorders on QOL, disregarding the type of skin condition or patient's comorbidities. Derived from Skindex-29, the questionnaire consists of 16 items.

It is composed of 16 items grouped under three subscales: symptoms (questions: 1–4), emotions (questions: 5–11), and functioning (questions: 12–16). Subscale scores are converted to a linear scale of 0-100, where higher scores indicate more impaired levels of HRQoL. Comparing Skindex-16, which focuses on the degree of bother rather than frequency and is shortened based on patients’ perspectives[22].

EQ-5D-5L

We measured general General Health-Related Quality of Life, HRQoL, by using the EQ-5D-5L and EQ visual analog scale (EQ-VAS) [23,24]. Every item of health has 5 levels of severity (no problems, slight problems, moderate problems, severe problems, or extreme problems) and their responses are converted into a utility score ranging from 0 (death) to 1 (full health) through an established algorithm to reflect the level of a patient’s well-being [25]. Each health state can be assigned a utility value (i.e. EQ-5D-5L index score) obtained from population studies reflecting the societal values. In absence of a national value set in Greece, the 5L value set for England developed by Devlin et al. was applied to generate index scores in this study ranging between -0.594 and 1 [26].An index score of zero indicates dead and negative values represent health states worse than dead [25,26].

Patient Health Questionnaire (PHQ-9)

PHQ-9 is a health self-rating inventory that was developed based on the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV [27, 28]. It is used to understand the time of patients suffering from nine issues comprising depression, interest reduction, and insomnia in the last two weeks. 0 = not at all; 1 = a few days; 2 = more than half the time; 3 = almost every day. The total score of the scale is 27, where 0 to 4, 5 to 9, 10 to 14, and 15 to 27 points accordingly represent no, mild, moderate, and severe depression [28].

Generalized Anxiety Disorder 7 (GAD-7)

GAD-7 (Generalized Anxiety Disorder 7) is a 7-item anxiety questionnaire and a brief measure for evaluating generalized anxiety disorder [29].The answer options vary from 0 points (not at all) to 3 points (nearly every day). The recall period is 4 weeks; the maximum sum score is 21. A sum of ≥10 shows the presence of anxiety [30].

Statistical Analysis

Baseline patient demographics, disease characteristics, and comorbidities were summarized descriptively with a mean (SD) for continuous variables and counts and percentages for categorical variables. Non-parametric Mann-Whitney U and Kruskal-Wallis H tests were used to compare patient- and physician-based outcome scores. Analysis of the relationship between continuous variables was accomplished by calculating Spearman’s correlation coefficients (weak correlation: rs<0.2; moderate correlation 0.4≤rs<0.6; strong correlation 0.6≤rs≤1). All statistical tests were performed using SPSS for Windows v25. Threshold statistical significance was set at a = 0.05 for all tests.

Baseline Patient Characteristics

A total of 70 consecutive HS patients with active disease, at least one flare over the last 6 months, were recruited from the Outpatient Clinics from the Dermatology Department of the University Hospital of Heraklion in Heraklion, Crete, Greece, between July 2020 and January 2022. There were 21/70 (30%) females and 49/70 (70%) males. The mean age of HS patients was 34.33 ± Standard Deviation (SD) 11.64 years, the mean age of onset of HS was 22.33 ±SD 7.60 years, and the mean duration of disease was 12.11 ±SD 9.53 years. Hurley stage I was 13/70 (18.6%), Hurley stage II 41/70 (58.6%), and Hurley stage III 16/70 (22.9%) of HS patients. Baseline demographic and disease characteristics and comorbidities are shown in Table 2.

Cutaneous Body Image

The mean value of CBI in our 70 HS patients was 5.97 ±1.58 (Table 3). 36/70 (51.4%) had mild dissatisfaction with CBI, 33/70 (47.1%) had moderate dissatisfaction and 1/70 (1.4%) had severe dissatisfaction with their CBI (Table 3).

CBI was statistically correlated with educational level of HS patients p<0.01, r=0.306 (Table 2); MBSRQ Appearance Evaluation (AE) Subscale p<0.01, r=0.544; MBSRQ Body Areas Satisfaction Subscale (BASS) p<0.01, r=0.481; MBSRQ Overweight preoccupation subscale (OWP) p=0.02, r=-0.267; Skindex-16 Emotions p<0.01, r=-0.302; and Skindex-16 Functioning p<0.01, r=-0.305 (Table 4).

MBSRQ-AS

MBSRQ Appearance Evaluation (AE) subscale was significant statistically correlated with skin phototype p=0.03, r=0.26; Skindex-16 Emotions p=0.01, r=-0.279; EQ VAS p=0.04,r=0.243 and PHQ-9 p=0.02,r=-0.271 ( Table 5). MBSRQ Body Areas Satisfaction Scale (BASS) was statistically correlated with skin phototype p=0.03, r=0.252 and Cutaneous Body Image Scale (CBIS) p<0.01, r=0.481. MBSRQ Overweight Preoccupation (OWP) was statistically correlated with Cutaneous Body Image Scale (CBIS) p=0.02, r=-0.267; DLQI p=0.02, r=0.268; Skindex-16 emotions p<0.01, r=0.356; Skindex-16 functioning p<0.01, r=0.346; EQ5D 5L p=0.05, r=-0.235 and GAD-7 p=0.03, r=0.251. MBSRQ Self Classified Weight (SCW) subscale was correlated with BMI p<0.01, r=0.69; duration of HS disease p=0.04, r=0.24; DLQI symptoms p=0.04, r=0.239; EQ VAS p=0.01, r=-0.283 and PHQ-9 p=0.02, r=0.261. (Table 5)

Disease Severity and health-related quality of life scores

Disease severity scores were not correlated with CBI (Table 5). Hurley staging of disease was significant statistically correlated with DLQI p=0.042, r=0.244; Skindex-16 Functioning p=0.029, r=0.261; EQ5D 5L index p=0.31, r=-0.258; EQ VAS p=0.024, r=-0.27 (Table 6). Patient’s Severity of Disease was statistically correlated with DLQI p=0.004, r=0.343; DLQI Symptoms p<0.01, r=0.326; DLQI daily activities p<0.01, r=0.343; DLQI Personal relationship p<0.01, r=0.333; DLQI treatment p=0.04, r=0.237; Skindex-16 emotions p<0.01, r=0.46; Skindex-16 functioning p<0.01, r=0.354 (Table 6).

The mean DLQI scores in our study was 11.70± SD 8.88. The mean DLQI in males was 12.37 ± SD 9.16 and the mean DLQI in females was 10.14 ± SD 8.19. DLQI was correlated with Hurley stage of disease p =0.04, r0.244; EQ5D-5L p<0.01, r=-0.559, anxiety p<0.01, r=0.525; and depression p<0..01,r= 0.534. The mean of the total Skindex-16 score was 51.63 ± SD 27.75. The skindex-16 total score was statistically correlated with gender, where males had a mean total Skindex-16 score of 58.97 ± SD 25.25 which was much higher than those reported in females 38.74 ± SD 28.75, p<0.01,r= -0.336. Current smokers had a higher mean total Skindex-16 score 61.09 ± SD 26.55, than that reported in no smokers 43.17± SD 24.87, or in ex-smokers 30.35 ± SD 23.99, p<0.01, r= -0.394. Total Skindex-16 score was correlated with patients’ disease severity of HS p<0.01, r =0.392, patients’ pain severity score p< 0.01, r=0.695, patients’ pruritus severity score p<0.01, r= 0.489; CBIS p<0.01, r= -0.288; MBSRQ AE p=0.025, r= -0.267, DLQI p<0.01, r=0.745; EQ5D-5L p<0.01, r=-0.554; PHQ-9 p<0.01, r=0.578; GAD-7 p<0.01, r=0.525 and BMI p<0.01, r=0.317. The mean PHQ-9 score was 7.64 ± SD 5.56 and the mean GAD-7 was 7.87± SD 5.23. (Table 4)

EQ5D 5L

The mean EQ5D 5L index was 0.75 ± SD 0.21 and then mean EQ-VAS score was 62.48 ± SD 21.12 (Table 4). The EQ5D 5L index was significant statistically correlated with patients’ pain severity p<0.01, r=-0.502; patients’ pruritus severity p<0.01, r=-0.416; Hurley stage p=0.31, r=-0.258; smoking status p=0.034, r=0.254; inguinal area involvement with HS p=0.027, r=0.264; MBSRQ Overweight Preoccupation (OP) p=0.05, r=-0.235; DLQI p<0.01, r=-0.559; DLQI Symptoms and feelings p<0.01, r=-0.383; DLQI Daily activities p<0.01, r=-0.534; DLQI leisure p<0.01, r=-0.530; DLQI work or leisure p<0.01, r=-0.334; DLQI Personal relationship p<0.01, r=-0.454; DLQI treatment p<0.0.1, r=-0.539; Skindex-16 symptoms p<0.01, r=-.0514; Skindex-16 emotions p<0.01, r=-0.467, Skindex-16 functioning p<0.01, r=-0.534, EQ VAS p<0.01, r=0.311; PHQ-9 p<0.01, r=-0.536; GAD-7 p<0.01, r=-0.624 ( Table 7).

To the best of our knowledge, here we have reported the first study that assesses CBI in HS patients. We also evaluated the relationship between CBI and demographic and clinical parameters and Health-Related Quality of Life measures among HS patients, revealing important information that may inform our approach to this group of patients. In our study, the mean CBI value was 4.11 ± SD 2.72.

A previous study on 127 dermatology patients conducted in Canada reported a mean ± SD CBIS score (possible variation from 0 to 9) of 4.44 ± 1.56. In this sample 28.3% had acne, 21.3% had psoriasis, 40.1% had onychomycosis/athletes’ foot, and 10.3% had atopic dermatitis/alopecia/other. The mean CBIS was much decreased (P = .004) than the 4.96 ± 1.73 scores in the 312 persons belonging to the community-based nonclinical group, consistent with greater body image dissatisfaction in the dermatology group [10, 11]. Likewise, in a study conducted in Japan, the CBIS values in dermatology patients (3.18 ± 1.69) were much lower than those among healthy individuals (4.11 ± 1.80) [31]. Probably, the lower mean scores in Japanese individuals than those in Canadian suggest that the Japanese group had greater CBI concerns. Previous studies showed a correlation between CBI and the body dissatisfaction subscale of the Eating Disorder Inventory [10], global and appearance-related self-esteem [32], negative experiences of skin disease (embarrassment and bullying), and age [33].

In our study, CBIS was correlated with educational level showing that patients at a University level were more satisfied with their CBI than those HS patients with secondary school educational level. CBI was correlated with MBSRQ-AE, AO, and OWP subscales but not with disease severity, the topography of lesions, or comorbidities of HS patients.

Previous studies have shown that HS patients have frequently reduced quality of life [3, 4], depression [8, 9], and impaired Body Image (BI) compared with healthy controls [5, 6]. In our study MBSRQ-AE subscale was correlated with skin phototype, depression, and Skindex-16 Emotions. MBSRQ-BASS was correlated with skin phototype but also with CBIS.

The DLQI and Skindex-16 scores from our results are in keeping with those reported in earlier studies. The mean DLQI score of our HS patients (11.70) was within the range of means from previous studies (8.31–12.67). Up to now, one Italian study reported mean Skindex-16 scores in 140 Italian HS patients (62.5) that were somewhat higher than our results (mean 52.90), and another Hungarian study reported a mean Skindex-16 score of 53.56 in 200 Hungarian HS patients that was slightly higher than our score.

In our study, we demonstrated that general health in HS patients as measured by EQ5D 5L index was correlated with Hurley stage disease severity, HS-related pain, inguinal involvement of HS, smoking status, anxiety, depression, MBSRQ Overweight Preoccupation subscale, DLQI, and Skindex-16.

Limitations of this study should be considered. First, because HS patients recruited from a single center in a tertiary referral hospital may differ from those in practice, therefore the generalizability of the study results may be limited. Second, our study enrolled a limited number of HS patients and there was no control group. Participants were only examined at a single time point. Future studies should collect longitudinal data over multiple points in time as this approach may yield information on how CBI changes or remains stable over time and depending on treatment response.

In conclusion, we recommend the use of CBIS across various settings, including clinical care and clinical research in HS patients. Regular evaluation of the CBI could be beneficial because it validates the patients’ concerns about their CBI as being clinically relevant. The medical practitioner may wish to document whether a significant discrepancy exists between the patient’s subjective evaluation of his or her cosmetic problem and an objective dermatologic evaluation of the cosmetic effect of the skin disorder because this could be an indication of body image pathology or other underlying psychiatric comorbidities. Patient dissatisfaction with cutaneous body image is often the primary consideration in deciding whether or not to commence treatment for various skin conditions. Assessment of CBI in the dermatology patient is best performed using a biopsychosocial model that involves assessment of concerns about the appearance of the skin, hair, and nails, assessment of comorbid body

image pathologies, and assessment of other psychiatric comorbidities. Future prospective studies before and after treatment in a large cohort of patients with HS are needed to provide more solid results.

Hidradenitis suppurativa

HRQoL

Health-related quality of life

QoL

Quality of Life

CBI

Cutaneous Body Image

CBIS

Cutaneous Body Image Scale

Body Image

HS-PGA

Physicians’ Global Assessment of HS severity

MSS

Modified Sartorius scale

HiSCR

Hidradenitis Suppurativa Clinical Response

BMI

Body Mass Index

PMH

Past Medical History

PDSAS

Patient’s Disease Severity Assessment Scale

MBSRQ

Multidimensional Body-Self Relations Questionnaire

MBSRQ-AS

Multidimensional Body-Self Relations Questionnaire-Appearance Scales

Appearance Evaluation

Appearance Orientation

BASS

Body Areas Satisfaction Scale

OWP

Overweight Preoccupation

SCW

Self-Classified Weight

DLQI

Dermatology Life Quality Index

PHQ-9

Patient Health Questionnaire-9

GAD-7

General Anxiety Disorder-7

EQ5D 5L

EuroQol- 5 Dimension

EQ VAS

visual analogue scale

IBD

inflammatory bowel syndrome

Standard Deviation

Number

C.I.

Confidence Interval

correlation coefficient

p-value

probability value

Competing Interests and Funding: None to declare

Conflict of interest: The authors declare no conflict of interest.

Funding statement: No funding has supported this work.

Ethical approval: Approval was obtained from the Ethical Review Board of the University Hospital of Heraklion, Heraklion, Crete. The methods used in this study comply with the principles of the Declaration of Helsinki.

Consent to participate: All participants gave their explicit written informed consent for participation in this study. For participants with age below 18-year-old, also their legal guardians consented to participate in the study.

Author contributions:

Conceptualization: Dimitra Koumaki, Alexander Katoulis, Marios Papadakis; Methodology: Dimitra Koumaki, Alexander Katoulis, Marios Papadakis; Formal analysis and investigation: Dimitra Koumaki, Erato Solia Apokidou, Evangelia Rovithi; Writing: Dimitra Koumaki; Writing – review, and editing: Dimitra Koumaki, Marios Papadakis, Alexander Katoulis, Konstantinos Krasagakis; Resources: Dimitra Koumaki, Konstantinos Krasagakis; Supervision: Dimitra Koumaki, Alexander Katoulis, Marios Papadakis, Konstantinos Krasagakis.

Data availability statement: The data that support the findings of this study are available from the corresponding author, Dimitra Koumaki, upon reasonable request.

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Τable 1: Cutaneous Body Image (CBI) scale

Using the following scale, please rate each of the following times with one number between 0 to 9 that best describes your response.
0 1 2 3 4 5 6 7 8 9
0=Not all, 1-3=slightly, 4-6= moderately, 7-8= markedly, 9= very markedly
Item	Rating 0 to 9
I like the overall appearance of my skin
I like my complexion or overall colour of my skin
I like the appearance of the skin of my face
I like the complexion or the overall colour of the skin of my face
I am very satisfied with my hair
I am satisfied with the appearance of my fingernails
I am satisfied with the appearance of my toenails
Cutaneous Body Image Scale (CBIS) score= average of all 7 ratings (possible range, 0 to 9)
CBI dissatisfaction grading using CBIS score: score <3=severe; 3 to 6= moderate; >6= mild to moderate

Table 2: Patients’ demographics and clinical characteristics in 70 patients with Hidradenitis Suppurativa (HS) of our study and correlations with Cutaneous Body Image (CBI) scale. A p-value less than 0.05 was considered as statistically significant. Correlation coefficient (r value) was considered strong, moderate and weak for values above 0.6, between 0.2 and 0.6 and below 0.2 respectively.

Variables		Median	95% C.I.	p-value	r-correlation coefficient
Gender	Number, (%)			P=0.34	0.116
Female N (%)	21/70 (30%)
Male N (%)	49/70 (70%)
	Mean (±SD)
Age (years) , mean (SD)	34.44 (±11.64)	34.00	31.67-37.22	P=0.54	-0.074
Age of onset of HS, mean (SD)	22.33(±7.60)	20.00	20.52-24.14	P=0.55	-0.071
Age of diagnosis of HS, mean (SD)	30.86 (±10.38)	30.00	28.38-33.33	P=0.21	-0.152
Age of onset of treatment, mean (SD)	31.49 (± 9.93)	30.00	29.12-33.85	P=0.15	-0.172
Duration of disease in years, mean (SD)	12.11 (±9.53)	10.50	9.84-14.39	P=0.78	-0.033
Patient’s severity of disease, mean (SD) (On a scale from 0 to 10)	6.20 (±2.59)	7.00	5.58-6.82	P=0.84	-0.019
Patients’ pain severity, mean (SD) (On a scale from 0 to 10)	4.80 (± 3.60)	5.50	3.94-5.66	P=0.70	-0.047
Patients’ pruritus severity, mean (SD) (On a scale from 0 to 10)	3.29 (±3.31)	2.50	2.50-4.08	P=0.45	-0.092
Disease Severity Scores, mean (SD)
Sartorius score, mean (SD)	67.06 (± 61.87)	47.00	52.31-81.81	P=0.82	-0.027
HiSCR, mean (SD)	18.93 (± 22.57)	11.50	13.55-24.31
Hurley stage				P=0.34	-0.116
Hurley stage I, N (%)	13/70 (18.6%)
Hurley stage II, N (%)	41/70 (58.6%)
Hurley stage III, N (%)	16/70 (22.9%)
HS-PGA score				P=0.91	-0.014
Clear, N (%)	1/70 (1.4%)
Minimal, N (%)	9/70 (12.9%)
Mild, N (%)	33/70 (47.1%)
Moderate, N (%)	17/70 (24.3%)
Severe, N (%)	6/70 (8.6%)
Very severe, N (%)	4/70 (5.7%)
Marital status				P=0.731	-0.042
Married, N (%)	33/70 (47.1%)
Single, N (%)	34/70 (48.6%)
Divorced, N (%)	3/70 (4.3%)
Employment status				P=0.555	0.072
Pupil, N (%)	2/70 (2.9%)
Student, N (%)	13/70 (18.6%)
Employed, N (%)	41/70 (58.6%)
Unemployed, N (%)	13/70 (18.6%)
Retired, N (%)	1/70 (1.4%)
Educational level				P=0.01	0.306
Primary school, N (%)	2/70 (2.9%)
Secondary school, N (%)	29/70 (41.4%)
Technical studies, N (%)	16/70 (22.9%)
University level, N (%)	23/70 (32.9%)
Skin phototypes				0.23	0.144
Skin type I, N (%)	0/70 (0%)
Skin type II, N (%)	4/70 (5.7%)
Skin type III, N (%)	55/70 (78.6%)
Skin type IV, N (%)	11/70 (15.7%)
Smoking status				P=0.05	0.051
Current smoker, N (%)	43/70 (61.4%)
No smoker, N (%)	20/70 (28.6%)
Ex-smoker, N (%)	7/70 (10%)
	Mean (±SD)	Median	95% C.I.
BMI	30.02	29.96	28.52-31.53	P=0.62	-0.060
Normal BMI, N (%)	14/70 (20%)
Overweight, N (%)	20/70 (28.6%)
Obese, N (%)	36/70 (51.4%)
Current treatment				P=0.94	-0.009
No treatment, N (%)	21/70 (30%)
Topical treatment, N (%)	21/70 (30%)
Oral treatment with antibiotics, N (%)	22/70 (31.4%)
Adalimumab treatment, N (%)	6/70 (8.6%)
Comorbidities
PMH of inflammatory bowel syndrome (IBD)				P=0.58	0.064
PMH of IBD, N (%)	11/70 (15.7%)
No PMH of IBD, N (%)	59/70 (84.3%)
Rheumatic disease				P=0.44	-0.071
PMH of rheumatic disease, N (%)	11/70 (15.7%)
No PMH of rheumatic disease, N (%)	59/70 (84.3%)
PMH of thyroid disease				P=0.98	-0.002
Hypothyroidism, N (%)	6/70 (8.6%)
Normal thyroid function, N (%)	57/70 (81.4%)
Bronchocele of thyroid, N (%)	7/70 (10%)
Hypertension				P=0.38	0.116
PMH of hypertension, N (%)	5/70 (7.1%)
No PMH of hypertension, N (%)	65/70 (92.9%)
Diabetes				P=0.32	-0.150
PMH of diabetes type II, N (%)	5/70 (7.1%)
No PMH of diabetes type II, N (%)	65/70 (92.9%)
Areas involved
Axilla area affected				P=0.73	0.041
Yes, N (%)	39/70 (55.7%)
No, N (%)	31/70 (44.3%)
Inguinal area affected				P=0.54	-0.118
Yes , N (%)	50/70 (71.4%)
No, N (%)	20/70 (28.6%)
Genital area affected				P=0.6	0.042
Yes, N (%)	31/70 (44.3%)
No, N (%)	39/70 (55.7%)
Buttocks affected				P=0.23	0.042
Yes, N (%)	31/70 (44.3%)
No, N (%)	39/70 (55.7%)
Thighs affected				P=0.34	0.049
Yes, N (%)	29/70 (41.4%)
No, N (%)	41/70 (58.6%)
Chest affected				P=0.83	0.099
Yes, N (%)	24/70 (34.3%)
No, N (%)	46/70 (65.7%)

Abbreviations: HS: Hidradenitis Suppurativa, SD: Standard Deviation, C.I. Confidence Interval, HiSCR: Hidradenitis Suppurativa Clinical Response, N: Number, BMI: Body Mass Index, PMH: Past Medical History, IBD: inflammatory bowel syndrome, HS-PGA: Physicians’ Global Assessment of HS severity, r: correlation coefficient, p -value: probability value.

Τable 3: Cutaneous Body Image scores of 70 patients with Hidradenitis Suppurativa in our study.

	Mean ± SD (Standard Deviation)	Median	95% C.I. (Confidence Interval)
Cutaneous Body Image (CBI) total	5.97 ± 1.58	6.14	5.59-6.35
CBI Question 1, mean ± SD	4.11 ± 2.72	4.50	3.46-4.76
CBI Question 2, mean ± SD	5.97 ± 2.34	6.50	5.41-6.53
CBI Question 3, mean ± SD	5.73 ± 2.47	6.00	5.14-6.32
CBI Question 4, mean ± SD	6 ± 2.27	6.13	5.46-6.13
CBI Question 5, mean ± SD	6.24 ± 2.39	7.00	5.67-6.81
CBI Question 6, mean ± SD	7.07 ± 1.73	8.00	6.66-7.48
CBI Question 7, mean ± SD	6.69± 2.08	7.00	6.19-7.18
CBI satisfaction
Slightly satisfied with CBI, N (%)	4/70 (5.7%)
Moderately satisfied with CBI, N (%)	31/70 (44.3%)
Markedly satisfied with CBI, N (%)	35/70 (50%)
CBI dissatisfaction
Severe dissatisfaction with CBI, N (%)	1/70 (1.4%)
Moderate dissatisfaction with CBI, N (%)	33/70 (47.1%)
Mild to none dissatisfaction with CBI, N (%)	36/70 (51.4%)

HS: Hidradenitis suppurativa, C.I. Confidence Interval , CBI: Cutaneous Body Image, SD: standard deviation, N: number

Table 4: Body image scores, DLQI, Skindex-16, PHQ9, GAD7, EQ5D 5L, EQ5D VAS of 70 patients with hidradenitis suppurativa (HS) and correlations with Cutaneous Body Image (CBI) scale. A p-value less than 0.05 was considered as statistically significant. Correlation coefficient (r value) was considered strong, moderate, and weak for values above 0.6, between 0.2 and 0.6, and below 0.2 respectively.

	Mean ± SD	Median	95% C.I. (Confidence Interval)	p-value	r-correlation coefficient
Body Image Scale
Appearance evaluation subscale, mean ± SD	3.03 ± 0.79	3.14	2.84-3.22	P=0.00	0.544
Appearance orientation subscale, mean ± SD	3.32 ± 0.52	3.33	3.11-3.36	P=0.34	-0.116
Body areas satisfaction subscale, mean ± SD	3.19 ± 0.73	3.22	3.02-3.37	P=0.00	0.481
Overweight preoccupation subscale, mean ± SD	2.73 ± 0.79	2.75	2.54-2.92	P=0.02	-0.267
Self-classified weight subscale, mean ± SD	3.76 ± 0.85	4.00	3.55-3.96	P=0.24	-0.141
DLQI total (0-30), mean ± SD	11.70 ± 8.88	11.00	9.58-13.82	P=0.52	-0.078
DLQI Symptoms and feelings (Questions 1 and 2, total score 0- 6)	3.53 ± 1.60	4.00	3.15-3.91	P=0.95	0.006
DLQI Daily activities (Questions 3 and 4, total score 0-6) , mean ± SD	2.23 ± 2.13	2.00	1.72-2.74	P=0.37	0.375
DLQI Leisure (Questions 5 and 6, total score 0-6) , mean ± SD	2.07 ± 2.15	1.00	1.56-2.59	P=0.87	-0.019
DLQI Work or Leisure (Question 7, total score 0-3), mean ± SD	0.94 ±1.36	0.00	0.62-1.27	P=0.59	-0.064
DLQI Personal relationship (Questions 8 and 9, total score 0-6), mean ± SD	2.10 ± 2.17	2.00	1.58-2.62	P=0.38	-0.106
DLQI Treatment (Question 10, total score 0-3), mean ± SD	0.79 ± 1.06	0.00	0.53-1.04	P=0.31	0.123
Skindex-16 Total, (0-100) mean ± SD	52.90± 27.75	48.43	46.28-59.52	P<0.01	-0.288
Skindex-16 Symptoms, mean ± SD ( 4 items)	49.94 ± 28.45	50.00	43.15-56.72	P=0.31	-0.121
Skindex-16 Emotions, mean ± SD (7 items)	60.91 ± 30.06	65.00	53.74-68.08	P=0.01	-0.302
Skindex-16 Functioning, mean ± SD (5 items)	44.04 ± 33.34	40.00	36.09-51.99	P=0.01	-0.305
PHQ9, mean ± SD	7.64 ± 5.56	7.00	6.32-8.97	P=0.31	-0.121
Mild depression, N (%)	29/70 (41.4%)
Moderate depression, N (%)	18/70 (25.7%)
Moderately severe depression, N (%)	15/70 (21.4%)
Severe depression, N (%)	8/70 (11.4%)
GAD7	7.87 ± 5.23	6.00	6.62-9.12	P=0.98	-0.002
Mild anxiety, N (%)	25/70 (35.7%)
Moderate anxiety, N (%)	26/70 (37.1%)
Moderately severe anxiety, N (%)	11/70 (15.7%)
Severe anxiety, N (%)	8/70 (11.4%)
EQ5D 5L, mean ± SD	0.75 ± 0.21	0.81	0.70-0.80	P=0.81	0.029
EQ VAS, mean ± SD	62.48 ± 21.12	60.00	57.44-67.52	P=0.66	0.053

Abbreviations: HS: Hidradenitis suppurativa, SD: standard deviation, C.I. Confidence Interval, CBI: Cutaneous Body Image, DLQI: Dermatology Life Quality Index, PHQ-9: Patient Health Questionnaire-9, GAD-7: General Anxiety Disorder-7, EQ5D 5L: EuroQol- 5 Dimension, EQ VAS: visual analogue scale, r: correlation coefficient, p -value: probability value.

Table 5 : MBSRQ-AS subscales and correlations with Hidradenitis Suppurativa (HS) disease severity, clinical characteristics, comorbidities, Cutaneous Body Image (CBI), DLQI, Skindex-16, PHQ9, GAD7, EQ5D 5L, EQ5D VAS of 70 patients with hidradenitis suppurativa (HS). A p-value less than 0.05 was considered as statistically significant. Correlation coefficient (r value) was considered strong, moderate and weak for values above 0.6, between 0.2 and 0.6 and below 0.2 respectively.

		AE: Appearance Evaluation		AO: Appearance Orientation		BASS: Body Areas Satisfaction Scale		OWP: Overweight Preoccupation		SCW: Self Classified Weight
		p-value	r-correlation coefficient	p-value	r-correlation coefficient	p-value	r-correlation coefficient	p-value	r-correlation coefficient	p-value	r-correlation coefficient
Age		0.30	-0.125	0.83	0.025	0.55	-0.072	0.66	0.053	0.09	0.202
Gender		0.31	0.124	0.88	0.018	0.30	0.125	0.05	-0.234	0.06	-0.221
BMI		P<0.01	-0.338	0.60	-0.063	0.11	-0.191	0.14	0.178	P<0.01	0.697
Marital status		0.39	0.105	0.74	-0.039	0.16	0.168	0.59	0.065	0.98	-0.002
Employment status		0.26	-0.136	0.91	-0.014	0.85	-0.022	0.40	-0.102	0.91	-0.013
Educational level		P<0.01	0.328	0.94	-0.008	0.20	0.154	0.29	-0.126	0.37	-0.107
Age of onset of HS		0.27	-0.132	0.90	0.015	0.42	-0.098	0.45	0.090	0.94	0.009
Age of HS diagnosis		0.12	-0.185	0.76	-0.037	0.20	-0.153	0.62	0.060	0.13	0.182
Age of onset of treatment		0.11	-0.194	0.93	-0.011	0.233	-0.144	0.73	0.042	0.10	1.193
Duration of disease		0.70	-0.047	0.87	0.019	0.93	-0.009	0.95	-0.007	0.04	0.240
Patients’ severity of disease		0.32	-0.122	0.60	-0.063	0.24	0.141	0.26	0.136	0.92	-0.011
Patients’ pain severity		0.14	-0.176	0.30	-0.125	0.49	-0.083	0.17	0.164	0.25	0.137
Patients’ pruritus severity		0.74	-0.040	0.07	-0.212	0.86	-0.021	0.12	0.184	0.56	0.070
Skin phototype		0.03	0.260	0.77	0.035	0.03	0.252	0.17	-0.165	0.07	-0.217
Hurley stage		0.305	-0.124	0.57	0.069	0.20	-0.153	0.11	0.191	0.18	0.162
Physicians’ Global Assessment of Disease (HS- PGA)		0.80	-0.023	0.51	0.08	0.85	0.022	0.48	0.085	0.99	0.001
Modified Sartorius Scale (MSS)		0.726	-0.043	0.84	0.024	0.33	-0.118	0.45	-0.091	0.31	0.123
HiSCR		0.645	0.056	0.72	0.043	0.71	-0.044	0.48	-0.085	0.42	0.097
Smoking status		0.55	0.073	0.26	0.134	0.37	0.108	0.62	0.060	0.14	0.175
Current treatment		0.94	-0.009	0.88	0.018	0.79	-0.032	0.08	0.210	0.76	0.036
Past medical history (PMH) of Inflammatory Bowel disease (IBD)		0.68	-0.052	0.93	0.010	0.75	-0.038	0.51	0.079	0.19	0.157
PMH of rheumatic disease		0.67	-0.052	0.85	0.022	0.48	-0.086	0.65	0.054	0.36	0.111
PMH of thyroid disease		0.79	-0.032	0.96	0.006	0.34	-0.115	0.66	0.053	0.80	-0.030
PMH of dyslipidemia		0.84	0.025	0.96	0.006	0.78	0.033	0.24	-0.142	0.19	-0.156
PMH of hypertension		0.44	0.093	0.31	-0.121	0.10	0.193	0.17	-0.162	0.08	-0.207
PMH of cardiovascular		0.34	0.115	0.19	-0.156	0.56	0.069	0.20	-0.154	0.78	-0.033
PMH of diabetes		0.25	-0.139	0.69	0.047	0.77	-0.034	0.26	0.135	0.14	-0.174
Axilla area		0.53	0.076	0.38	0.106	0.96	-0.006	0.83	0.025	0.37	-0.108
Inguinal area		0.29	0.127	0.30	0.24	0.21	0.15	0.41	-0.098	0.05	-0.233
Genital area		0.85	0.024	0.47	0.087	0.32	0.119	0.95	-0.007	0.71	-0.044
Buttocks		0.33	-0.117	0.93	0.009	0.89	0.016	0.28	0.129	0.45	0.091
Thighs		0.69	-0.047	0.33	0.117	0.49	0.083	0.78	-0.033	0.28	-0.131
Chest		0.17	0.163	0.93	-0.010	0.01	0.292	0.51	-0.079	0.07	-0.217
Cutaneous Body Image (CBI)		P<0.01	0.544	0.33	-0.116	P<0.01	0.481	0.02	-0.267	0.24	-0.141
CBI dissatisfaction		P<0.01	0.43	0.23	-0.145	P<0.01	0.45	0.07	-0.213	0.265	-0.135
CBI satisfaction		P<0.01	0.451	0.49	-0.084	P<0.01	0.425	0.44	-0.242	0.33	-0.117
Body Image Scale, MBSRQ
Appearance evaluation subscale, mean ± SD				0.24	0.141	P<0.01	0.537	0.05	-0.229	P<0.01	-0.498
Appearance orientation subscale, mean ± SD		0.24	0.141			0.48	0.086	P<0.01	0.404	0.11	-0.193
Body areas satisfaction subscale, mean ± SD		P<0.01	0.537	0.48	0.086			0.11	-0.189	P<0.01	-0.406
Overweight preoccupation subscale, mean ± SD		0.06	-0.229	P<0.01	0.404	0.11	-0.189			P<0.01	0.336
Self-classified weight subscale, mean ± SD		P<0.01	-0.498	0.11	-0.193	P<0.01	-0.406
DLQI total		0.09	-0.204	0.55	0.073	0.93	-0.011	0.02	0.268	0.32	0.121
DLQI Symptoms and feelings (Questions 1 and 2, total score 0- 6)		P<0.01	-0.347	0.45	-0.091	0.59	-0.064	0.17	0.164	0.04	0.239
DLQI Daily activities (Questions 3 and 4, total score 0-6) , mean ± SD		0.18	-0.16	0.55	0.072	0.64	0.057	0.01	0.302	0.683	0.005
DLQI Leisure (Questions 5 and 6, total score 0-6) , mean ± SD		0.46	-0.089	0.60	0.062	0.78	0.034	0.13	0.182	0.59	0.064
DLQI Work or Leisure (Question 7, total score 0-3), mean ± SD		0.392	-0.104	0.21	0.151	0.77	-0.035	0.41	0.099	0.41	0.100
DLQI Personal relationship (Questions 8 and 9, total score 0-6), mean ± SD		0.12	-0.188	0.41	0.099	0.67	-0.052	0.01	0.285	0.55	0.071
DLQI Treatment (Question 10, total score 0-3), mean ± SD		0.24	-0.141	0.46	0.089	0.97	-0.005	0.03	0.253	0.47	0.087
Skindex-16 total		0.02	-0.267	0.78	-0.034	0.17	-0.16	P<0.01	0.343	0.05	0.229
Skindex-16 Symptoms, mean ± SD ( 4 items)		0.18	-0.16	0.35	-0.113	0.50	-0.081	0.15	0.171	0.24	0.142
Skindex-16 Emotions, mean ± SD (7 items)		0.02	-0.279	0.95	-0.006	0.11	-0.192	P<0.01	0.356	0.05	0.228
Skindex-16 Functioning, mean ± SD (5 items)		0.03	-0.251	0.96	-0.005	0.25	-0.139	P<0.01	0.346	0.06	0.225
PHQ9, mean ± SD		0.02	-0.27	0.12	-0.187	0.96	-0.006	0.18	0.15	0.02	0.261
Mild depression, N (%)
Moderate depression, N (%)
Moderately severe depression, N (%)
Severe depression, N (%)
GAD7		0.61	-0.061	0.40	-0.102	0.83	0.025	0.03	0.251	0.10	0.193
Mild anxiety, N (%)
Moderate anxiety, N (%)
Moderately severe anxiety, N (%)
Severe anxiety, N (%)
EQ 5D 5L		0.92	0.011	0.41	0.099	0.909	0.014	0.05	-0.235	0.38	-0.105
EQ VAS, mean ± SD	57.44-67.52	0.04	0.243	0.97	0.004	0.522	0.078	0.39	-0.102	0.01	-0.283
BMI categories		P<0.01	-0.418	0.29	-0.128	0.83	0.025	0.05	0.231	P<0.01	0.773

Abbreviations: HS: Hidradenitis suppurativa, SD: standard deviation, C.I. Confidence Interval, CBI: Cutaneous Body Image, , HS-PGA: The six-point hidradenitis suppurativa Physician Global Assessment, HiSCR (Hidradenitis Suppurativa Clinical Response

PMH: Past medical history, IBD: Inflammatory Bowel disease (IBD), MBSRQ-AS: Multidimensional Body-Self Relations Questionnaire-Appearance Scales , AE: Appearance Evaluation , AO: Appearance Orientation, BASS: Body Areas Satisfaction Scale , OWP: Overweight Preoccupation , SCW: Self Classified Weight , DLQI: Dermatology Life Quality Index, PHQ-9: Patient Health Questionnaire-9, GAD-7: General Anxiety Disorder-7, EQ5D 5L: EuroQol- 5 Dimension, EQ VAS: visual analogue scale, r: correlation coefficient, p -value: probability value.

Table 6: Hidradenitis Suppurativa (HS) Disease Severity Scores and correlations with Cutaneous Body Image (CBI), MBSRQ Body Image subscales, DLQI, Skindex-16, PHQ9, GAD7, EQ5D 5L, EQ5D VAS of 70 patients with hidradenitis suppurativa (HS). A p-value less than 0.05 was considered as statistically significant. Correlation coefficient (r value) was considered strong, moderate and weak for values above 0.6, between 0.2 and 0.6 and below 0.2 respectively.

	Hurley stage of disease		HS-PGA		Modified Sartorius score (MSS)		HiSCR		Patients’ severity of disease
	p-value	r-correlation coefficient	p-value	r-correlation coefficient	p-value	r-correlation coefficient	p-value	r-correlation coefficient	p-value	r-correlation coefficient
Cutaneous Body Image (CBI)	0.34	-0.116	0.91	-0.14	0.82	0.027	0.47	0.087	0.87	-0.019
Body Image Scale, MBSRQ
Appearance evaluation subscale, mean ± SD	P=0.30	-0.124	0.85	-0.023	0.73	-0.043	0.64	0.056	0.32	-0.122
Appearance orientation subscale, mean ± SD	P=0.57	0.069	0.51	0.08	0.84	0.024	0.72	0.043	0.60	-0.063
Body areas satisfaction subscale, mean ± SD	P=0.20	-0.153	0.86	0.022	0.33	-0.118	0.72	-0.044	0.24	0.141
Overweight preoccupation subscale, mean ± SD	P=0.11	0.191	0.49	0.085	0.45	-0.091	0.483	-0.085	0.26	0.136
Self-classified weight subscale, mean ± SD	P=0.18	0.162	0.99	0.001	0.31	0.123	0.42	0.097	0.93	-0.011
DLQI total	P=0.04	0.244	0.28	0.131	0.45	0.091	0.70	0.047	0.004	0.343
DLQI Symptoms and feelings (Questions 1 and 2, total score 0- 6)	P=0.23	0.149	0.12	0.189	0.62	0.060	0.63	0.058	P<0.01	0.326
DLQI Daily activities (Questions 3 and 4, total score 0-6) , mean ± SD	P=0.11	0.192	0.56	0.072	0.76	0.038	0.83	-0.027	P<0.01	0.343
DLQI Leisure (Questions 5 and 6, total score 0-6) , mean ± SD	P=0.13	0.185	0.57	0.069	0.57	0.068	0.82	0.028	0.057	0.228
DLQI Work or Leisure (Question 7, total score 0-3), mean ± SD	P=0.26	0.135	0.76	0.037	0.75	0.039	0.83	0.026	0.04	0.246
DLQI Personal relationship (Questions 8 and 9, total score 0-6), mean ± SD	P<0.01	0.327	0.17	0.164	0.16	0.169	0.29	0.128	P<0.01	0.333
DLQI Treatment (Question 10, total score 0-3), mean ± SD	P=0.131	0.182	0.31	0.122	0.48	0.084	0.79	0.032	0.04	0.237
Skindex-16 Total	0.05	0.228	0.36	0.110	0.06	0.223	0.37	0.10	P<0.01	0.392
Skindex-16 Symptoms, mean ± SD ( 4 items)	P=0.16	0.171	0.13	0.182	0.39	0.102	0.79	0.31	0.21	0.15
Skindex-16 Emotions, mean ± SD (7 items)	P=0.13	0.183	0.56	0.70	0.16	0.286	0.12	0.186	P<0.01	0.46
Skindex-16 Functioning, mean ± SD (5 items)	P=0.03	0.0261	0.509	0.8	0.17	0.163	0.81	0.029	P<0.01	0.354
PHQ9, mean ± SD	P=0.98	-0.004	0.89	0.017	0.67	-0.052	0.42	-0.097	0.13	0.181
Mild depression, N (%)
Moderate depression, N (%)
Moderately severe depression, N (%)
Severe depression, N (%)
GAD7	P=0.74	0.04	0.43	0.096	0.55	-0.072	0.56	-0.070	0.02	0.288
Mild anxiety, N (%)
Moderate anxiety, N (%)
Moderately severe anxiety, N (%)
Severe anxiety, N (%)
EQ5D 5L, mean ± SD	P=0.3	-0.258	0.07	-0.221	0.641	-0.057	0.75	-0.039	0.082	-0.209
EQ VAS, mean ± SD	P=0.02	-0.270	0.33	-0.255	0.31	0.124	0.95	0.007	0.062	-0.224

Abbreviations: HS: Hidradenitis suppurativa, SD: standard deviation, C.I. Confidence Interval, HS-PGA: The six-point hidradenitis suppurativa Physician Global Assessment, MSS: Modified Sartorius score, HiSCR : Hidradenitis Suppurativa Clinical Response,

CBI: Cutaneous Body Image, MBSRQ: Multidimensional Body-Self Relations Questionnaire,

DLQI: Dermatology Life Quality Index, PHQ-9: Patient Health Questionnaire-9, GAD-7: General Anxiety Disorder-7, EQ5D 5L: EuroQol- 5 Dimension, EQ VAS: visual analogue scale, r: correlation coefficient, p -value: probability value.

Table 7: EQ5D 5L index and correlations with Hidradenitis Suppurativa (HS) disease severity, clinical characteristics, comorbidities, Cutaneous Body Image (CBI), MBSRQ Body Image subscales, DLQI, Skindex-16, PHQ9, GAD7, EQ5D 5L, EQ5D VAS of 70 patients with hidradenitis suppurativa (HS). A p-value less than 0.05 was considered as statistically significant. Correlation coefficient (r value) was considered strong, moderate and weak for values above 0.6, between 0.2 and 0.6 and below 0.2 respectively.

EQ5D 5L
		p-value	r-correlation coefficient
Age		0.907	-0.014
Gender		0.43	0.096
BMI		0.29	-0.128
Marital status		0.71	-0.045
Employment status		0.79	0.031
Educational level		0.28	0.130
Age of onset of HS		0.26	-0.135
Age of HS diagnosis		0.89	0.016
Age of onset of treatment		0.63	0.058
Duration of disease		0.46	0.09
Patients’ severity of disease		0.08	-0.209
Patients’ pain severity		<0.01	-0.502
Patients’ pruritus severity		<0.01	-0.416
Skin phototype		0.49	0.084
Hurley stage		0.03	-0.258
Physicians’ Global Assessment of Disease (PGA HS)		0.06	-0.221
Modified Sartorius Scale (MSS)		0.64	-0.057
HiSCR		0.75	-0.039
Smoking status		0.03	0.254
Current treatment		0.31	-0.123
Past medical history (PMH) of Inflammatory Bowel disease (IBD)		0.81	-0.030
PMH of rheumatic disease		0.47	0.087
PMH of thyroid disease		0.67	0.054
PMH of dyslipidemia		0.46	0.089
PMH of hypertension		0.79	-0.032
PMH of cardiovascular		0.28	0.13
PMH of diabetes		0.52	0.077
Axilla area		0.66	-0.053
Inguinal area		0.02	0.264
Genital area		0.86	0.022
Buttocks		0.07	-0.213
Thighs		0.36	0.11
Chest		0.73	-0.042
Cutaneous Body Image (CBI)		0.812	0.029
Body Image Scale, MBSRQ
Appearance evaluation subscale, mean ± SD		P=0.93	0.011
Appearance orientation subscale, mean ± SD		P=0.41	0.099
Body areas satisfaction subscale, mean ± SD		P=0.91	0.014
Overweight preoccupation subscale, mean ± SD		P=0.05	-0.235
Self-classified weight subscale, mean ± SD		P=0.387	-0.105
DLQI total		P<0.01	-0.559
DLQI Symptoms and feelings (Questions 1 and 2, total score 0- 6)		P=0.01	-0.383
DLQI Daily activities (Questions 3 and 4, total score 0-6) , mean ± SD		P<0.01	-0.534
DLQI Leisure (Questions 5 and 6, total score 0-6) , mean ± SD		P<0.01	-0.530
DLQI Work or Leisure (Question 7, total score 0-3), mean ± SD		P=0.05	-0.334
DLQI Personal relationship (Questions 8 and 9, total score 0-6), mean ± SD		P<0.01	-0.454
DLQI Treatment (Question 10, total score 0-3), mean ± SD		P<0.01	-0.539
Skindex-16 total		P<0.01	-0.554
Skindex-16 Symptoms, mean ± SD ( 4 items)		P<0.01	-0.514
Skindex-16 Emotions, mean ± SD (7 items)		P<0.01	-0.467
Skindex-16 Functioning, mean ± SD (5 items)		P<0.01	-0.535
PHQ9, mean ± SD		P<0.01	-0.536
Mild depression, N (%)
Moderate depression, N (%)
Moderately severe depression, N (%)
Severe depression, N (%)
GAD7		P<0.01	-0.551
Mild anxiety, N (%)
Moderate anxiety, N (%)
Moderately severe anxiety, N (%)
Severe anxiety, N (%)
EQ VAS, mean ± SD	57.44-67.52	P<0.01	0.311
BMI categories		P=0.053	-0.233

Abbreviations: HS: Hidradenitis suppurativa, SD: standard deviation, C.I. Confidence Interval, CBI: Cutaneous Body Image, MBSRQ: Multidimensional Body-Self Relations Questionnaire, HS-PGA: The six-point hidradenitis suppurativa Physician Global Assessment, HiSCR (Hidradenitis Suppurativa Clinical Response

PMH: Past medical history, IBD: Inflammatory Bowel disease (IBD)

No competing interests reported.

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Cutaneous Body Image (CBI) in patients with hidradenitis suppurativa (HS): a hospital- based cross-sectional study.

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