Can Patients Develop Hidradenitis Suppurativa Later in Life?
Yes, patients can develop hidradenitis suppurativa (HS) later in life, though this is less common than onset in younger adults. The typical age of onset is in the second to fourth decades of life (roughly ages 20-40), but the disease can present outside this window 1.
Age Distribution and Onset Patterns
- The highest standardized prevalence of HS occurs in patients aged 18-39 years, representing the peak age range for disease onset 1
- While HS usually presents after puberty, only 2% of cases occur before age 11 years, and approximately 7.7% report onset before age 13 years 1
- The disease can manifest in older adults beyond the typical second to fourth decade window, though this represents a smaller proportion of cases 1
Clinical Implications of Later-Life Onset
The key clinical point is that HS should remain on the differential diagnosis even in older patients presenting with painful nodules, abscesses, or draining lesions in flexural areas (axillae, groin, perineum, buttocks, submammary region, or inframammary folds) 1.
Diagnostic Criteria Apply Regardless of Age
- Diagnosis requires typical lesions (painful nodules, abscesses, sinus tracts, bridged scars, or open comedones) in typical anatomic sites with chronic and recurrent presentation 1
- The disease must be distinguished from other conditions that can present similarly in older adults, including bacterial folliculitis, carbuncles, or other infectious processes 1
Risk Factors That May Influence Later-Life Onset
- Smoking: Odds ratio of 36 compared with controls, and 92.2% of HS patients report tobacco use 1, 2
- Obesity: Odds ratio of 33 compared with controls, with obese patients showing lower remission rates (23%) compared to non-obese patients (45%) 1, 2
- Female sex: 3:1 female-to-male predominance overall, though this may vary by geographic region 1
- Race: African-American individuals have 3-fold higher prevalence and biracial individuals have 2-fold higher prevalence compared to white individuals 1
Critical Pitfall to Avoid
Do not dismiss the possibility of HS in older patients simply because they are beyond the typical age of onset. Late-onset cases do occur, and delayed diagnosis leads to progression of irreversible skin damage including sinus tract formation, fistulae, and disfiguring scarring 1, 3. The average delay in diagnosis contributes to worse outcomes, with 48% of pediatric patients already having scarring at initial dermatologic assessment, suggesting similar delays may occur across all age groups 4.
Prognosis Considerations
- Long-term follow-up data (median 22 years) shows that 39.4% of patients report remission, 31.5% report improvement, 20.5% remain unchanged, and 8.7% experience worsening disease 2
- Remission rates are higher in nonsmokers (40%) compared to active smokers (29%), suggesting that lifestyle modification remains important regardless of age at onset 2