**Background:** Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition associated with significant psychosocial comorbidities (depression, anxiety, substance use disorder, intimate partner violence) and modifiable comorbidities (obesity, smoking, metabolic syndrome, cardiovascular disease). Despite guidelines recommending comprehensive care including psychosocial screening and lifestyle counseling, the frequency of these practices in US ambulatory visits for HS had not been characterized.
**Methods:** This cross-sectional study analyzed publicly available data from the National Ambulatory Medical Care Survey (NAMCS) between 2008 and 2018 (2017 unavailable). Visits with an HS diagnosis were identified using ICD-9 code 705.83 and ICD-10 code L73.2. Survey weights were applied to generate national estimates. Descriptive statistics were calculated for demographics and rates of screening and counseling. T tests and multivariate logistic regressions analyzed trends while controlling for race, sex, and age. Visits with missing data were excluded. All analyses used SAS Studio 9.04.01.
**Key Results:** From 2008–2018, an estimated 2.33 million ambulatory visits (95% CI, 1.95 million–2.71 million) had a diagnosis of HS. Patients were 71.1% female, 75.6% white, 23.0% black, with a mean age of 37.9 ± 1.0 years (range 12–69). Most visits were to dermatology (30.2%), family practice (24.2%), or general surgery (18.9%). Depression screening occurred in only 2.0% of visits, and none of these screenings were in black patients. No visits reported screening for alcohol misuse, substance abuse, or domestic violence. Counseling rates were low: weight reduction 7.8%, diet/nutrition 3.3%, exercise 2.4%, tobacco use/exposure 1.0%, and substance abuse 0.7%. Black patients were more likely to receive weight reduction counseling (OR 4.95, 95% CI 2.02–12.13, p = 0.003) but less likely to receive diet/nutrition counseling (OR 0.52, 95% CI 0.32–0.85, p = 0.01). No black patients received counseling on exercise, substance abuse, or tobacco use. Older patients were less likely to receive counseling on diet/nutrition (OR 0.98, 95% CI 0.96–1.00, p = 0.01), exercise (OR 0.94, 95% CI 0.91–0.97, p = 0.001), and weight reduction (OR 0.90, 95% CI 0.87–0.94, p < 0.001). Patients with higher BMI were more likely to receive counseling on exercise (OR 1.24, 95% CI 1.09–1.41, p = 0.002), weight reduction (OR 1.09, 95% CI 1.06–1.12, p < 0.001), and diet/nutrition (OR 1.07, 95% CI 1.05–1.08, p < 0.001). Visits funded by public insurance were significantly less likely to receive weight reduction counseling (OR 0.08, 95% CI 0.01–0.79, p = 0.03).
**Clinical Implications:** Rates of psychosocial screening and lifestyle counseling in HS ambulatory visits are extremely low despite high rates of depression (up to 26%), substance use disorder (4% vs. 2% in controls), and intimate partner violence (2.4 times higher than acne patients) in this population. Racial and socioeconomic disparities are evident, with black patients and those with public insurance receiving less screening and counseling overall. Given that black patients and those with low socioeconomic status are disproportionately affected by HS, these disparities are particularly concerning. The authors suggest implementing quick screening tools (e.g., PHQ-2), streamlined mental health referral pathways, and educational handouts on lifestyle modifications to overcome time constraints in clinic visits. All specialties caring for HS patients should incorporate psychosocial screening and lifestyle counseling to improve patient outcomes.