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Patients with hidradenitis suppurativa (HS) experience chronic pain and have significant physical, emotional, and psychological disease impact. These patients may be at risk for substance abuse.To evaluate substance use disorder (SUD) among patients with HS in the United States.This cross-sectional analysis of adult HS patients (n = 32,625) identified using electronic health records data was pulled from a population-based sample of >50 million patients.The prevalence of SUD among patients with HS was 4.0% (1315/32,625) compared to 2.0% (195,260/9,581,640) for patients without HS (P < .001). The most common forms of substance misuse among HS patients were alcohol (630/1315, 47.9% of SUD cases), followed by opioids (430/1315, 32.7% of SUD cases) and cannabis (430/1315, 29.7% of SUD cases). Patients with HS had 1.50 (95% confidence interval 1.42–1.59) times the adjusted odds of SUD compared to patients without HS. Patients with HS had significantly greater odds of SUD across demographic subgroups. The association between HS and SUD was generally stronger for patients 45 to 64 years of age, nonwhites, privately insured, and those without depressive or anxiety disorder.SUD may not be accurately diagnosed.Patients with HS have higher odds of SUD and may benefit from periodic screening for substance abuse.