Diet and Weight Loss
The association of HS and obesity has been well documented with multiple studies demonstrating that higher body mass index (BMI) correlates with greater disease severity.15 Obesity increases skin-to-skin contact predisposing patients to mechanical friction and pressure increasing the amount of HS lesions.16 A systematic literature review found that weight loss through dietary modification led to HS lesion regression, particularly in high friction areas.16
Diets eliminating dairy products, high glycemic index foods, and foods high in fat have also been reported to decrease HS symptoms.14-17 Intake of dairy, fats, and high glycemic foods can trigger insulin resistance. Therefore, it is believed that the consumption of these foods can ultimately result in an exacerbation of HS symptoms and increase in disease severity through weight gain.16
Dairy and high glycemic foods also raise insulin and insulin-like growth factor 1 that trigger androgen receptors and promote hyperkeratinization.15,16 This hyperkeratinization then creates follicular occlusion and inflammation.16 By avoiding dairy, patients can stabilize their disease and even see improvement of their HS lesions.17 Preliminary results from a trial that enrolled patients who selected dairy-free diets found that 83% of the 47 patients reported improvement of HS symptoms and none experienced worsening symptoms.15
The 2019 North American Clinical Management Guidelines for Hidradenitis Suppurativa state that practitioners may recommend oral zinc supplementation.18 However, only limited evidence of benefit is noted.18 Findings from a prospective pilot study investigating zinc gluconate 90 mg daily for 3 months in patients with HS refractory to previous treatments showed that 99.6% of patients reported a partial or complete remission of HS symptoms.19 Low serum zinc and vitamin D levels are associated with higher disease burden and supplementation is warranted. Supplementation of vitamin B12 and magnesium also can be effective in improving or resolving HS lesions.17 Additional randomized controlled trials investigating dietary modifications are needed to formalize dietary recommendations and supplementations in HS patients. Nevertheless, these findings show promising possible interventions and can provide guidance if patients desire diet recommendations.16,17
Patients with HS are 4 times more likely to be smokers.20 Nonsmokers with HS tend to have greater success with first-line medical therapy than smokers.21 Smoking tobacco is associated with an increase in systemic inflammatory markers and theorized to contribute to a proinflammatory state furthering the development and severity of HS.14 Smokers with HS are more likely to have worsening HS lesions that affect more body areas compared with patients who are nonsmokers.22 Smoking cessation has been shown to improve symptoms based on Hurley staging as well as patient report.14 Smoking cessation should be routinely recommended for smokers with HS.22
Symptomatic improvements have been noted in HS patients after halting use of harsh body soaps and laundry detergents.14 These agents can promote cutaneous inflammation by altering the pH balance of the skin and worsening HS symptoms.14 Some depilatory products can also contribute to hair follicle inflammation and occlusion resulting in more severe HS symptoms.14 Gentle cleansers that are soap, dye, and fragrance-free as well as fragrance-free laundry detergents are best for preventing further skin irritation. Similar improvement in symptoms has been seen when patients stop using aluminum-containing deodorants and irritating shaving products.14
Additional modifiable factors to improve HS symptoms include wearing loose-fit clothing made from absorbent and breathable material.23 To reduce mechanical stress, friction, and irritation, providers should incorporate a discussion of undergarment and clothing selection with patients.23 Recommendations of undergarments for women should include avoiding tight elastic bands or underwire bras in the inframammary area and seamless underwear without bands in the inguinal folds.23 Men should be advised to avoid tight briefs and instead wear loose-fitted boxers.23 Clothing material should be absorbent, breathable, and temperature controlled to reduce the risk of microbial colonization. These characteristics can be found in rayon cellulose-based lyocell, 100% cotton, and bamboo-based fabrics.23
Hidradenitis suppurativa is a debilitating skin disorder that negatively impacts patient quality of life. While HS treatment modalities are broad and include systemic and topical antibiotics, biologic therapy, intralesional corticosteroid injections, laser therapy, and local excisions, providers should not overlook the importance of lifestyle modifications.7,12,13,23 The disease is associated with environmental factors such as obesity, diet, and smoking suggesting a key role of lifestyle modification in disease management.17 Through practical lifestyle changes such as weight loss, exclusion of dairy and high glycemic foods, smoking cessation, use of absorbent and breathable loose clothing, and use of nonirritating personal care products, patients can reduce HS symptoms and flares and improve quality of life. Although additional randomized controlled trials investigating these lifestyle modifications are needed, current findings show possible interventions that are noninvasive and can allow providers to better support and guide HS patients to remission.16
Emily Sinclair, PA-S, is a student in the Physician Assistant Program at Augusta University in Augusta, GA; Rachel Ziganti, MPA, PA-C, is a physician assistant working with the Department of Rheumatic and Immunologic Diseases of the Cleveland Clinic in Cleveland, Ohio.
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