PracticalDermatology

Hidradenitis suppurativa (HS) is a chronic, inflammatory disease characterized by recurrent painful and deep dermal abscesses primarily involving the axillae, perineum, and inframammary regions.¹ HS significantly reduces quality of life and is debilitating both physically and mentally. The pathophysiology of HS is not well understood but is thought to be primarily a disorder of follicular occlusion. Despite some therapeutic success with conventional therapies, such as antibiotics and immunomodulators, management remains challenging and marked by recurrences, undesirable side effects, and financial burden.

Faced with these challenges, many patients seek complementary and alternative medicine (CAM) approaches. Literature on CAMs for HS is relatively limited, but there are some thought-provoking signals. Importantly, many patients report the use of CAMs, but the majority do not inform health care providers about their use.² To increase patient trust and provider knowledge on appropriate use, familiarity with the literature on these interventions is vital for comprehensive management of the disease. Here we highlight a few areas that may be particularly noteworthy or encouraging of further research.

Lifestyle

Smoking cessation and weight loss are often the crux of lifestyle management. Tobacco smoke promotes proinflammatory cytokines found in HS lesions and activates nicotinic acetylcholine and aryl hydrocarbon receptors, which suppress the Notch signaling pathway implicated in the pathogenesis of HS.³ Remarkably, nearly three quarters of patients with HS smoke cigarettes.⁴ There is support for a structured smoking cessation clinic to reduce smoking rates with the goal of lessening smoking associated morbidity of HS.⁶ Additionally, given the significant mechanical friction in intertriginous areas combined with a pro-inflammatory state, excessive weight seems to play a role in the development and worsening of HS.^7,8 Unsurpringly, several studies have shown weight loss can lead to overall reduction in HS activity and improvement of lesions.^7-9

Diet

Yeast intolerance is present among some patients with HS and subsequent dietary elimination has been explored. Cannistra et al. reported 12 HS patients with prior history of surgical excision that were proven to have a brewer’s yeast and wheat reaction through anti-saccharomyces cervisiae antibodies. These patients were placed on a controlled brewer’s yeast-free diet for 12 months and demonstrated stabilization of clinical symptoms with a return of quality of life.¹⁰ Further, Aboud et al. followed a group of 185 patients for six years, of which, 37 were treated with a brewer’s and baker’s yeast exclusion diet. Fully 70 percent of patients reported an improvement in HS symptomatology without any other treatment.¹¹ Those requiring medical and surgical intervention, required remarkably less invasive procedures. Thus, brewer’s and baker’s yeast elimination could be considered in the context of medical management.

In addition to yeast elimination, reduction in dairy, high-fat, and high-glycemic index foods has also been reported to provide some benefit for HS patients. The most frequently reported exacerbating foods are sweets, bread/pasta/rice, dairy, and high-fat foods; alleviating foods include vegetables, fruit, chicken, and fish.¹² Diets high in dairy and glycemic index have been shown to cause sebaceous gland plugging and subsequent follicular-pilosebaceous unit rupture.¹³ Dairy products contain insulin-like growth factor-1 (IGF-1), whey and simple carbohydrates, as well as 5α-reduced dihydrotestosterone (DHT), which increase insulin and induce opening of androgen receptors that play a role in HS.¹³ These mechanisms support the associations reported between Metabolic syndrome and HS and ultimately warrant assessment of nutrition status by providers with follow-up of appropriate dietary modifications.^13,14

The Mediterranean diet (MD) is widely recognized for its anti-inflammatory potential and has been examined in the multidisciplinary approach to HS. The MD characteristically consists of a high intake of fruits and vegetables, whole grains, legumes, nuts, fish, white meats, and olive oil.¹⁵ In a case-controlled, cross-sectional study by Barrea et al., higher adherence to the MD was found to be associated with a lower severity of HS.¹⁶

Vitamins, Minerals & Supplements

Vitamins, minerals, and supplements with the most reported literature for positive clinical effects in HS include zinc, vitamin D, and turmeric/curcumin. Preliminary evidence supports the use of Zinc in HS. Zinc has been reported in several studies to significantly decrease disease severity.^17-22 However, the dosage and form of zinc utilized remains controversial along with its anti- vs. pro-inflammatory effects and the role it plays in the deficient innate immunity of HS lesions.

Vitamin D is an important component of skin homeostasis, especially hair follicles, and has proven to be frequently deficient in HS patients.²³ Subsequent supplementation in deficient individuals with HS has resulted in improvement and regression of HS lesions.^23,24 However, data has been inconclusive in correlating vitamin D deficiency to HS itself rather than associated smoking, obesity, etc.

Finally, curcumin is known to improve glycemic control and reduce inflammatory cytokines, both of which may be beneficial in patients who have associated HS comorbidities.²⁵

Ayurveda

Ayurveda is a comprehensive approach to health care that originated in the ancient Vedic times of India.²⁷ Ayurveda classically relates HS to a term called Nadivrana, which encompasses pus drainage and tract formation alongside other comparable clinical symptoms to HS.^28-30 The management mode for Navidrana, is through Ksharasutra application, which involves excision, incision, scraping, purification, and epithelialization of healthy granulation tissue utilizing ayurvedic medicine.²⁹ Hirudo medicinalis leech application on HS lesions and use of guggul, an herbal ingredient, have also been described.^28,30 Reported improvements in several ayurvedic case studies include a reduction in pus drainage, inflammation, and swelling, and improved abscesses.^28-31 These modalities may be utilized by those with expertise in the field, however many barriers exist to providing these treatments in the United States.

Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) is derived from an ancient system of knowledge that is fundamentally defined by therapeutic procedures such as acupuncture, manual therapy, and Chinese herbal medicine.³²

A study by Feng et al. analyzed treatment of perianal HS by TCM in combination with western medicine vs. western medicine alone. Twenty four out of 48 patients were treated with TCM and the other half with western medicine alone as the control group. The cure rate of the treatment group was 83.33 percent vs 50 percent in the control group.³³ These findings suggest that utilization of TCM may be beneficial in patients with HS, especially perianal lesions.

Wound Care

A plant native to New Zealand, Leptospermum scoparium, allows for the production of manuka honey, which has antimicrobial and antioxidant properties that can be used in dressings.³⁵ A review by Braunberger et al. analyzing dressing methods in HS discussed the use of manuka honey dressings in a patient who had previously undergone surgical excision. A refractory wound was dressed with manuka honey-impregnated dressings; recurrent infection with Staphylococcus subsided and the wound subsequently healed.³⁶ Although further studies are needed, manuka honey’s properties in wound healing show promising features for patients with HS.

Mental Health Management

Mental health heavily intertwines with physical health and can exacerbate chronic disease states and prevent appropriate healing. In a systematic review by Machado et al, in a cohort of 40,307 participants with HS, depression had a prevalence of 16.9 percent and anxiety had a prevalence of 4.9 percent.³⁷ “Mind-body” CAMs such as meditation, hypnosis, tai chi, yoga, and massage therapy are some of the methods reported in the literature.³⁸ Depression strongly impacts pain perceptions, thus modalities, such as cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT), could be utilized in HS patients to reduce pain and psychological distress.³⁹

An Integrative Approach

An integrative approach to HS would involve assessing overall health, metabolic risk factors, and the role of associated comorbidities in targeting management. CAMs such as lifestyle changes and dietary control could benefit patients as part of a comprehensive management plan. Some of the modalities discussed may be beneficial with concomitant conventional treatments and may help achieve desirable outcomes for patients. Although the evidence is generally too sparse for firm recommendations, many of these modalities warrant further investigation. In the meantime, their relative safety and accessibility may make them valuable considerations for certain patients who continue to have unmet needs.

The authors have no conflicts of interest to declare that are relevant to the content of this review.

1. Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol. 2009;60(4):539-61; quiz 62-3.

2. Price KN, Thompson AM, Rizvi O, Hendricks AJ, Alavi A, Hsiao JNL, et al. Complementary and Alternative Medicine Use in Patients With Hidradenitis Suppurativa. Jama Dermatology. 2020;156(3):345-8.

3. Bukvić Mokos Z, Miše J, Balić A, Marinović B. Understanding the Relationship Between Smoking and Hidradenitis Suppurativa. Acta Dermatovenerol Croat. 2020;28(1):9-13.

4. Alikhan A, Sayed C, Alavi A, Alhusayen R, Brassard A, Burkhart C, et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management. J Am Acad Dermatol. 2019;81(1):76-90.

5. Acharya P, Mathur M. Hidradenitis suppurativa and smoking: A systematic review and meta-analysis. Journal of the American Academy of Dermatology. 2020;82(4):1006-11.

6. Cheng HM, Liu WC, Chua G, Liew CF, Li W, Choo W, et al. Impact of a pharmacy-led smoking cessation clinic in a dermatology centre. Singapore Med J. 2019;60(1):31-3.

7. Boer J. Resolution of hidradenitis suppurativa after weight loss by dietary measures, especially on frictional locations. J Eur Acad Dermatol Venereol. 2016;30(5):895-6.

8. Barrea L, Fabbrocini G, Annunziata G, Muscogiuri G, Donnarumma M, Marasca C, et al. Role of nutrition and adherence to the Mediterranean diet in the multidisciplinary approach of hidradenitis suppurativa: evaluation of nutritional status and its association with severity of disease. Nutrients. 2019;11(1):57.

9. Macklis PC, Tyler K, Kaffenberger J, Kwatra S, Kaffenberger BH. Lifestyle modifications associated with symptom improvement in hidradenitis suppurativa patients. Arch Dermatol Res. 2021.

10. Cannistrà C, Finocchi V, Trivisonno A, Tambasco D. New perspectives in the treatment of hidradenitis suppurativa: surgery and brewer’s yeast-exclusion diet. Surgery. 2013;154(5):1126-30.

11. Aboud C, Zamaria N, Cannistrà C. Treatment of hidradenitis suppurativa: Surgery and yeast (Saccharomyces cerevisiae)-exclusion diet. Results after 6 years. Surgery. 2020;167(6):1012-5.

12. Fernandez JM, Marr KD, Hendricks AJ, Price KN, Ludwig CM, Maarouf M, et al. Alleviating and exacerbating foods in hidradenitis suppurativa. Dermatol Ther. 2020;33(6):e14246

13. William Danby F. Diet in the prevention of hidradenitis suppurativa (acne inversa). Journal of the American Academy of Dermatology. 2015;73(5):S52-S4.

14. Maarouf M, Platto JF, Shi VY. The role of nutrition in inflammatory pilosebaceous disorders: Implication of the skin-gut axis. Australas J Dermatol. 2019;60(2):e90-e8.

15. Urquiaga I, Echeverría G, Dussaillant C, Rigotti A. [Origin, components and mechanisms of action of the Mediterranean diet]. Rev Med Chil. 2017;145(1):85-95.

16. Barrea L, Fabbrocini G, Annunziata G, Muscogiuri G, Donnarumma M, Marasca C, et al. Role of nutrition and adherence to the Mediterranean diet in the multidisciplinary approach of hidradenitis suppurativa: evaluation of nutritional status and its association with severity of disease. Nutrients. 2019;11(1):57.

17. Brocard A, Dréno B. Innate immunity: a crucial target for zinc in the treatment of inflammatory dermatosis. J Eur Acad Dermatol Venereol. 2011;25(10):1146-52.

18. Danesh MJ, Kimball AB. Pyrithione zinc as a general management strategy for hidradenitis suppurativa. J Am Acad Dermatol. 2015;73(5):e175.

19. Hessam S, Sand M, Meier NM, Gambichler T, Scholl L, Bechara FG. Combination of oral zinc gluconate and topical triclosan: An anti-inflammatory treatment modality for initial hidradenitis suppurativa. J Dermatol Sci. 2016;84(2):197-202.

20. Dréno B, Khammari A, Brocard A, Moyse D, Blouin E, Guillet G, et al. Hidradenitis suppurativa: the role of deficient cutaneous innate immunity. Arch Dermatol. 2012;148(2):182-6.

21. Dhaliwal S, Nguyen M, Vaughn AR, Notay M, Chambers CJ, Sivamani RK. Effects of Zinc Supplementation on Inflammatory Skin Diseases: A Systematic Review of the Clinical Evidence. Am J Clin Dermatol. 2020;21(1):21-39.

22. Molinelli E, Brisigotti V, Campanati A, Sapigni C, Giacchetti A, Cota C, et al. Efficacy of oral zinc and nicotinamide as maintenance therapy for mild/moderate hidradenitis suppurativa: A controlled retrospective clinical study. J Am Acad Dermatol. 2020;83(2):665-7.

23. Brandao L, Moura R, Tricarico PM, Gratton R, Genovese G, Moltrasio C, et al. Altered keratinization and vitamin D metabolism may be key pathogenetic pathways in syndromic hidradenitis suppurativa: a novel whole exome sequencing approach. Journal of Dermatological Science. 2020;99(1):17-22.

24. Guillet A, Brocard A, Bach Ngohou K, Graveline N, Leloup AG, Ali D, et al. Verneuil’s disease, innate immunity and vitamin D: a pilot study. J Eur Acad Dermatol Venereol. 2015;29(7):1347-53.

25. Mantzorou M, Pavlidou E, Vasios G, Tsagalioti E, Giaginis C. Effects of curcumin consumption on human chronic diseases: A narrative review of the most recent clinical data. Phytother Res. 2018;32(6):957-75.

26. Donnarumma M, Marasca C, Palma M, Vastarella M, Annunziata MC, Fabbrocini G. An oral supplementation based on myo-inositol, folic acid and liposomal magnesium may act synergistically with antibiotic therapy and can improve metabolic profile in patients affected by Hidradenitis suppurativa: our experience. G Ital Dermatol Venereol. 2020;155(6):749-53.

27. Sharma H, Keith Wallace R. Ayurveda and Epigenetics. Medicina (Kaunas). 2020;56(12).

28. Jagdhane VC, Sharma VM. A Case Report to Study the Clinical Utility of Traditional Healer-Leech Therapy in the Management of Axillary Suppurativa Hidradenitis Wsr Nadi Vrana. 2020.

29. Malavika G, Nair CR. An Ayurvedic Approach to Hidradenitis Suppurativa: A Case Series. AYUSH: International Research Journal of Ayurveda Teachers Association. 2021;1(01).

30. Sarika A, Poornima M, Masalekar S. Management of Hidradenitis Suppurativa by Guggulu based Apamarga Ksharasutra-A Case Study. Journal of Ayurveda and Integrated Medical Sciences. 2021;6(3):201-4.

31. Kumar C, Fathima SA, Sharad K. Management of Hydradenitis Suppurativa by Apamarga Kshara Sutra-A Case Study. Journal of Ayurveda and Integrated Medical Sciences. 2017;2(05):194-7.

32. Oravecz M, Mészáros J. [Traditional Chinese medicine: theoretical background and its use in China]. Orv Hetil. 2012;153(19):723-31.

33. FENG L-q, SONG W-p, SHI S-m, SUN X-c. Explore of top-level removal and TCM treatment of perianal hidradenitis suppurativa. China Journal of Traditional Chinese Medicine and Pharmacy. 2013.

34. Li Y, Ye J, Shen S, Jiao Z, Li Y. Heshi Fire Needling Combined with Herbal Prescription for Hidradenitis Suppurativa. International Journal of Clinical Acupuncture. 2018;27(4):271-3.

35. Alvarez-Suarez JM, Gasparrini M, Forbes-Hernández TY, Mazzoni L, Giampieri F. The Composition and Biological Activity of Honey: A Focus on Manuka Honey. Foods. 2014;3(3):420-32.

36. Braunberger TL, Fatima S, Vellaichamy G, Nahhas AF, Parks-Miller A, Hamzavi IH. Dress for Success: a Review of Dressings and Wound Care in Hidradenitis Suppurativa. Current Dermatology Reports. 2018;7(4):269-77.

37. Machado MO, Stergiopoulos V, Maes M, Kurdyak PA, Lin PY, Wang LJ, et al. Depression and Anxiety in Adults With Hidradenitis Suppurativa: A Systematic Review and Meta-analysis. JAMA Dermatol. 2019;155(8):939-45.

38. Amatore F, Devey S, Tabelé C, Troin L, Monestier S, Malissen N, et al. Comparison of complementary and alternative medicine use between patients with skin cancer and inflammatory skin diseases. Journal of the European Academy of Dermatology & Venereology. 2020;34(4):e182-e3.

39. Savage KT, Singh V, Patel ZS, Yannuzzi CA, McKenzie-Brown AM, Lowes MA, et al. Pain management in hidradenitis suppurativa and a proposed treatment algorithm. J Am Acad Dermatol. 2021;85(1):187-99.