Understanding Hidradenitis Suppurativa (HS): An In-Depth Exploration

Hidradenitis Suppurativa (HS) is a chronic dermatological condition affecting approximately 0.3% of the global population. This ailment is characterized by the recurrent development of painful, suppurating lesions, primarily in regions such as the axillary, inguinal, and inframammary areas. While the exact cause is still not fully understood, recent research has shed light on the potential role of the skin and gut microbiome in HS.

In this article, we will delve into the latest scientific findings about hidradenitis suppurativa.

Comprehending the Pathophysiology of HS

Hidradenitis Suppurativa is a multifaceted disease characterized by inflammation and the occlusion of apocrine sweat glands. Often referred to as “acne inversa” due to its occurrence in anatomically inverse locations relative to common acne manifestations, HS is attributed to a dysregulation of immunological mediators, notably cytokines such as TNF, IL-8, and IL-1β. Therapeutic interventions, such as the administration of Humira (adalimumab), an FDA-approved anti-TNF agent for moderate to severe refractory HS, have demonstrated efficacy in the management of HS symptoms. However, there is no “cure” for hidradenitis suppurativa.

Unveiling the Role of the Skin Microbiome

HS lesions often harbor bacterial infections, which were historically regarded as secondary to the condition. However, research shows that the skin microbiome in HS patients is distinct from healthy individuals. Anaerobic bacteria, notably Prevotella and Porphyromonas, exhibit increased prevalence within HS lesions, while aerobic bacterial populations are reduced. Certain bacteria like Fusobacterium and Parvimonas have been found to correlate with disease severity, making them potential biomarkers.

Gut Microbiome and Dietary Implications

Interestingly, HS has been linked to gut health, particularly Crohn’s disease (CD) and ulcerative colitis (UC), collectively known as inflammatory bowel disease (IBD). Both HS and these gut conditions respond to some anti-cytokine treatments, suggesting similar underlying mechanisms. The presence of anti-Saccharomyces cerevisiae antibodies (ASCAs) in HS patients also links it to intestinal disorders like Crohn’s and celiac disease.

Dietary interventions have been suggested for HS management. Obesity is a known risk factor, and a weight loss of at least 15% has been associated with reduced disease severity. Diets high in fat can imbalance the gut microbiome, although it is not yet clear how this affects HS. Avoiding foods containing yeast S. cerevisiae has shown promise in reducing inflammation and improving treatment outcomes.

What You Can Do: Dietary and Lifestyle Interventions for HS

Dietary Interventions

• Nutrient-dense, lower fat and sugar diet: A healthy diet is the most durable way to help shift your gut microbiome towards health—you are providing the right fertilizer for the good microbes! Avoiding high-fat, high-sugar, and processed foods in favor of a wide variety of vegetables and healthy fruits is a good start in most patients.
• Yeast-Free Diet: Studies have shown that avoiding brewer’s yeast can lead to remission of HS lesions. In one study, 70% of patients who followed a yeast-exclusion diet for six years saw improvement without any other treatment. Given that elevated levels of anti-Saccharomyces cerevisiae antibody (ASCA) have been identified in HS patients, particularly those with severe disease, a yeast-free diet could be a low-risk intervention to consider.
• Weight Loss: Obesity is a known risk factor for HS. A weight loss of at least 15% has been associated with reduced disease severity. This could be particularly beneficial given the link between HS and diets high in fat.

Lifestyle Changes

• Regular Gentle Exercise: Physical activity can help manage weight and may have anti-inflammatory effects, which could be beneficial for HS.
• Smoking Cessation: Given that smoking has been associated with worsening HS symptoms, quitting smoking can be a significant step towards managing the condition.

Conclusion

HS is a multifaceted condition with a complex interplay between the skin and gut microbiome. As research progresses, we hope to gain a clearer understanding of how the microbiome influences HS and how we can use this knowledge for better treatment options.  Lifestyle changes, particularly in diet and smoking habits, can have a beneficial impact on disease severity. It is crucial to consult with your dermatologist or healthcare provider before making any significant changes to your diet or lifestyle. These interventions are not a substitute for medical treatment but could serve as complementary approaches to managing HS.

Sources:

De Pessemier B, Grine L, Debaere M, Maes A, Paetzold B, Callewaert C. Gut-Skin Axis: Current Knowledge of the Interrelationship between Microbial Dysbiosis and Skin Conditions. Microorganisms. 2021 Feb 11;9(2):353. doi: 10.3390/microorganisms9020353. PMID: 33670115; PMCID: PMC7916842.

Wark KJL, Cains GD. The Microbiome in Hidradenitis Suppurativa: A Review. Dermatol Ther (Heidelb). 2021 Feb;11(1):39-52. doi: 10.1007/s13555-020-00465-w. Epub 2020 Nov 26. PMID: 33244661; PMCID: PMC7859000.

Christopher M. Edens, MD, FAAD, is a board-certified dermatologist. As a fellow of the American Academy of Dermatology, he has been diagnosing and treating a wide variety of skin conditions since 2013. Dr. Edens has a strong interest in the use of dermoscopy for the early detection of skin cancer, complex medical dermatology, and in the use of functional and lifestyle medicine interventions to address the broader aspects of health. He is committed to helping patients look and feel their very best!