Effects of Exercise and Dietary Modifications on Hidradenitis Suppurativa

A Systematic Review

Isaac Weber; Josie Giefer; Kari L. Martin

Am J Clin Dermatol. 2023;24(3):343-357.

Abstract and Introduction

Abstract

Background: Hidradenitis suppurativa affects up to 4% of the population worldwide. Many treatment options exist but these come with a significant side-effect profile. Exercise, weight loss, and dietary modifications may be simple inexpensive alternatives and/or adjuncts to treating this disease.

Objectives: We aimed to summarize published evidence on the effects of dietary, weight loss, and exercise interventions on the clinical course, severity, or subjective improvement of hidradenitis suppurativa and to provide a framework regarding dietary changes and exercise modalities for clinicians treating this disease.

Methods: A literature search of Scopus (1993 onwards), PubMed (1986 onwards), and MEDLINE (OVID interface, 1946 onwards) was conducted on 22 October, 2022. Case–control studies, cohort studies, and randomized controlled trials with five or more subjects conducted on adult participants (aged >18 years) were included; case reports, case series, and review papers were excluded.

Results: Fifteen studies involving 2829 patients were included, encompassing nine cohort studies, five cross-sectional studies, and one cross-over study. Patients who were female, lost more than 50 pounds (22.7 kg), or were obese prior to weight loss saw improvement in hidradenitis suppurativa severity with weight loss. There was evidence for beneficial effects of diets, such as the Mediterranean diet that minimizes sugar, highly processed carbohydrates, and dairy, and emphasizes chicken, fruits, and vegetables, in patients with hidradenitis suppurativa. Evidence also supported benefit from oral zinc and vitamin D supplementation.

Conclusions: More evidence is needed in the form of randomized controlled trials or well-designed controlled trials to evaluate the effect of exercise and dietary manipulation on the hidradenitis suppurativa disease course. Overall, there is significant but weak evidence to support improvement in hidradenitis suppurativa severity with weight loss, dietary changes, and micronutrient supplementation. There is no significant evidence to support improvement in hidradenitis suppurativa symptomology with any type of exercise intervention.

Clinical Trial Registration: This protocol was registered with PROSPERO with the registration number CRD4202235099.

Introduction

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition also known as acne inverse.^[1] This disease can be associated with discomfort and disfigurement leading to social isolation, and a notable reduction in quality of life. It most commonly affects intertriginous regions of skin including the groin, perineal, inframammary, and axillary areas. The complete pathophysiology of HS is still unclear; however, lesion formation is thought to involve follicular hyperkeratosis within the folliculopilosebaceous units.^[2] Hormonal changes stemming from diet, obesity, and androgen excess have been postulated to contribute to the follicular plugging and subsequent rupture and immune response associated with the genesis of HS.^[3] In addition, sweat retention, friction, and larger intertriginous skin folds likely contribute to the exacerbation of this condition.^[3]

Multiple treatment modalities exist for managing this disease and include anti-androgens, topical and systemic antibiotics, biologics, immunosuppressive drugs, biguanides, fumarates, retinoids, surgical excision, and phototherapy.^[4] For patients who struggle with HS, dietary, exercise, and weight loss interventions may be promising tools that can be made available to reduce the severity of this debilitating disease. We aim to answer the question of: how do the effects of dietary, weight loss, and/or exercise interventions affect the clinical course, severity, and/or subjective improvement of HS in adults over 18 years old? The goal of this review is to incorporate studies looking at diet, exercise, and weight loss interventions utilized for HS into a concise framework that can be used by clinicians to make evidence-based recommendations for patients struggling with this disease.

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Abstract and Introduction
Methods
Results
Discussion
Conclusions
References
Sidebar

Table 1. Summary of included studies
Author/year	Study design	Subjects	Sample	Limitations	Intervention	Findings	Evidence level [31]
Weight loss interventions
Kjarsgaard Andersen et al./2021 [10]	Prospective cohort	Danish blood donors with self-reported HS	430	Self-reported HS likely includes a higher rate of false positives than those diagnosed by a physician Unknown and uncontrolled active treatment status	Validated HS screening questionnaire administered at two time-points at least 6 months apart (no comparison) HS assessed by: previously validated HS screening-questionnaire including all clinical obligatory diagnostic criteria	Female weight loss: significantly associated with a higher likelihood of HS remission (HR = 1.07, 95% CI 1.05–1.11, p = 6.6 × 10⁻⁷) Male weight loss: no association (HR = 1.00, 95% CI 0.97–1.04, p = 0.86)	3
Macklis et al./2021 [9]	Cross-sectional survey	Patients with self-reported HS on social media groups	591	Recall bias Selection bias The statistical analysis demonstrates differences in symptom improvement across all attempted interventions but does not verify that improvements seen within any individual lifestyle intervention are statistically significant	Single survey containing a combination of discrete and Likert scale questions on participant demographics, oral health, modifiable lifestyle factors, and HS symptom severity (no comparison) HS assessed by: rating severity of HS before and after modifiable lifestyle changes using a combination of 5-point patient global assessment of disease (no disease, mild, moderate, severe, or very severe disease) and self-identification of Hurley stage using the previously validated HS Symptom Assessment tool	Paleo, keto, gluten-free, anti-inflammatory, detox, Mediterranean, and "Other" diet categories: average improvement >0.6 subjective points Paleo and anti-inflammatory diet categories: highest percentage of both 1 and 2+ point subjective improvements Reduction in sugar: >0.7 subjective point, >0.3 levels Hurley improvement Reduction in dairy: >0.5 subjective point, >0.2 levels Hurley improvement Improvement for all weight loss categories: 0.6 subjective points, 0.3 levels Hurley improvement Improvement for those who lost >50 lbs: >1 subjective point, 0.6 levels Hurley improvement	3
Garcovich et al./2018 [11]	Retrospective descriptive study	Hospital-based cohort of patients with validated HS and previous exposure to any type of BS intervention	12	Selection bias Recall bias Confounding factors Long latency period between the weight loss and the occurrence or change in HS activity	Clinical characteristics and BS-related outcomes were retrospectively analyzed by chart review (no comparison) HS assessed by: Hurley stage	10/12 patients developed validated HS (primarily Hurley stage II/III) post-BS with >20% improvement in total weight loss 2/12 patients had HS prior to BS with neither seeing Hurley stage improvement post-BS	3
Kromann et al./2014 [7]	Retrospective cohort	Patients with HS with obesity (BMI >30) undergoing BS (gastric bypass or banding)	35	Confounding variables Response bias Recall bias Inclusion of only obese (BMI >30) individuals with substantial weight loss	BS leading to weight loss of at least 15% (no comparison) HS assessed by: previously validated HS questionnaire modified to include a description of the pre-surgical state, using the same questions Graded the severity of their skin problems by use of an NRS	17/35 (48.6%) experienced no HS symptoms after weight loss 7/35 (20%) experienced fewer active eruption sites 7/35 (20%) experienced no changes in disease activity 4/35 (11%) experienced more active eruption sites The mean number of eruption sites was significantly reduced from 1.93 to 1.22 (p = 0.003, ES = 2.92) Skin problems rated by NRS in those with HS symptoms and substantial weight loss showed a tendency to improve with a mean decrease of −0.2 (p = 0.74, ES = 0.48) [not significant]	3
Exacerbating and alleviating foods/diets
Fernandez/2020 [13]	Cross-sectional questionnaire	Patients with self-reported HS in Facebook HS support groups and North American HS specialty clinics	770	Recall bias Self-reported diagnosis of HS and Hurley stage	Survey querying demographics, disease characteristics, and dietary patterns (no comparison) HS assessed by: non-validated subjective improvement reported by respondents	Exacerbating foods reported: sweets (67.9%); bread/pasta (51.1%); dairy (50.6%); high-fat foods (42.2%) Alleviating foods reported: vegetables (78.7%); fruit (56.2%); chicken (51.7%); fish (42.7%)	3
Dempsey/2019 [12]	Cross-sectional survey	Self-reported HS from multiple sources	242	Recall bias Under-representation of male individuals Confounding variables Under-representation of the non-White population	Survey querying food alterations in the prior 6 months HS assessed by: self-reported HS activity	65.2% of patients who made dietary changes perceived positive changes in their HS symptoms they attributed to diet Tomato intake alteration (elimination) was negatively associated with improvement (OR = 0.236; p = 0.01) Dairy alteration (elimination) was significantly associated with reported improvement (OR 2.18 [95% CI 1.01–4.68], p = 0.05) Legume alteration (elimination) was significantly associated with reported improvement (OR 3.79 [95% CI 1.30–11.06], p = 0.01)	3
Kurzen et al./2019 [14]	Retrospective cohort	Patients with validated HS who had at least two clinic visits	40	Confounding variables Lack of data involving if weight changes were associated with these dietary interventions	Dietary restrictions or influence of certain food compounds on HS severity were assessed in first clinic visit and on the second visit, proposed preventive strategies were inquired about and whether they had turned out to be helpful in the course of the disease (no comparison) HS assessed by: non-validated subjective improvement reported by respondents	9 respondents reported introduction of low-dairy/low-carbohydrate diet considerably improved HS subjective symptoms (2 were cases of gluten-sensitive enteropathy)	3
Damiani et al./2019 [19]	Observational cross-over study	Validated HS patients aged >18 years	55	Small sample size Lack of controls	Ramadan fasting every day, from dawn to sunset, for one month (cross-over comparison) HS assessed by: ADDI score, Hurley score, and IHS4 score	Overall effect of fasting on the IHS4 score was statistically significant (F = 41.61, p < 0.0001) 35/51 (68.6%) patients experienced a decrease in the number of abscesses at the end of the Ramadan with 14/55 (25.5%) maintaining this improvement 1 month later 9/24 (37.5%) experienced a decrease in the number of draining fistulas with 15/24 (20.8%) maintaining this improvement 1 month later The ectopic phenotype experienced the largest change in symptom severity before and after fasting (Delta IHS4 = −2.33 ± 0.58)	3
Lorite-Fuentes et al./2022 [15]	Cross-sectional study	Validated HS patients aged >18 years	221 (from two separate populations)	Differential selection bias due to inclusion of two different populations Cross-sectional design impeding causal inference	PREDIMED Questionnaire evaluating adherence to a Mediterranean diet and the International Physical Activity Questionnaire to determine activity level (no comparison) HS assessed by: Hurley Stage, IHS4, self-reported disease activity by NRS	Lower self-reported disease activity, lower self-reported Hurley score, and higher levels of physical activity were independently associated with higher adherence to the MD Higher adherence to the MD was related to lower IHS4 (B = −0.10, p < 0.001) Use of extra virgin olive oil as the main culinary liquid and poultry rather than red meat were dietary habits that implied a lower degree of disease severity (p < 0.05) Self-reported disease severity (p = 0.14) and IHS4 (p = 0.27) showed an inverse trend in association with intensity of exercise regardless of adherence to MD	3
Cannistrà et al./2013 [20]	Prospective single cohort	All patients with HS followed at center Patients had incision and debridement or surgical excision, followed by brewer's yeast-free diet	12	Lack of control All patients were found to have a specific immunology IgG reaction to ASCA (>10 U/mL)	Brewer's yeast-free diet for 12 months (no comparison) HS assessed by: clinical findings from follow-up appointments evaluating the number and severity of abscesses, fistulas, and lesions	All patients demonstrated immediate stabilization of clinical symptoms with regression of skin lesions over the 12-month treatment period All patients demonstrated an immediate recurrence of skin lesions following accidental or voluntary consumption of beer or other foods containing brewer's yeast or wheat	3
Aboud et al./2020 [22]	Retrospective cohort questionnaire	Thirty-seven patients were treated in a center for 6 years with a brewer's and baker's yeast definitive exclusion diet followed by operative intervention The 148 other patients were members of a large, French, nonprofit public association of patients affected with HS	185	Response bias Recall bias	Survey evaluating the long-term effectiveness of a yeast-exclusion diet protocol on the stabilization or regression of HS in comparison to other traditional treatments HS assessed by: non-validated online questionnaire reporting subjective improvement in HS symptomology	Of the 37 patients who had followed the yeast-exclusion diet: 26 patients (70%) reported an improvement of HS symptomatology without any other treatment, 21 of these 26 patients reported improvement occurred in less than 6 months 32 patients (87%) following the diet reported recurrence of HS symptoms after eating a restricted food	3
Barrea et al./2019 [16]	Cross-sectional Study	Forty-one treatment-naïve (no treatment for >3 months) patients with diagnosed HS for >6 months and 41 age-, sex-, and BMI-matched healthy Caucasian controls	82	Cross-sectional design does not allow the determination of a causal association between MD and HS	Adherence to the MD was assessed using a 14 question PREDIMED questionnaire that assigned a score 1 and 0 for each item 0–5: low adherence 6–9: average adherence ≥10: highest adherence (controlled) HS assessed by: Sartorius HS score, Hurley Stages, and HS Physician's Global Assessment	Higher values of HS Sartorius scores were evidenced in low adherers to MD, compared with average-higher MD adherers (p < 0.001) Low adherence to MD: 59.38 ± 13.02 Sartorius score Average adherence to MD: 51.37 ± 9.81 Sartorius score High adherence to MD: 39.00 ± 8.76 Sartorius score	3
Micronutrient/supplement interventions
Molinelli et al./2020 [24]	Cohort pilot study	Hurley stage I and II HS previously treated with oral tetracycline (minocycline 100 mg daily) for 12 weeks with clinical and ultra-sonographic benefit	92	Retrospective nature Absence of a randomized blinded control group	90 mg of zinc gluconate and 30 mg of nicotinamide once daily for 90 days (controlled) HS assessed by: mean Visual Analog Scale, Dermatology Life Quality, IHS4 evaluated at baseline, 90 days, and 180 days after treatment	Treated group reported a significant marked reduction in mean Visual Analog Scale, Dermatology Life Quality Index, and IHS4 scores compared with the control group both at 12 and 24 weeks (p < 0.005) Disease-free survival was significantly longer and showed sustained improvement after discontinuation of oral supplementation in the treated group	3
Brocard et al./2007 [23]	Cohort pilot study	Mainly grade I or II Hurley classification HS that had previously been prescribed a treatment (antibiotic, isotretinoin, surgery, or anti-androgens), which was inefficient	22	Inclusion of only low-stage HS and absence of a randomized blinded control group	90 mg of zinc gluconate per day until complete or partial remission was obtained and then zinc gluconate was decreased by 15 mg every 2 months (not controlled) HS assessed by: Hurley Staging	8/22 (36%) experienced a complete remission (reduction in treatment to 30–60 mg of zinc gluconate caused relapses to occur, recurrences disappeared when the dose of zinc salts was increased back to 90 mg) 14/22 (63.6%) patients experienced partial remission No patients experienced deterioration of their HS during the treatment Dropout: 1 patient because of nausea and vomiting	3
Fabbrocini et al./2020 [25]	Cohort pilot study	Patients with HS treated for 6 months with topical or systemic therapies without significant clinical improvements	40	Small size of the study Lack of follow-up	Oral supplementation with 25OHD for 6 months depending on status (sufficient = 0 IU of vitamin D/month; deficiency = 50.000 IU of vitamin D/month; insufficiency = 25.000 IU/month) The supplementation was stopped when the level of 25-OHD was 30 ng/mL (controlled) HS assessed by: Sartorius Score	27 patients had a significant improvement of clinical responsivity to prescribed therapies (reduction of Sartorius Score of >20 points) equal to the increase of vitamin D levels	3

ADDI Autoinflammatory Disease Damage Index, ASCA anti-Saccharomyces cerevisiae antibodies, BS bariatric surgery, BMI body mass index, CI confidence interval, ES effect size, HR hazard ratio, HS hidradenitis suppurativa, IHS4 International Hidradenitis Suppurativa Severity Score System, IU international units, MD Mediterranean diet, NRS Numerical Rating Scale, OR odds ratio, 25OHD 5-hydroxycholecalciferol