Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by inflammatory nodules, abscesses, recurrent furuncles, and fistulas in the axillae, groin, perianal, or inframammary regions. It significantly affects quality of life and can cause depression and anxiety.1 Treatment is complex and often unsatisfactory. Treatments used include antibiotics, topical or systemic corticosteroids, classical immunosuppressants, tumor necrosis factor α (TNFα) inhibitors (e.g. adalimumab), antiandrogens, antidiabetics such as metformin, and surgical procedures. Nonpharmacological interventions such as dietary supplements can be indicated, although evidence supporting their utility is scarce (Table 1).2
Nonpharmacological Treatments for Hidradenitis Suppurativa.
| Agent | Authors | Intervention | Indication | n | Evidence | Results |
|---|---|---|---|---|---|---|
| Dietary supplements | ||||||
| Zinc | Brocard et al., 2007 | Zn gluconate (90mg/d PO) | Mild-to-moderate HS (Hurley stage I–II) | 22 | Pilot study | Complete and partial response observed in 8 (36%) and 13 (59.1%) out of 22 patients |
| Hessam et al., 2016 | Zn gluconate (90mg/d PO) and topical 2% triclosan 2 times/d | HS without active treatment or treatment in the preceding 4 wk | 54 | Uncontrolled retrospective study | Significant decrease in HS severity in 43 of 54 (79.6%) patientsImprovement in quality of life in 40 of 54 (74%) patientsGastrointestinal adverse effects in 12 patients (22%)Treatment discontinuation in 5 patients, dose reduction in 4 patients | |
| Molinelli et al., 2020 | Zn gluconate (90 mg/d)+nicotinamide (30mg/d) PO for 90 d | Mild-to-moderate HS (Hurley stage I–II) previously treated for 12 wk with minocycline (100mg/d, PO) | 92 | Controlled retrospective study | Significant decrease in flare number and duration, improved quality of life, and increased disease-free survival in 47 treated patients versus untreated control group | |
| Vitamin B12 | Mortimore and Florin, 2010 | Intramuscular vitamin B12, 1000μg/14 d for 6 wk, and monthly thereafter | Inflammatory bowel disease associated with HS or similar skin lesions (perianal fistulae, inflammatory nodules) | 12 | Case series | Complete or partial response in 8 of 12 patients |
| Vitamin D | Guillet et al., 2015 | Vitamin D in drinkable ampoules (100,000 IU) according to levels of 25-OH-vitamin D3 | HS of any stage with vitamin D deficiency | 44 | Pilot study | Vitamin D supplementation decreased the number of nodules by 75% in patients with vitamin D deficiency |
| Dietary interventions | ||||||
| Mediterranean diet | Barrea et al., 2019 | Adherence to Mediterranean diet evaluated using PREDIMED scale | HS of any stage | 82 | Cross-sectional case–control study | HS severity was inversely proportional to the level of patient adherence to the Mediterranean diet |
| Yeast-free diet | Cannistrà et al., 2013 | Surgery and yeast-free diet | HS of any stage | 12 | Prospective pilot study | All patients showed stabilization and reduction in skin lesions at 12 moLesion recurrence in all patients who resumed consumption of yeast or wheat |
| Colboc et al., 2016 | Yeast-free diet for 3 mo | HS of any stage with medical treatment | 20 | Uncontrolled prospective study | Pain, inflammation, suppuration, and flare duration improved in 50% of patients with good adherence to dietPatients with poor adherence reported less improvement in HS | |
| Lifestyle modificationsa | ||||||
| Overweight and obesity | Kromann et al., 2014 | Weight loss | HS of any stage with bariatric surgery | 249 | Uncontrolled retrospective study | After bariatric surgery with significant weight loss, complete and partial remission was observed in 17 (48.6%) and 7 (20%) patients, respectively, out of 35 patients with HS |
| Thomas et al., 2014 | Weight loss | HS and morbid obesity | 1 | Patient | An isolated case in which, after bariatric surgery with significant weight loss, the symptoms of HS, which had been refractory to various treatments, resolved | |
| Laser hair removal | ||||||
| Nd:YAG laser | Tierney et al., 2009 | 4 monthly Nd:YAG laser sessions | Moderate-to-severe HS | 22 | Prospective randomized controlled study | After 3 mo of treatment, reductions in HS severity were observed: 65.3% in all anatomical areas, 73.4% in the inguinal area, 62% in the axillary region, and 53.1% in the inframammary area |
| Mahmoud et al., 2010 | 4 monthly Nd:YAG laser sessions | Moderate HS with bilateral and symmetrical lesions | 22 | Prospective randomized controlled intra-patient (right-left) study | 72.7% improvement on the treated side versus 22.9% on the control side | |
| Xu et al., 2011 | 2 monthly Nd:YAG laser sessions | Moderate HS | 20 | Prospective randomized controlled intra-patient (right-left) study | An average improvement of 31.6% was observed in all anatomical regions compared to the control side | |
| IPL | Highton et al., 2011 | 2 sessions per wk for 4 wk | Moderate-to-severe HS with bilateral symmetric involvement | 18 | Prospective randomized controlled intra-patient (right-left) study | Significant improvement in HS lesion severity on the treated side at 3, 6, and 12 mo |
| Piccolo et al., 2014 | 4 IPL sessions at intervals of 15–20 d | Mild-to-moderate HS | 2 | Case series | Patients with HS showed a complete response after finishing treatment | |
| Alexandrite laser | Koch et al., 2013 | 6 laser sessions separated by 6–8 wk | Moderate HS | 1 | Retrospective study, review of medical records | The HS patient showed complete resolution of the lesions in the groin area, without requiring systemic antibiotic treatment |
| Diode laser | Sehgal et al., 2011 | 6 laser sessions separated by 3–4 mo | Bilateral moderate HS affecting the axillae | 1 | Patient | After 6 sessions, the patient showed an objective improvement in HS lesions |
Other recommendations include quitting tobacco, avoiding shaving, and improving skin hygiene and care.
Abbreviations: HS, hidradenitis suppurativa; IPL, intense pulsed light; Nd:YAG: neodymium-doped yttrium aluminum garnet; PREDIMED, prevention with Mediterranean diet; Zn, zinc.
Source: Hendricks et al.2
A recent retrospective study, which included 92 patients with mild-to-moderate HS successfully treated with oral tetracyclines, evaluated the utility of oral zinc gluconate (ZnG) (90mg/d) and nicotinamide (30mg/d) as maintenance treatment for 90 days in 47 patients versus 45 untreated control patients. Significant decreases were observed in the treated versus the control group at weeks 12 and 24 in the following parameters: lesion severity, according to the International Hidradenitis Suppurativa Severity Score System (4.0 and 4.7 versus 6.2 and 7.8, respectively); quality of life according to the Dermatology Life Quality Index (2.9 and 3.5 versus 7.5 and 10.6, respectively); pain (mean visual analog scale score of 2.0 and 2.4 versus 7.5 and 10.6, respectively); and mean duration of flares (3.8 and 4.9 d versus 5 .6 and 8.9 d, respectively). Mean disease-free survival was also significantly longer in the treated group (20.4 d versus 5.4 d in the control group). All these differences were statistically significant (P<0.005). Reported adverse effects consisted of nausea in 2 patients, neither of whom discontinued treatment.3
Two previous studies also support the utility of ZnG in HS. The first pilot study4 included 22 patients with HS refractory to conventional treatment, treated with 90mg/d ZnG. All individuals showed an improvement, either partial (63.6%) or complete (36%). Adverse effects were observed in only 3 patients. Another study5 evaluated the efficacy of ZnG and topical 2% triclosan in 66 patients with mild-to-moderate HS, and reported a significant improvement at 3 months in disease severity, the number of inflammatory nodules and flares, and in quality of life. Gastrointestinal adverse effects were observed in 22 individuals, of whom 5 discontinued treatment. The beneficial effects of ZnG in HS and in other dermatoses may be explained by its anti-inflammatory activity: it inhibits neutrophil chemotaxis, activates natural killer cells and phagocytes, regulates the expression of integrins in keratinocytes, and modulates the production of proinflammatory cytokines, such as TNFα and interleukin 6.4 Nicotinamide also has anti-inflammatory and antioxidant properties and decreases the accumulation of free radicals.
Management of HS is complex and nonpharmacological interventions can be particularly useful. The combination of ZnG and nicotinamide is a low-cost and well-tolerated alternative, and may be useful as a maintenance treatment or as an adjunct to conventional therapy.
Conflicts of InterestThe authors declare no conflicts of interest.
