Physician shares alternative medicine practices for hidradenitis suppurativa
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Key takeaways:
- Nutrition and other lifestyle changes can play an important role in the management of hidradenitis suppurativa.
- These recommendations are to be considered in conjunction with standard of care treatment.
SAN DIEGO — The implementation of dietary modifications, supplementation and other lifestyle changes can significantly improve hidradenitis suppurativa, according to a speaker here.
“Due to the lack of a silver bullet medication for HS, it is important to create treatment regimens with synergistic use of pharmacologic and nonpharmacologic medicine to optimize improvement outcomes,” Vivian Shi, MD, FAAD, associate professor of dermatology at University of Arkansas for Medical Sciences, told Healio. “Complementary and alternative medicine for HS helps provide patients with various management options that act as adjunctive treatment.”
In her presentation at the American Academy of Dermatology Annual Meeting, Shi outlined evidence-supported strategies that physicians should implement with their patients for the management of their HS.
Nutrition
One of the most important lifestyle changes that patients can make to improve their HS includes dietary modifications, Shi explained. According to a study published in 2020 in Dermatologic Therapy, the most common foods that worsen HS are sweet foods, bread/pasta/rice, dairy and high-fat foods. On the other hand, the most reported alleviating foods for HS were vegetables, fruits, chicken and fish — all of which are staples in a Mediterranean diet.
As a result, a 2018 study published in Nutrients evaluated the effects of a Mediterranean diet on HS among 41 patients. Results showed that patients who loosely adhered to the Mediterranean diet experienced higher HS severity than those who strictly adhered to the diet.
“Something to consider about this is that it’s expensive, so what I learned is to do food swamps,” Shi said during her presentation. “Instead of cutting out sugar altogether, change it to a healthier, more accessible and affordable option for your patients.”
Intermittent fasting has also demonstrated an ability to improve HS. In a 2019 study published in Nutrients, 60 patients with HS underwent Ramadan fasting — a Muslim practice where participants fast from sunrise to sunset for 1 month out of the year. Results showed that 1 month after the end of Ramadan, patients experienced a significant decrease in their Hidradenitis Suppurativa Severity score (IHS4) across all phenotypes (0.85 ± 0.83; P < .0001).
“We don’t know if fasting works because of the time of day or because of the overall lower caloric intake,” Shi explained. “But these patients also had less need for HS medications including topicals, systemic antibiotics and even biologics.”
Brewer’s yeast, a single-cell fungus found in “all of the yummy foods,” Shi said, such as beer, wine and baked goods, may also exacerbate HS. According to a study published in 2020 in Surgery, 70% of 148 HS patients that followed a yeast-elimination diet for 6 years saw an improvement in their HS symptoms, 81% of which saw this improvement within 6 months.
Further, 87% had immediate recurrence of skin lesions less than 1 week after consuming yeast-containing foods.
“This was especially true for patients that had comorbid inflammatory bowel disease with their HS,” Shi added.
Overall, Shi recommends that patients with HS should partake in Mediterranean diets, consuming vegetables, fruits, corn-based cereals, white meat and fish. Additionally, these patients should avoid the standard American diet — red meat, high-fat foods, high-calorie foods, processed foods — insulinotropic foods, leucine-rich foods and Brewer’s yeast or wheat-containing foods.
Supplementation
“Zinc is one of my favorites,” Shi said. “The rationale for zinc in HS is that it decreases the neutrophilic burden as well as the level of a lot of cytokines that have shown to play a role in HS.”
Shi stated that in a 2020 study published in the Journal of the American Academy of Dermatology, 80% of HS patients treated with Zinc had a significant decrease in HS severity. After 24 weeks of treatment, the mean IHS4 score among the treatment group was 4.7 ± 2.1, whereas the control group’s was 7.8 ± 2.2 (P = .003).
Shi recommended that physicians give their patients 100 mg to 150 mg of zinc daily and to not exceed 200 mg as this can cause gastrointestinal side effects.
“When you supplement with zinc long-term at high doses like this you also need to give your patients copper,” Shi said, suggesting that physicians give their patients one dose of copper for every eight to 10 doses of zinc.
According to Shi, nearly all HS patients are also deficient in vitamin D with some patients having a vitamin D level less than 30 ng/mL.
“I used to not check for vitamin D but now I do,” she said, stressing that this is an important supplement for HS patients.
Vitamin D helps these patients because it modulates their immune function and regulates their hair cycle and skin cell density. Patients with vitamin D levels between 20 ng/mL and 30 ng/mL should receive a replacement dose of 600 IU to 800 IU daily. Patients with levels between 12 ng/mL and less than 20 ng/mL should receive 800 IU to 1000 IU daily and those with levels less than 12 ng/mL need 25,000 IU to 50,000 IU once a week for 6 to 8 weeks followed by 800 IU daily.
Lifestyle changes
In addition to dietary modifications and supplementation, smoking cessation is one of the necessary lifestyle changes patients with HS should make if they want to see improvement.
“We talk about smoking a lot, it’s almost like a broken record,” Shi said during her presentation. “But it wasn’t until recently that we really understood why smoking tobacco is bad for HS.”
Shi discussed a study published in 2016 in Dermatologic Clinics that showed that one of the byproducts of burning tobacco is dioxin-like compounds. Dioxin-like compounds are directly linked to the induction of epidermal hyperplasia, which creates an environment where lesions such as acne or HS can thrive. Burning tobacco while smoking not only increases epidermal hyperplasia but also activates a heavy immune response characterized by an increase of neutrophil, all of which can exacerbate HS.
“I find it’s helpful to not just tell patients to stop smoking, but to explain to them why,” Shi said.
Physicians can also recommend other lifestyle modifications, including low-friction weight loss programs such as Pilates or swimming, bamboo or cotton undergarments, laser hair reduction vs. shaving, silicone-based anti-chafing products and hypoallergenic deodorants.
Conclusion
Shi emphasized that while none of these strategies should replace standard of care treatments, they can certainly act as supporting players in the management of HS. However, patients are not usually eager to modify their lifestyle habits. Therefore, it is up to physicians to support their patients in the adoption of these holistic practices.
“Engaging in the recommendation of complementary and alternative medicine for HS is important for the encouragement of lifestyle changes,” Shi told Healio.
References:
- Damiani G, et al. Nutrients. 2019; doi:10.3390/nu11081781.
- Molinelli E, et al. J Am Acad Dermatol. 2020; doi:10.1016/j/jaad.2020.04.092.
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Shi V, et al. Complementary and alternative medicine for HS. Presented at: American Academy of Dermatology Annual Meeting; March 8-13, 2024; San Diego.
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