Living with hidradenitis suppurativa can be painful and impact physical and mental health. Hidradenitis suppurativa is a chronic autoinflammatory condition that causes painful and deep lesions to form under the skin. This occurs due to an attack on hair follicles that results in inflammation and recurring abscesses.

This condition usually begins after puberty, generally before age 40. Overall, around 1% to 4% of people are impacted. Hidradenitis suppurativa is three times more common in women and most common in Black individuals due to genetic factors.

An integrative approach can complement traditional medical and surgical treatment of hidradenitis suppurativa by uncovering underlying root causes and addressing them with diet, supplements, and lifestyle changes to bring the body back into balance.

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What is Hidradenitis Suppurativa?

Hidradenitis suppurativa is a chronic autoinflammatory skin condition that is also known as acne inversa since it causes small, painful abscesses to form under the skin. These lesions can drain pus with a strong odor, take a long time to heal, and often come back, which can be physically and psychologically taxing. Over time, this can create tunnels under the skin and scarring. 

These skin lesions form due to inflammation and not an infection, so hidradenitis suppurativa is not contagious.

Hidradenitis Suppurativa Signs & Symptoms

Hidradenitis suppurativa is characterized by skin lesions that form under the skin in one or several areas of the body, most frequently in areas where the skin rubs together (armpits, groin, buttocks, and breasts) and/or sweats. These lesions can be painful and drain pus with a strong odor. 

Skin findings that are typical of hidradenitis suppurativa include:

• Painful deep-seated abscesses that form under the skin 
• Abscesses ranging in size from 0.5 to 2 centimeters on average
• Lesions often persist for weeks or months
• Pockets of pus in these lesions that may drain and have a strong odor
• Tunnels that form connecting the lumps under the skin which often drain pus and blood and leave scarring

Hidradenitis Suppurativa Possible Causes 

Hidradenitis suppurativa is autoinflammatory in nature with genetic, environmental, and behavioral influences. It occurs when the immune system attacks hair follicles under the skin, resulting in inflammation and the formation of abscesses. 

When the immune system targets the hair follicle, inflammation develops that can block the follicle, causing it to rupture and spill its contents, including keratin and bacteria, into the surrounding skin tissue. This further attracts cells of the immune system, which release inflammatory cytokines that lead to abscess formation and destruction of the tissue. 

Abnormalities in immune responses, antimicrobial peptides, glandular secretions, and numbers of sebaceous glands have also been observed. Studies suggest that some of these immune abnormalities may be related to imbalances in the microbes that inhabit the skin and/or gut. People with hidradenitis suppurativa have an altered balance of the types of bacteria that normally inhabit the skin, even when skin lesions are not present. For example, they show greater numbers of anaerobic gram-negative bacteria in the skin. 

In addition, people with hidradenitis suppurativa have changes in their gut microbiomes which seem to contribute to systemic inflammation that leads to skin lesions via the gut–skin axis. It is believed that imbalances in gut bacteria or dysbiosis, potentially influenced by a high-fat diet, elevate inflammatory cytokines, which increase substances that cause damage and inflammation in the skin (matrix metalloproteinases), creating skin lesions in susceptible individuals.

This condition is more common in women and is most likely to develop at times when sex hormones like estrogen and androgens are fluctuating, such as after puberty and before menopause. In people with a uterus, flare-ups of hidradenitis suppurativa often occur before the onset of a period. 

Genetics influence the risk of developing hidradenitis suppurativa. Around 40% of impacted people have a first-degree relative who also experiences the condition. It is thought that this condition is inherited in an autosomal dominant manner.

Hidradenitis suppurativa is also more common in those with excessive hair growth (hirsutism), obesity, and/or issues with insulin and blood sugar balance like diabetes and metabolic syndrome. Being overweight can increase the amount of contact, sweat retention, and friction in areas of skin that rub together, like the armpits and groin. Issues with insulin resistance and blood sugar imbalances, as well as certain hormonal changes like a relative androgen excess, may co-occur with obesity or on their own and increase the risk of developing hidradenitis suppurativa.

This skin condition is also associated with severe acne, arthritis, and inflammatory bowel disease. In addition, smoking increases the risk of these skin lesions developing and can contribute to more severe lesions. This may be due to the impact of nicotine on increased clogging of the hair follicles. 

Functional Medicine Labs to Test for Root Cause of Hidradenitis Suppurativa

Functional medicine laboratory testing can help to uncover root causes that contribute to the development of hidradenitis suppurativa. Testing can assess blood sugar balance and insulin function, markers of gut health and the microbiome, food allergies and sensitivities, hormone levels, and vitamin D status to uncover areas that can be targeted to help bring the body back into balance.

Blood Sugar and Insulin Balance

Since insulin resistance is a root cause of obesity, blood sugar imbalances like metabolic syndrome, and hidradenitis suppurativa, it is important to assess these metabolic markers with testing. Several tests can help to evaluate how well insulin is functioning and the resulting balance of sugar in the blood. Fasting glucose looks at the levels of sugars in the blood when you have not recently eaten, while hemoglobin A1c measures the average blood sugar level over the previous six weeks. Insulin can be evaluated by measuring fasting insulin and C-peptide, a marker that the body is producing insulin.

When these tests are evaluated together, insulin resistance can be identified and addressed with dietary and lifestyle changes. One way to receive an overall assessment of blood sugar metabolism is with the Metabolomic Profile, which looks at many of these metabolic markers of glucose balance and insulin function as well as several markers of adiposity (fat tissue), like leptin and adiponectin. 

Gut Health

Since the gut microbiome has such a significant impact on systemic and skin inflammation and plays a role in the development of hidradenitis suppurativa, a comprehensive stool test like the GI Effects can help to evaluate the overall health and balance of the digestive tract. This test provides an assessment of the variety of microbes in the gut and intestinal health markers to help guide an individualized approach to regaining balance. 

Food Allergies and Sensitivities 

Food sensitivities contribute to inflammation throughout the body and impact the development of hidradenitis suppurativa skin lesions. Testing can help to uncover foods to which one is sensitive or allergic that can be avoided to help reduce inflammation. For example, the Mosaic Diagnostics' IgG Food MAP with Candida + Yeast evaluates sensitivity to 190 foods that are commonly consumed in the Western, Asian, and Mediterranean diets as well as evaluating candida and yeast. Additional testing for gluten sensitivity or celiac disease with Genova Diagnostics Celiac and Gluten Sensitivity and evaluation of the leaky gut marker zonulin can also help to uncover additional factors that may be adding to skin inflammation.

Androgens/Hormones

The DUTCH Complete is a dried urine test that can easily be completed at home to evaluate hormone levels and how these hormones are metabolized or broken down. This test can help evaluate metabolites of estrogens, progesterone, testosterone, and cortisol to assess how hormonal imbalances may contribute to hidradenitis suppurativa.

Vitamin D Levels

Since many people with hidradenitis suppurativa are deficient in vitamin D, measuring blood levels of this vitamin can help to guide repletion during treatment.  

Additional Lab Tests 

If pus or drainage occurs, a swab sample can be obtained and sent to the laboratory for testing to rule out infection. Bacteria do not cause hidradenitis suppurativa, so a culture from unruptured lesions is typically sterile, although bacterial infection can secondarily worsen the condition.

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Conventional Treatment for Hidradenitis Suppurativa

Conventional treatment of hidradenitis suppurativa generally involves a combination of medical and surgical approaches. 

Daily skin care can help to reduce lesions from appearing. An antiseptic wash such as chlorhexidine 4% or benzoyl peroxide wash may be used. In addition, topical retinoids (vitamin A derivatives) are used to reduce inflamed lesions.

Although hidradenitis suppurativa is not an infection, antibiotics may be applied topically to the skin in areas of lesions for mild symptoms or be taken orally (doxycycline, clindamycin, rifampin) if lesions occur in more areas of the body for their ability to reduce inflammation. For intensely swollen and inflamed sores, steroid injections of triamcinolone acetonide or Kenalog-10 may be used.

Since hormone fluctuations can cause flares of hidradenitis suppurativa, oral contraceptives or the diabetes medication metformin are sometimes used. In other cases, spironolactone may be used to reduce the need for antibiotics, but this medication is not used in men due to side effects like breast growth. 

To address the imbalances in the immune system that contribute to hidradenitis suppurativa, biologic medications are sometimes used. These medications, such as the tumor necrosis factor inhibitors adalimumab and infliximab, are approved to treat moderate to severe hidradenitis suppurativa.

When tunnels or abscesses occur that do not heal, surgical intervention is often needed. This can involve exposing the affected area to allow it to drain, debridement to remove lesions or impacted tissue, or complete surgical removal with skin grafting. 

Functional Medicine Treatment for Hidradenitis Suppurativa

An integrated approach aims to address the underlying immune imbalances contributing to inflammation, minimize pain and drainage, decrease the frequency of recurrence, and prevent disease progression. 

Nutrition Considerations for Hidradenitis Suppurativa

Since nutrition has a significant impact on the microbiome and immune health, dietary approaches can help balance the dysregulation of the immune system that occurs in inflammatory skin conditions like hidradenitis suppurativa. 

A personalized anti-inflammatory diet that removes any allergens or foods to which an individual is sensitive can help reduce inflammation contributing to skin lesions. In particular, a Mediterranean diet emphasizing whole fresh vegetables and fruits, legumes, nuts, and olive oil and limiting processed foods and additives, caffeine, and alcohol has been shown to improve body composition and decrease the severity of hidradenitis suppurativa symptoms. This way of eating can also help to improve insulin resistance and balance blood sugars, factors that often contribute to hidradenitis suppurativa.

Dairy, red meat, and foods with a high glycemic index are associated with worsening hidradenitis suppurativa symptoms. Research shows that diets high in dairy and higher glycemic index foods like white bread, rice cakes, most crackers, bagels, cakes, doughnuts, croissants, and processed breakfast cereals can contribute to the plugging up of sebaceous glands that can lead to the rupture of follicles as occurs in hidradenitis suppurativa. Studies suggest that people with hidradenitis suppurativa reported improvement in their symptoms when removing foods such as gluten, dairy, refined sugars, tomatoes, and alcohol from their diet. 

Research also suggests that yeast and wheat intolerance plays a role in hidradenitis suppurativa. For example, a small study showed that patients with hidradenitis suppurativa had serology-proven reactions to brewer’s yeast and wheat (anti-Saccharomyces cerevisiae antibodies), and their skin lesions resolved when following a brewer’s yeast-free diet for 12 months. 

Supplements & Herbs for Hidradenitis Suppurativa

In addition to addressing nutrient status with diet, supplementation can help rebalance the immune system and inflammation levels in people with hidradenitis suppurativa. Zinc, turmeric, and vitamin D have all been studied for their role in improving skin symptoms in this condition.

Zinc

Zinc plays an integral role in immunity within the skin and has been shown to have anti-inflammatory effects. Supplementation with 90mg/day of oral zinc gluconate significantly decreased hidradenitis suppurativa disease severity, redness, and the number of inflammatory nodules. Another study showed similar improvements when combining zinc supplementation with nicotinamide. Patients given 90 mg zinc gluconate and 30 mg nicotinamide orally once daily for 90 days had significant improvement in symptoms of hidradenitis suppurativa compared to controls. When long-term zinc supplementation is used, it is important to monitor levels of zinc and copper as well as look for anemia. 

Turmeric 

Turmeric is a medicinal herb from which curcumin is derived. Curcumin has been shown to modulate immune cells, which are involved in the inflammatory process that causes hidradenitis suppurativa skin lesions. Both topical preparations and oral supplementation with turmeric can improve skin inflammation as well as benefit comorbidities of hidradenitis suppurativa, such as metabolic syndrome, diabetes, and obesity.

Vitamin D

Vitamin D plays an important role in immune health and the regulation of skin and related structures like hair follicles. Research has shown that people with hidradenitis suppurativa may have changes in vitamin D metabolism and low levels of serum vitamin D. Additional studies suggest that supplementation with vitamin D can improve symptoms of hidradenitis suppurativa, especially in those with proven deficiency.

Complementary and Integrative Medicine for Hidradenitis Suppurativa

An integrative approach uses lifestyle approaches like avoiding smoking and maintaining a healthy weight as well as traditional healing methods like traditional Chinese medicine and Ayurveda to heal the body and skin. 

Lifestyle approaches

Lifestyle changes such as quitting smoking and maintaining a balanced weight can help reduce the recurrence of hidradenitis suppurativa.  

Traditional Chinese Medicine (TCM)

TCM is an ancient tradition of healing that incorporates modalities, including acupuncture, manual therapy, and Chinese herbal medicine. From this philosophy, individuals with hidradenitis suppurativa cannot detoxify and have abnormal tissue regeneration. TCM seems to improve symptoms of hidradenitis suppurativa, especially perianal lesions.

Ayurveda

Ayurveda is another ancient healing practice for mind, body, and spirit heavily rooted in science. From this approach, hidradenitis suppurativa is related to Nadivrana, which encompasses pus drainage and tract formation that occurs in this condition. Ksharasutra is used to address this type of imbalance by using excision, incision, scraping, purification, and epithelialization of healthy granulation tissue utilizing Ayurvedic medicine. Case reports have shown that this approach is successful at managing hidradenitis suppurativa lesions. 

Some Ayurvedic approaches also incorporate Guggulu, an herbal substance derived from the Commiphora wightii plant that has anti-inflammatory and pain-relieving properties. 

In addition, heeler leech therapy has been used in Ayurveda to successfully address hidradenitis suppurativa skin lesions. This approach uses the local application of Hirudo medicinalis leeches to extract impure blood, pus, and toxins.

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Summary

Hidradenitis suppurativa, or acne inversus, is a chronic autoinflammatory condition that causes deep-seated nodules and abscesses in the skin that can progress to draining tracts and fibrotic scars. Lesions occur most frequently in areas of skin that rub together and/or sweat, like the armpits, groin, and breast area, and can be triggered by changes in hormones or smoking. The disease arises due to genetic susceptibility and immune dysregulation that contribute to increased inflammation around the hair follicles in the skin.

A conventional approach to treating hidradenitis suppurativa utilizes a combination of treatments ranging from topical/intralesional steroids, retinoids, and/or antibiotics, systemic antibiotics, medications to prevent hormonal fluctuations, systemic immunomodulators, and biologics. An integrated approach incorporates lifestyle, nutrition, and supplementation to help reduce the side effects of treatment and improve quality of life. 

An anti-inflammatory Mediterranean diet that removes wheat, dairy, and foods with a high-glycemic index can help to manage hidradenitis suppurativa and its comorbidities like obesity and metabolic syndrome. Quitting smoking and balancing weight can reduce inflammation and prevent flares of disease. Supplementation with vitamin D, turmeric, and zinc can improve inflammation and skin lesions.