Hidradenitis suppurativa - Solutions
by: Sarah Penney, ND
Dermatological conditions can often produce some of the most disturbing symptoms for patients to experience. They can be painful, itchy or release fluids, cause issues with self esteem and be constantly present as a reminder of an underlying condition. From the cases I have seen in practice hidradenitis suppurativa (HS) is the perfect storm of all these concerns. This chronic condition presents as large boil type abscess, often found in clusters in areas that experience chafing like the groin, underarms, buttocks and under the breasts. Patients may think they have developed an infected ingrown hair while shaving, or they have an enlarged lymph node in the area. HS is often referred to as ‘acne inversa’, as the lesions found in these areas can rupture and release malodorous pus. Tunnels can also form between lesions leading to expansion of abscesses. They are generally tender to touch and can cause great discomfort with activity depending on severity of the condition. Lesion usually first start appearing after puberty and generally progress as time goes on, although symptoms can come and go and severity can vary between cases. Significant scarring can be left after abscesses drain. (1)
Diagnosis of HS requires the presence of deep painful nodules that can be draining, bridging scars or open lesions present in the underarm area, groin, perineal regions, buttocks and near any skin folds. It must also be chronic and reoccurring. HS occurs three times more often in women than men although men are more likely to have severe forms of this disease, the reason for which is not yet known. Anywhere from 1% to 4% of the population is though to be experiencing this condition. It can vary greatly in severity and is classified in three levels. The first stage is diagnosed when one or more isolated abscesses are present, with no formation of tracts between them or scarring in the area. The second stage develops when the abscesses become recurrent and there is a sinus tract that forms between them, and the third involves multiple connections between abscesses often consuming an entire region. Early lesions can often heal without treatment, or they can progress within hours or days to a large or ruptured lesion. Other classifications systems focus on how many regions are involved and how many abscesses are present in total, how close they are and how well defined they are. (2)
Knowledge is constantly evolving regarding the underlying cause of HS. It is not contagious, and it is not caused by poor hygiene. The basic physiology begins much like acne with the overgrowth of bacteria plugging a hair follicle, and some theories postulate that this underlying bacterial imbalance is the cause. More recent theories however discuss bacterial infections as a secondary occurrence, and blame overproduction of a substance called keratin for plugging pores and causing lesions much like in the formation of blackheads (3) Incidence is highest in obesity, so it is possible that friction in skin folds could lead to the development of this condition, although prevalence does not mirror that of obesity. Hormonal imbalances may also come into play in affected individuals– higher levels of androgens (testosterone, DHT) increase the release of oils in hair follicles and stimulate the growth of bacteria, the combination of which could aggravate otherwise mild infections in hair follicles. Another thought is that this infection triggers an autoimmune reaction in those with HS, causing a cascade of inflammation and aggravation in the area of the blocked follicles. Alternately, the immune function may be too low to fight bacterial infections, allowing the progression of lesions (4). More research is needed to clarify what role the immune system plays in HS. Smoking is another risk factor closely linked to development. Research has shown that nicotine exposure can cause thickening of the dermis, the top layer of skin, which in predisposed individuals may initiate the plugging of hair follicles. (5) There may also be multiple factors that play a role in the development of this dermatological condition.
Treatment of HS is challenging. To date, there are actually no approved treatments for HS by the FDA, meaning the use of any medication is considered ‘off label’. Research is ongoing to identify effective treatments that relieve the symptoms of this condition, the goal being to reduce or clear breakouts, prevent scarring and tunneling and prevent future episodes of lesions. Selection of treatment largely depends on extent and severity of disease. Mild to moderate lesions are initially addressed using topical therapies – antibiotics are steroids are often the mainstay of treatment. Steroid injections around lesions may also be used to rapidly reduce pain and discomfort in some cases. Systemic therapies including antibiotics are often considered and may provide long-term relief for some. More serious cases may be treated using systemic retinoids (vitamin A derivatives like Acutane) although benefit from use is unclear and side effects can be undesirable. Immunosupressive medication is another intervention that has been studied for severe cases of HS, although more research is needed to clarify which medication will work best. Treatment for cases that do not show improvement or are too severe for less invasive measures may warrant surgery to remove disease tissue through excision or laser therapy. (3)
One nutrient that may be helpful in this condition is zinc. Zinc may help lower androgen levels that can lead to excess oil production and gland blockage, and have anti-inflammatory properties. One pilot study has shown improvement after supplementation of 90g zinc gluconate per day in 22 participants, reporting that 8 achieved complete remission and 14 showed significant improvement. Varying response may possibly be due to zinc deficiencies in some patients that show improvement and not in others. A second study has measured inflammatory markers through biopsy in HS lesions before and after 9 months of supplementation with 90mg zinc. Authors reported a decrease in inflammatory markers, which may be contributing to lesions in this condition. Although more research is needed to clarify the role of zinc in HS, supplementation should be considered in these patients due to the low risk of complications. (6) If high doses of zinc are taken without copper this may lead to a copper deficiency, so be sure to talk to a naturopathic doctor about a product that is right for you.
From a naturopathic approach, HS may be addressed using nutrients, herbs and dietary strategies that offer anti-inflammatory properties. Lowering any inflammatory triggers and possible contributing compounds like cytokines in the body may improve redness and aggravation of lesions. Identifying food triggers may be a start – in the patients I have seen with this condition decreasing intake of dairy and refined sugar seemed to provide some relief, although triggers are likely patient specific. An IgG food sensitivity test may help guide dietary elimination if triggers are unclear. As a mainstay in anti-inflammatory therapies, fish oil with a high level of EPA is the first supplement that comes to mind to address the underlying cause of this condition. The health and balance of gut flora may also be affecting skin health in these patients, and a quality probiotic may be indicated after discussing digestive concerns and dietary habits. Topical application of castor oil packs or directly to the skin as an anti-inflammatory measure could also be considered, alternating with applications of an antibacterial oil like tea tree in a carrier oil or oil of oregano applied to the affected area.
There is a high correlation in presence of HS and obesity, and studies suggest that degree of obesity corresponds with severity of disease. In patients who are overweight or obese, body mass may be contributing in several ways this condition. Excess adipose tissue has been shown to increase levels of inflammation and affect hormone levels, which may aggravate the inflammatory lesions involved in HS. Increased body weight may also aggravate friction in folds and predispose to obstruction and irritation of lesions that are present, while another possible explanation for this connection is a common underlying genetic predisposition to obesity and HS that is currently being investigated. (7) Weight loss as a treatment for HS has been investigated in one small study demonstrating a 15% weight loss is associated with significant disease improvement (8). HS is however not uncommon in patients of normal body weight, in whom weight loss would not be likely to influence disease progression, and in some patients weight loss an leave skin folds that increase friction. This observation also suggests that weight could be more of an aggravating factor that a cause of this condition.
Although data to support natural therapies in the treatment of HS is lacking, difficulty in resolution or a high risk of side effects from conventional therapies may lead patients to seek alternatives. As always, resolution or improvement of this condition depends on identification of any triggers in each unique patient, and some may respond better than others. Education about prognosis and available options is an important part of consultation so patients can make the decision that is best for their quality of life.