Can Aldactone (spironolactone) and zinc be helpful in treating hidradenitis suppurativa?

Spironolactone and Zinc for Hidradenitis Suppurativa

Zinc supplements are strongly recommended for hidradenitis suppurativa (HS), while spironolactone is suggested as an anti-androgen therapy for female patients with HS, particularly adolescents. 1

Evidence for Zinc in HS

• Zinc supplements are recommended with strong evidence (moderate quality) for HS patients seeking natural therapies, with particular safety evidence in pregnancy 1
• Zinc pyrithione can be used as an antiseptic wash for HS with conditional recommendation (very low quality evidence) 1
• A pilot study showed clinical response in all 22 patients treated with zinc gluconate (90 mg daily), with 8 complete remissions and 14 partial remissions 2
• Zinc salts may provide a therapeutic alternative for HS treatment, with mainly gastrointestinal side effects reported 2

Evidence for Spironolactone in HS

• Spironolactone is suggested for adolescent female patients with HS who require anti-androgens (conditional recommendation) 1
• Spironolactone has shown efficacy in reducing:
  • Pain scores (average reduction of 1.5 points, P = .01) 3
  • Inflammatory lesion count (average reduction of 1.3 lesions, P = .02) 3
  • HS Physician's Global Assessment scores (average reduction of 0.6 points, P < .001) 3
• Lower doses of spironolactone (average 45 mg/day) appear to be as effective as higher doses (average 112 mg/day) 3
• Response rates are lower in patients with severe disease (Hurley stage 3), who are 85% less likely to show improvement with spironolactone therapy 4

Treatment Considerations

For Spironolactone:

• Typical dosing ranges from 50-100 mg daily for dermatologic conditions 5
• Should not be used in pregnant or lactating women 5
• Not typically used in men due to risk of feminization 5
• Factors associated with poor response include:
  • Axillary involvement 4
  • Previous treatment failures 4
  • Concurrent use of intralesional steroids 4
  • Hurley stage 3 disease 4

For Zinc:

• Dosing of 90 mg zinc gluconate daily (15 mg elemental zinc per capsule) has shown efficacy 2
• Once complete remission is achieved, treatment can be progressively decreased (average maintenance dose: 3.5 capsules/day) 2
• Main side effects are gastrointestinal 2

Treatment Algorithm Based on Disease Severity

• For mild disease (Hurley Stage I):

  • First-line: Topical clindamycin 1% solution/gel twice daily for 12 weeks 6
  • Consider zinc supplements and zinc pyrithione washes as adjunctive therapy 1

• For moderate disease (Hurley Stage II):

  • First-line: Oral tetracycline or doxycycline for up to 4 months 6
  • Second-line: Clindamycin 300 mg twice daily with rifampicin 300-600 mg daily for 10-12 weeks 6
  • Consider spironolactone for female patients, particularly adolescents 1
  • Continue zinc supplements as adjunctive therapy 2

• For severe disease (Hurley Stage III):

  • First-line: Adalimumab (FDA-approved for moderate to severe HS) 6
  • Consider spironolactone for female patients with less severe disease (note: less effective in Hurley stage 3) 4
  • Continue zinc supplements as adjunctive therapy 2

Monitoring and Follow-up

• Assess treatment response after 12 weeks using Hidradenitis Suppurativa Clinical Response (HiSCR) and patient-reported outcomes 6
• For spironolactone, monitor for side effects including menstrual irregularities and hyperkalemia 5
• For zinc supplementation, monitor for gastrointestinal side effects 2