What are the most effective preventive lifestyle habits for hidradenitis suppurativa?

Preventive Lifestyle Habits for Hidradenitis Suppurativa

Smoking Cessation

Smoking cessation is the single most important preventive lifestyle modification for hidradenitis suppurativa, as 70-75% of patients smoke and nicotine directly promotes follicular plugging and epidermal hyperplasia that drives disease pathogenesis. 1, 2

• Smoking confers an odds ratio of 36 for developing HS compared to non-smokers, making it one of the strongest modifiable risk factors 2
• Two case reports documented complete remission in women with HS after smoking cessation 1
• Patients who quit smoking report both subjective and objective improvements in symptom severity 3
• Refer all patients to formal smoking cessation services at every visit 1, 4

Weight Loss and Obesity Management

Weight reduction of >15% body weight produces complete remission in approximately 50% of patients and improvement in another 20%, making it the second most critical preventive intervention. 1

• More than 75% of HS patients are obese, with an odds ratio of 33 for disease development 1, 2
• In a survey of 35 patients who underwent bariatric surgery, 48.6% achieved complete remission with >15% weight loss, 20% reported improvement, and 20% had no change 1
• Obesity increases mechanical friction at flexural sites and elevates pro-inflammatory cytokines (IL-1β, TNF-α) that amplify disease activity 2
• Refer patients with elevated BMI to structured weight management programs 1, 4

Dietary Modifications

Elimination of dairy products and adoption of a low-glycemic-load diet may prevent new lesions and reduce disease progression, though evidence quality is limited. 1

Dairy Elimination

• In surveys of 47 patients avoiding dairy, 83% reported improvement and none reported worsening, though response bias likely influenced results 1
• Two cases of gluten-sensitive enteropathy showed HS improvement after introducing gluten-free diet 5
• Seven additional patients experienced considerable improvement with low-dairy/low-carbohydrate diet 5

Brewer's Yeast Avoidance

• A study of 12 patients avoiding brewer's yeast (Saccharomyces cerevisiae) after HS surgery showed improvement over 12 months, with recurrence only after consuming brewer's yeast, though surgical effects confound interpretation 1

Low Glycemic-Load Diet

• Preliminary observations suggest a fully natural zero-dairy and low glycemic-load diet may prevent new lesions even when medications fail 6
• Diet stimulation of insulin and IGF-1 may impact signaling pathways involved in HS pathogenesis 7

Skin Care and Friction Reduction

Use gentle skin care products in intertriginous areas and avoid mechanical irritation, as 77.5% of patients report never using any skin care in affected regions. 5

• Implementing secondary prevention by reducing irritation, avoiding shaving, and improving skin care led to improvement in 62.5% of patients 5
• Of 110 patients surveyed, 16% reported worsening from "tight clothing/friction" whereas 11% reported relief from "loose/cotton clothing/cleanliness/drying/cold" 1
• Evidence linking friction to epidermal hyperplasia is limited to patient surveys and anecdotes, but the biological plausibility is strong 1
• Consider laser epilation as an alternative to shaving to reduce follicular trauma 5

Personal Care Products

• Evidence regarding deodorants, antiperspirants, and chemical depilatories is weak and contradictory 1
• In a chart review of 11 patients, 6 reported adverse reactions to antiperspirant or deodorant use around HS onset, but recall bias is high 1
• HS was not linked to daily shaving or use of depilatories in one small study 1

Supplementation Considerations

Evidence is insufficient to recommend routine zinc or vitamin D supplementation, though they may be considered in deficient patients with Hurley stage I-II disease. 1

Zinc

• A retrospective study of 54 patients with Hurley stage I-II treated with zinc gluconate 90 mg daily plus topical triclosan 2% for 3 months showed improvement in mean DLQI score (P=.039) 1
• A prospective study of 22 patients receiving 90 mg daily reported improvement in all patients (8 complete responses, 14 partial responses) 1

Vitamin D

• Of 22 vitamin D-deficient HS patients who received supplements to achieve normal levels, 63% achieved a 20% decrease in inflammatory nodules 1

Comorbidity Screening and Management

Screen all patients for metabolic syndrome components, as HS patients have a 1.5-3-fold increased risk of type 2 diabetes (prevalence up to 30%) and >3-fold risk of polycystic ovarian syndrome. 1, 4

• Measure HbA1c or fasting glucose in patients with signs/symptoms of diabetes 1
• Screen blood pressure, lipid profile, and BMI at baseline 1, 4
• Screen for depression and anxiety using validated tools, as psychiatric comorbidity is highly prevalent 1, 4, 8
• Perform thorough gastrointestinal review to detect possible inflammatory bowel disease 1, 8

Critical Pitfalls to Avoid

• Do not recommend clothing restrictions or specific fabric choices as evidence is insufficient and based only on patient surveys 1
• Do not order routine bacterial cultures unless there are clear signs of secondary infection, as mixed normal flora does not guide therapy 4
• Do not rely solely on dietary modifications without addressing smoking and obesity, which have the strongest evidence for disease modification 1, 2
• Avoid making definitive recommendations about personal care products (deodorants, antiperspirants) given weak and contradictory evidence 1