Hidradenitis suppurativa (HS) is a chronic inflammatory condition that affects about 1% to 4% of the worldwide population and is 3 times more common in women than men.1 It is characterized by painful, inflamed nodules in the apocrine gland-bearing regions that can progress to abscesses, sinus tracts, and scarring.1 The physical manifestations of the disease are debilitating, but are a small component of the overall burden of HS, a disease that is associated with intense pain, work disability, and poor quality of life.1
Research on HS has focused on identifying and managing the risk factors that contribute to symptoms and overall quality of life in these patients. One of those risk factors, and one which is strongly associated with HS, is obesity. The prevalence of HS in obese populations is around 18%, which is significantly higher than that in the general population.2 HS is also associated with metabolic syndrome, a set of related disorders including obesity, type 2 diabetes, hypertension, and dyslipidemia.3 This association increases the risk of cardiovascular disease and subsequently raises the risk of morbidity and mortality.3 One study showed that the risk of cardiovascular events such as strokes and heart attacks in HS patients is increased compared with controls.4
Given the strong association of obesity and HS, weight management is an important intervention for this population of patients and should be implemented concurrently with medical treatment of HS. Obese patients, particularly women, exhibit more severe symptoms overall. In addition, weight loss may be necessary for patients who will need surgical intervention for treating HS, which typically requires patients to have a body mass index (BMI) of <35.
Although weight management is not their area of expertise, dermatologists play an active role in the process. It is important to discuss the most common risk factors of HS, including obesity, during the patient’s initial visit, and continue to address the subject in follow-up appointments. Some clinicians are able to refer patients to weight management services within the same facility.
The road to achieving healthy weight- loss goals is challenging, however, it can be done with a supportive environment and effective interventions. A good patient-physician relationship is vital for motivating patients to undertake lifestyle changes, given that this journey is filled with triumphs and setbacks. Possible interventions can range from basic education about diet and weight, to formal weight-loss programs, and sometimes, in extreme cases, bariatric surgery may be recommended. Different strategies are met with varying degrees of success because weight loss is an individual process for each patient; therefore, it is best for clinicians to have a good understanding of all the available options.
Making sure patients have a thorough understanding of not only their disease, but also related risk factors including obesity and how those might exacerbate symptoms, is paramount, and should be the first step toward any weight-loss goal. It can give patients a sense of self-control and empowerment to know that, along with taking appropriate medications, they can actively participate in improving their symptoms and overall well-being through modifiable risk factors such as diet and exercise.
Dermatologists can begin educating patients during the initial clinic visit, by using educational pamphlets and directing patients to helpful resources such as the HS Foundation website, https://www.hs-foundation.org.
Education on weight loss is also most effective when there are multiple sessions dedicated to teaching patients about how to implement lifestyle changes.5 Dermatologists should adopt a multidisciplinary approach to this, involving the patient’s primary care physician and any other needed health care professionals
Motivational interviewing (MI) is an effective behavioral technique that can help patients lose weight. It is a patient-centered strategy that increases motivation and behavior change. It involves asking patients open-ended questions (in other words, questions that cannot be answered with a simple yes or no) in an empathetic manner, allowing for reflective listening and avoiding confrontation to help patients intrinsically increase their motivation for change. A recent meta-analysis examined the effectiveness of MI in weight loss. One-third of studies showed that participants significantly lost weight compared with controls and half of the studies led to participants losing 5% of their initial weight.6 Examples of MI can be found at https://motivationalinterviewing.org/motivational-interviewing-resources.
There is no particular diet recommended for HS, but there is some research indicating that dairy-free and brewer’s yeast-free diets may help. Hormonal imbalances may contribute to the pathogenesis of HS, as evidenced by increased treatment response to spironolactone in HS patients. Dairy promotes androgen stimulation; therefore, a dairy-free diet may alleviate the dysregulation of hormones. In one study, 83% of 47 patients on a dairy-free
diet clinically improved and none reported worsening of disease.7 Another study followed 12 patients who eliminated foods containing brewer’s yeast, such as breads, beer, and fermented cheese, and all reported regression of symptoms of the disease.8 Both these studies had small sample sizes and further research is needed to critically evaluate the role of diet in HS.
Currently, there is no particular diet recommended for HS patients; it is best to promote healthy eating habits such as eating adequate fiber, lean protein, and healthy fats, and limit unhealthy saturated fats and simple carbohydrates like sugar. A balanced diet and consuming calories in moderation is the best way to achieve and maintain weight loss.
Diet remains the main factor in weight loss and maintenance, but physical activity also plays a key role. The American College of Sports Medicine recommends 225 to 420 minutes per week of physical activity to achieve weight loss and 200 to 300 minutes per week of physical activity to prevent weight gain after weight loss.9 Physical activities should include aerobic activities such as walking, running, hiking, swimming, and dancing.9 Resistance training, which involves exercises where muscles contract against external resistance such as weight lifting, also leads to a reduction in body fat.9
Exercise can also be implemented in everyday activities such as using the stairs instead of the elevator, biking to work, and leisure activities such as walking the dog. It is also important for individuals to set small goals along the way in order to slowly increase the level and intensity of physical activity to maintain long-term healthy habits.
It is important to be aware that often, obese patients complain that exercise makes HS lesions worse due to increase friction and sweating. An evaluation by a qualified nutritionist, behavioral psychologist, and sports medicine specialist can help tailor an exercise program to take a patient’s comfort level into account.
Formal Weight-Loss Programs
There also may be a need to refer HS patients to formal weight-loss programs that are customized for each patient. They provide patients with weight loss-techniques from qualified experts, dietary plans,
exercise programs, and behavioral modification as well as support groups.10 Combining various techniques into one program may help patients maintain long-term weight loss. The cost of these programs, however, can be prohibitive and is highly dependent on health insurance coverage.
Dermatologists can assist patients in finding such programs by referring them to a weight management specialist or their primary care physician. One vital component of enrolling in a formal program to keep in mind is how necessary it is to keep the patient motivated to maintain the weight and avoid regaining it, even after they are no longer in the program. Programs often provide patients with resources to help them, continue their success and achieve their ultimate goals. Support groups or a strong support system for the patient can also be useful.
Bariatric surgery is also a possible option for patients who have not been able to achieve weight loss with the aforementioned interventions and are good candidates for surgery. A candidate for bariatric surgery has a BMI >40 or a BMI >35 and at least one or more obesity-related comorbidities such as type 2 diabetes, hypertension, sleep apnea, or heart disease.11 In one study, 35% of patients reported improvement in HS symptoms following bariatric surgery and weight loss.2 A major hurdle with this intervention is the high cost and poor insurance coverage.12 It is also important to bear in mind that bariatric surgery is not an effortless solution because patients must maintain healthy dietary and exercise habits to keep weight off following surgery.12
A Multipronged Approach
Overweight or obese HS patients benefit from weight management, not just in terms of improved symptoms of their disease but also in overall health and well-being. Achieving healthy weight loss requires a support system including a good patient-physician relationship, which allows physicians to educate, motivate, and help patients implement lifestyle changes. In addition, weight loss may be necessary for patients who will need surgical intervention for treating HS, which typically requires patients to have a BMI of <35. The road to weight loss is difficult, but it can be done with the right environment and tools that motivate and empower patients to take on the challenge.
Ms Kolli attends The Robert Larner, M.D. College of Medicine at University of Vermont and is currently doing a research fellowship at Center for Dermatology Research at Wake Forest School of Medicine in Winston-Salem, NC.
Dr Pichardo is an associate professor and director of the International Fellowship Program at Wake Forest Baptist Health in Winston-Salem, NC.
Disclosure: The authors report no relevant financial relationships.
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