I. Introduction

Making lifestyle changes and adding complementary and alternative medicines (CAM) to your treatment plan can improve your HS by working together with your HS medicines. This chapter reviews common lifestyle changes that can help your HS, such as exercise, weight loss, clothing choices, stress reduction, quitting smoking, and CAM.

II. Lifestyle Changes

Nutrition and Diet. Changing what you eat can help with weight management and your HS symptoms. Nutrition can affect your HS symptoms because foods can increase or decrease inflammatory cytokines in your body. Cytokines are small proteins in our body that help cells in our immune system communicate. Current research suggests that the best diet for patients with HS is the Mediterranean diet. Examples of foods included in this diet are shown in Table 14.1. Several research studies have shown that patients with HS following the Mediterranean diet experienced a decrease in the severity of their HS symptoms. In one study, they compared two groups of people eating the same number of calories. One group ate mostly unprocessed foods included in the Mediterranean diet, and the other group ate more processed foods. Although both groups were consuming the same amount of calories, the group eating more unprocessed foods had significant improvements in HS symptoms.

Similarly, foods containing dairy, Brewer’s yeast, and simple carbohydrates can worsen HS by increasing inflammatory cytokines in the body. Studies have found that patients experienced significant improvement in their symptoms with the elimination of these foods. Examples of these foods are outlined in Table 14.2.

Highly-processed carbohydrates – or simple carbohydrates – are easy for the body to digest. As a result, they spike your blood sugar very quickly, which is pro-inflammatory. Complex carbohydrates are mainly unprocessed carbohydrates that contain more fiber and take longer to digest, which help to stabilize your blood sugar levels. Simple carbohydrates are more often found in highly-processed foods because they taste good. Limiting processed foods is a key component of the recommended Mediterranean diet. Processed foods usually come in a package, and the ingredients will have many taste-enhancing ingredients and preservatives. Although it is hard to completely cut out some of these foods, limiting them can also help. Table 14.3 below lists some healthy food swap ideas to help with lifestyle changes.

While incorporating healthier foods into your diet, to make foods taste better you can season with different spices and herbs which add great flavor and taste without adding extra fat or calories. Small swaps to ingredients in regular dishes can help make your food that much healthier. For example, if you are used to eating a lot of white rice or white bread, you can swap for whole wheat rice and bread, instead of eliminating those foods completely.

The fields of nutrigenetics and nutrigenomics study how our bodies respond to nutrients and how nutrients affect our bodies based on our unique genetics. This means that the diet that works for one person might have different effects on another. To find your ideal diet, you may have to work with your healthcare providers or nutritionist and try different foods.

The best way to make long term nutritional modifications is through small changes that will help you sustain your lifestyle long term.

These changes may seem very hard at first, but over time, as you develop new recipes and routines for healthy eating, it will become easier.

Exercise. Exercise is very helpful for HS because it can help you lose weight if needed, boost your mood, and improve your overall health. However, exercising can be hard for patients with HS because the friction of common exercise methods can worsen HS symptoms. Try activities that are low intensity and low impact to decrease over-sweating and overheating. Exercising in a cool environment can help with keeping you cool. Swimming, yoga, and Pilates are some of the best exercise methods for HS. After your exercise session, take a short lukewarm shower to wash off any sweat.

Weight Management. Many studies have found that excess weight can contribute to increased HS symptoms. Extra fatty tissue can cause your body to produce increased hormones or cytokines that worsen inflammation and HS symptoms. Losing weight decreases the amount of fat cells, also known as adipocytes, which leads to fewer hormones, cytokines, and overall less inflammation in the body. Weight loss can also help decrease the amount of skin that rubs together in skin fold areas where HS is common, like the armpits, under the breast, and groin.

One common myth about HS is that weight loss will “cure” HS. However, this is not true. Weight management can be used with other lifestyle modifications and medications to help control symptoms and flares. Several studies following people with HS who have lost a significant amount of weight showed improvement in their HS symptoms. Diet and exercise are the recommended ways to lose weight. The ideal way to lose weight is through small healthy changes that can help you maintain your weight loss long term. This can take many months to several years. Your doctor may be able to recommend nutritional and weight loss programs often covered by insurance.

If you have previously tried diet and exercise to lose weight for a long time and it has not worked for you, you may be eligible for weight loss surgery. Currently, medical guidelines recommend considering weight loss surgery for people who have a body mass index (BMI) over 40, those who have a BMI over 35 with other health concerns, or those who have previously tried diet and exercise without results. There are many different types of weight loss surgeries. Some examples are gastric banding, sleeve gastrectomy, and gastric bypass surgery. Ask your main healthcare provider if this is an option for you, and they can refer you to a weight loss surgeon who specializes in these surgeries.

Clothing Choices.

HS can be triggered by friction between skin folds or between skin and clothing

Therefore, it is important to pick your clothing – particularly undergarments – very carefully and take into consideration clothing material and clothing fit. Table 14.4 provides a summary of recommended undergarment styles and fabrics for clothing.

Wearing light and breathable clothing can help control your body heat and sweating. This can be important since sweat is commonly reported as a trigger for HS flares. Clothing made with nonabsorbable fabrics can worsen HS because of increased heat and sweating. Fabrics like nylon and wool might irritate your skin so should be avoided. On the other hand, clothing made with cotton are typically soft and comfortable. Some other fabrics that may be comfortable for people with HS include moisture-wicking fabrics, such as Lyocell or bamboo-fiber. Though often more costly compared to cotton, these moisture-wicking fabrics provide the added benefit of even greater temperature control and absorbency.

Especially during flares, it can help to wear loose, comfortable clothing that will not rub against your skin. When selecting undergarments, keep in mind that the groin and buttock areas are especially prone to developing lesions and wounds in many people with HS. It can help to choose undergarments without underwires and without tight elastic bands, and to avoid wearing very tight clothes over areas where HS flares occur. Cotton bra or tummy liners can help wick away sweat and prevent clothes from rubbing and further irritating HS lesions in those areas. They can also help absorb drainage.

For women with HS, it can be helpful to avoid bras that contain underwire and bras with tight, thin linings. If this is difficult, consider using padding (for example, in the form of bra liners discussed above) to help minimize the pressure and stress on your skin. When possible, consider wearing sports bras or camisole tanks that can provide support without being too tight or chafing your skin. For underwear, women can consider wearing styles like boy shorts, briefs, high-cut briefs, and “cheeky” underwear.

Men with HS should consider avoiding tight briefs and instead wear loose boxers or trunks.

Smoking. Smoking cigarettes/cigars, vaping, or using other tobacco products may worsen HS. When inhaled, the ingredients in tobacco products can increase inflammatory cytokines in your body that worsen HS and can also plug the hair follicles. Several studies have shown that smoking rates are higher among people with HS. Patients with HS that smoke cigarettes are encouraged to quit smoking. It can be helpful to speak to your healthcare provider to discuss medications that can help you quit smoking, and for referral to a smoking cessation program for support.

Decreasing Stress. Many patients with HS experience stress and mental health conditions like depression and anxiety. This can be due to many things, such as the physical and social impact that HS lesions have on people. There is also evidence that shows inflammatory cytokines involved in HS can have a direct impact on the brain, causing depression. Studies have shown that patients with HS are more likely to have mental health conditions compared to the general population. Fortunately, there are resources to support patients with HS to reduce stress.

If you feel that your HS is affecting your mental health, you should ask your doctor about going to see a mental health counselor or psychiatrist.

There are also support groups specifically for HS that can help you connect with other HS patients, or those offering helpful HS resources.

III. Complementary and Alternative Medicine

Supplements. Supplements can be used in addition to the medication that your healthcare provider prescribes for your HS. Speak to your healthcare provider before starting any supplements to make sure it is okay with your current medical regimen. Supplements that have been found to be helpful for patients with HS include vitamin D, niacinamide/nicotinamide (vitamin B3), vitamin B12, zinc, and magnesium.

Studies have shown patients with HS who had a vitamin D deficiency experienced a decrease in their HS symptoms when they treated the vitamin D deficiency. For the average person, 1,500 to 2,000 International Units of daily vitamin D is recommended through diet and supplements to maintain healthy levels. If you are found to have a deficiency, you may temporarily require a higher dose which has to be prescribed by your healthcare provider.

When Vitamin B12 is low in the body, inflammatory markers that contribute to HS symptoms can increase. Therefore, it is important for patients with HS to maintain normal levels of vitamin B12. In a study where patients with HS were given high doses of vitamin B12, patients reported a decrease in HS flares. The dosage of vitamin B12 used in this study was 1,000 micrograms.

Zinc and niacinamide/nicotinamide (vitamin B3) have been shown to help patients with HS by decreasing inflammatory cytokines. In a study where patients with HS received zinc gluconate and niacinamide supplementation, patients had a significant decrease in HS flares. The study supplemented patients with 30 milligrams (mg) of niacinamide. The recommended dose of zinc is 100 mg daily. When taking zinc supplements, it is important that you also take copper supplements at the same time. This is because zinc in high amounts can block your body from absorbing copper, which is necessary for your body to function. When taking 100 mg of zinc, you should also take 10 mg of copper.

Magnesium has been shown to help patients with HS by decreasing inflammatory cytokines, decreasing pain, and improving metabolic profile which is the way your body responds to sugars and fats that you eat. There is currently no recommended dose of magnesium for treatment of HS, but you should take no more than 350 mg daily.

Please consult with your healthcare provider before starting any supplements to discuss recommended dosing and any potential safety issues.
Bathing Regimens

Bleach and magnesium sulfate baths can be used to relieve pain and itching caused by HS lesions. They are thought to work by decreasing inflammatory cytokines and blocking the pain pathway from the skin to the brain. Baths are helpful because they can cover your whole body if you have widespread lesions. The table below describes how to prepare both types of baths.

Acupuncture/Acupressure. Acupuncture is a traditional Chinese therapy in which very thin needles are placed onto your skin at different points of your body to reduce pain. Battlefield acupuncture focuses on points on the ear, and is a technique that was developed to help war veterans with chronic pain. Acupressure uses pressure instead of needles to achieve the same effect. There are ongoing studies to look at the benefits of acupuncture for patients with HS. Acupuncture/acupressure can be used along with your other medicines to decrease pain.