The treatment of hidradenitis suppurativa with the glucagon‐like peptide‐1 agonist liraglutide

Evaluating dietary considerations in hidradenitis suppurativa: a critical examination of existing knowledge

Hidradenitis suppurativa (HS) is a chronic condition that can overwhelm patients, and the effectiveness of supplementary dietary treatments remains uncertain. The primary aim of this review is to explore the connection between diet and HS progression. However, it is imperative to note that the evidence supporting a substantial role of the diet in HS remains weak. Dietary alterations alone should not be considered independent solutions for managing HS. Medical therapy continues to be indispensable for adequate treatment. Research indicates that the Mediterranean lifestyle and diet may provide cost-effective and beneficial adjustments when combined with traditional therapies. Conversely, foods with a high glycemic index and dairy could worsen HS symptoms, conceivably through mechanisms linked to insulin resistance and inflammation. Zinc, known for its antioxidant properties, shows promise as an adjunct therapy. Moreover, evidence suggests a connection between vitamin D deficiency and HS severity, although the findings are inconclusive. Brewer's yeast-free diet, B12 supplementation, intermittent fasting, and reducing the intake of refined sugar and dairy merit further investigation. In conclusion, this review highlights the need for additional research because of the lack of standardized reporting of clinical effects in the studies under scrutiny. A deeper exploration of the pathophysiology focusing on dietary modifications and their potential associations with HS severity is essential. Furthermore, it is crucial to recognize that patients' willingness to experiment with new diets makes them vulnerable to fraudulent interventions, highlighting the importance of evidence-based dietary guidance.

Liraglutide for the treatment of obesity among patients with hidradenitis suppurativa

BACKGROUND AND AIMS

Hidradenitis suppurativa (HS) is associated with obesity. Weight loss is frequently reflected in an amelioration in the severity of the lesions. Case reports have suggested that liraglutide might improve not only weight but also skin. We aimed to study the effects of liraglutide 3mg in patients with obesity and HS on metabolic and dermatological parameters.

METHODS

14 patients started treatment with liraglutide for 3 months. Severity of the lesions was evaluated using the Hurley Staging System and quality of life with the DLQI (Dermatology Quality Index).

RESULTS

There was a significant reduction in BMI (39.3±6.2 vs 35.6±5.8; p=0.002), waist circumference (121.3±19.2 vs 110.6±18.1cm; p=0.01), CRP (4.5±2.2 vs 3±2.1mg/L; p=0.04), homocysteine (16.2±2.9 vs 13.3±3μmol/L; p=0.005) and plasma cortisol (15.9±4.8 vs 12.6±4.5μg/dL; p=0.007). Hurley (2.6±0.5 vs 1.1±0.3; p=0.002) and DLQI (12.3±2.8 vs 9.7±6.9; p=0.04) improved significantly. In multiple regression analysis, weight loss did not correlate with any inflammatory parameter or Hurley.

CONCLUSIONS

Liraglutide 3mg is effective and safe among patients with HS and obesity. Long-term studies are mandatory to assess the effects of liraglutide on skin lesions and inflammatory markers among subjects with HS beyond weight loss.

Expert consensus on priority research gaps in dietary and lifestyle factors in hidradenitis suppurativa: a Delphi consensus study

Hidradenitis suppurativa (HS) is a debilitating systemic inflammatory disease with limited treatment options. Although management through dietary and lifestyle changes is a primary interest of the HS patient community, there is lack of consensus regarding recommendations due to the paucity of evidence. To establish the priority research gaps on this topic, we performed and moderated a Delphi consensus study by integrating expert opinions and the relevant literature. Based on a literature review, research questions on dietary and lifestyle interventions in HS were constructed. HS dietary and lifestyle research questions were sent to an expert panel, consisting of 22 international members, including dermatologists, dietitians, pharmacists, and endocrinologists. Voting on the research questions was conducted using a modified Delphi technique. The primary outcome measure was whether participants could reach consensus on the priority of each research question in the HS dietary and lifestyle factors. After three rounds of surveys investigating the relationships between HS and various diet and lifestyle factors, "BMI", "Obesity", and "Smoking", reached consensus as high priority research questions. Low research priorities per consensus included "effects of iron supplements", "effects of magnesium supplements", "alcohol consumption" and "limiting Brewer's yeast intake. Smoking and obesity were identified as important research questions, concurrent to the literature indicating their association with more significant impact on disease activity. By shedding light on high priority research questions, our study provides a roadmap for further research on dietary and lifestyle modifications in HS and will help determine evidence-based lifestyle and dietary recommendations for patients with HS.

Obesity and hidradenitis suppurativa: targeting meta-inflammation for therapeutic gain

Hidradenitis suppurativa (HS) is a chronic, inflammatory condition of the pilosebaceous unit. The typical patient with HS is characterized as someone with obesity, who smokes and who has nodules, abscesses and/or draining tunnels predominantly distributed in intertriginous skin. It has been established that lifestyle and genetic factors are the main pathophysiological drivers of HS. In this critical review, we explore the interrelatedness of meta-inflammation, obesity and HS and discuss if and how this relationship may be manipulated for a therapeutic end.

Hidradenitis suppurativa should be recognized as a weight-related comorbidity in National Institute for Health and Care guidelines on managing obesity

We propose hidradenitis suppurativa (HS) is added to the list of weight-related comorbidities in the new National Institute for Health and Care Excellence guideline on obesity. Effective obesity management in patients with HS could help reduce disease severity, pain and cardiovascular risk, and improve quality of life and the efficacy of biologic therapy. In addition, it could reduce the costs of HS-associated care (GP visits, hospital outpatient attendances, biologic drugs, inpatient admissions, elective and emergency surgery).

Metformin Treatment of Hidradenitis Suppurativa: Effect on Metabolic Parameters, Inflammation, Cardiovascular Risk Biomarkers, and Immune Mediators

Hidradenitis suppurativa (HS) is a common cutaneous and systemic inflammatory disease with a significant impact on mental health and quality of life. It is associated with obesity, insulin resistance, metabolic syndrome, cardiovascular (CV) disease, and increased all-cause mortality. Metformin is used frequently in HS treatment and is effective for some patients. The mechanism of action of metformin in HS is unknown. A case-control study of 40 patients with HS (20 on metformin and 20 controls) was conducted to assess differences in metabolic markers, inflammation (C-reactive protein [CRP], serum adipokines, and CV risk biomarkers), and serum immune mediators. Body mass index (BMI), insulin resistance (77%), and metabolic syndrome (44%) were high overall, but not significantly different between the groups. This highlights the need for co-morbidity screening and management. A significant reduction in fasting insulin and a trend towards a reduction in insulin resistance were identified in the metformin group compared with pre-treatment levels. CV risk biomarkers were significantly favourable in the metformin group (lymphocytes, monocyte-lymphocyte ratio, neutrophil-lymphocyte ratio, and platelet-lymphocyte ratio). CRP was lower in the metformin group but was not statistically significant. Adipokines were dysregulated overall but were not different between the two groups. Serum IFN-γ, IL-8, TNF-α, and CXCL1 trended lower in the metformin group but did not reach significance. These results suggest that metformin improves CV risk biomarkers and insulin resistance in patients with HS. When the results of this study are considered alongside other studies in HS and related conditions, it is likely that metformin also has beneficial effects on metabolic markers and systemic inflammation in HS (CRP, serum adipokines, and immune mediators), warranting further research.

The Role of Hormones in Hidradenitis Suppurativa: A Systematic Review

Hidradenitis suppurativa (HS) is a chronic inflammatory disease manifesting in inverse body regions. In a systematic review, the role of hormones in HS will be presented to better understand the pathomechanisms of HS. The review is based on the PRISMA criteria. Systematic research was carried out using keywords. Subsequently, the data were analyzed based on the clinical response and other relevant information. The main focus of our systematic review was on HS manifestation, exacerbation, sex hormones, antiandrogen therapy, thyroid function, polycystic ovary syndrome, insulin resistance, and adipokines. In HS, there appears to be a dysregulated adipokine release that is shifted towards pro-inflammatory adipokines. Insulin resistance is significantly more common in HS than in healthy patients regardless of BMI, age, and gender. Insulin resistance in HS patients leads to further cardiovascular disease. The mechanism of insulin resistance and role of adipokines should be investigated in future studies to better provide the pathomechanisms of HS. The role of androgens seems to be important in a certain subgroup of female patients. Anti-androgenic therapy can be useful and helpful in some patients. However, further studies are needed to better understand the hormonal relationship in HS.

Advances in molecular pathogenesis of hidradenitis suppurativa: Dysregulated keratins and ECM signaling

Hidradenitis suppurativa (HS) is characterized by deep-seated, highly inflamed, and painful lumps/abscesses, fistulae, and sinus tracts that grow extensively deep in the dermis and are highly immunogenic in nature. In about one-third of the HS patients there is strong evidence for the role of γ-secretase mutations along with dysregulated Notch signaling. However, the contribution of dysregulated Notch signaling in HS pathogenesis in relation to hair follicle alterations and hyper-activation of the immune system remains undefined. A genome-wide association study (GWAS), proteomic data and functional investigations of identified sequence variants in HS pathology are not fully revealing. The disease initiation or progression may involve bacterial infection besides intrinsic functional defects in keratinocytes, which may be key to further exacerbate immune cell infiltration and cytokine production in and around the lesional tissue. The absence of a suitable animal model that could fully recapitulate the pathogenesis of HS is a major impediment for proper understanding the underlying mechanisms and development of effective treatments. The presence of extracellular matrix (ECM) degradation products along with dysregulation in keratinocytes and, dermal fibroblasts ultimately affect immune regulation and are various components of HS pathogenesis. Bacterial infection further exacerbates the complexity of the disease progression. While anti-TNFα therapy shows partial efficacy, treatment to cure HS is absent. Multiple clinical trials targeting various cytokines, complement C5a and ECM products are in progress. This review provides state-of-the-art information on these aspects with a focus on dysregulated keratinocyte and immune cells; and role of ECM, and Keratin functions in this regard.

The role of incretins and incretin-based drugs in autoimmune diseases

Incretin hormones, including glucagon-like peptide (GLP)-1, GLP-2 and glucose-dependent insulinotropic polypeptide (GIP), are gastrointestinal peptides secreted from enteroendocrine cells. These hormones play significant roles in many physiological processes via binding to G-protein coupled receptors (GPCRs) on different organs and tissues; one of them is the immunomodulatory effect on the immune system and its molecular components such as cytokines and chemokines. Anti-inflammatory effects of incretins and dependent molecules involving long-acting analogs and DPP4 inhibitors through regulation of T and B cell activation may attenuate autoimmune diseases caused by immune system disorders in mistakenly recognizing self as the foreign agent. In this review, we investigate incretin effects on the immune system response and the potential benefits of incretin-based therapy for treating autoimmune diseases.

Medical and Surgical Management of Hidradenitis Suppurativa: A Review of International Treatment Guidelines and Implementation in General Dermatology Practice

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic painful skin disease that severely impairs patients' quality of life. While high-quality trials of HS therapies remain limited, medical knowledge of best treatment practices is rapidly evolving, leading to the recent publication of multiple international treatment guidelines for HS.

SUMMARY

This review compares international HS treatment guidelines, describes evidence for effectiveness of common and emerging HS therapies, and provides guidance for integrating evidence-based HS care into practice. Although over 50 medical and procedural treatments are mentioned across international HS guidelines, only adalimumab and infliximab have grade B/weak recommendation or higher across all major guidelines. This review describes the appropriate patient selection and effectiveness of the most commonly used medical and procedural treatments for HS. It also includes recommendations for counseling, dosing, and duration of medical therapies as well as procedure videos for the practicing dermatologist.

Emerging medical treatments for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory disease affecting intertriginous skin areas, and it is characterized by recurrent painful episodes of inflammatory drainage. Although the pathophysiology of HS is not fully understood, recent research points to an imbalance of cytokines as a contributing factor to the associated symptoms of purulent drainage and sinus tract formation. HS lesions are often characterized by a superimposed pathogenic/commensal bacterial infection that can improve with targeted antibiotic therapy. New medical treatments have emerged in recent years, many of which specifically work against a variety of proinflammatory mediators associated with HS. These newer, specified treatment options, in conjunction with surgery and lasers, are thought to provide positive outcomes and an overall improvement in quality of life in patients with HS.

Hidradenitis suppurativa: Current and emerging treatments

The treatment of hidradenitis suppurativa (HS) has remained challenging because of the many knowledge gaps regarding etiology. However, recent studies into the pathogenesis of HS have enabled the investigation of newer therapies. The second article in this continuing medical education series reviews the evidence for established therapies for HS, including anti-inflammatories, antibiotics, and surgery. New and emerging therapies that specifically target cytokines involved in HS pathogenesis will be covered. The potential therapeutic roles of anticytokine therapies, including both the expanded application of existing molecules as well as the specific development of novel therapies for HS are discussed. With increased attention on HS and with numerous clinical trials currently underway, we hope that the variety of treatment options for HS will be expanded.

Weight Loss and Dietary Interventions for Hidradenitis Suppurativa: A Systematic Review

Hidradenitis suppurativa (HS) is a common inflammatory disorder characterized by recurrent, painful, and malodorous abscesses and nodules predominantly in skin folds. HS is associated with substantial morbidity and poor quality of life. There are no curative therapies, and the only approved biologic drug has variable efficacy and requires high doses, making adjunct treatments crucial. An important risk factor for disease severity is obesity. Our primary objective was to conduct a systematic review examining weight loss and dietary interventions, in HS. Our secondary objective was to examine nutritional supplements in HS.A systematic literature search was conducted using Medline, EMBASE, and the Cochrane Database. We included all study types in adults (>18 years), with a minimum sample size of 5, examining the effects of any dietary or weight loss intervention on HS severity. Two authors screened n = 1279 articles of which 9 met inclusion criteria. All included studies were observational and all interventions were associated with various measures of decreased HS severity. Patient-controlled weight loss and bariatric surgery were associated with HS regression, though a subset of patients with significant increase in panniculi experienced exacerbations and required excision of excess skin. Diets demonstrating benefit eliminated dairy and brewer's yeast. Nutritional supplements including zinc gluconate, vitamin D, and riboflavin had a suppressive, rather than curative, effect on HS lesions in single studies. Overall, the reviewed interventions show promise as potential adjunct treatments in a HS management plan. Prospective randomized controlled trials should validate these findings.

T helper 17 cell/regulatory T-cell imbalance in hidradenitis suppurativa/acne inversa: the link to hair follicle dissection, obesity, smoking and autoimmune comorbidities

BACKGROUND

Disintegration of the infundibula of terminal hair follicles (HFs) in intertriginous skin areas exhibits the histological hallmark of hidradenitis suppurativa (HS)/acne inversa, featuring a dissecting terminal hair folliculitis. Elevated serum levels of interleukin (IL)-17 and local increase in the ratio of proinflammatory T helper (Th)17 cells and anti-inflammatory regulatory T cells (Tregs) have been reported. Perifollicular Tregs play a key role in HF stem cell homeostasis and infundibular integrity.

OBJECTIVES

In this review, we evaluate the Th17/Treg ratio in HS, its aggravating conditions and associated comorbidities. Furthermore, we intended to clarify whether drugs with reported beneficial effects in the treatment of HS readjust the deviated Th17/Treg axis.

METHODS

PubMed-listed, peer-reviewed original research articles characterizing Th17/Treg regulation in HS/acne inversa and associated comorbidities were selected for this review.

RESULTS

This review presents HS as a disease that exhibits an increased Th17/Treg ratio. Perifollicular deficiencies in Treg numbers or function may disturb HF stem cell homeostasis, initiating infundibular dissection of terminal HFs and perifollicular inflammation. The Th17/Treg imbalance is aggravated by obesity, smoking and decreased Notch signalling. In addition, HS-associated autoimmune diseases exhibit a disturbed Th17/Treg axis resulting in a Th17-dominant state. All drugs that have beneficial effects in the treatment of HS normalize the Th17/Treg ratio.

CONCLUSIONS

HS immunopathogenesis is closely related to deviations of the Th17/Treg balance, which may negatively affect Treg-controlled HF stem cell homeostasis and infundibular integrity. Pharmacological intervention should not only attenuate Th17/IL-17 signalling, but should also improve Treg function in order to stabilize HF stem cell homeostasis and infundibular integrity.

An update on the pathogenesis of hidradenitis suppurativa: implications for therapy

INTRODUCTION

Hidradenitis suppurativa is a chronic, inflammatory disease characterized by painful nodules, abscesses, and sinuses in the intertriginous areas, with significant associated comorbidities. The pathogenesis remains unclear, although advances have been made in understanding the disease process. Management of the disease is challenging, with a wide range of treatment options available with variable clinical response. Areas covered: This review discusses the most updated studies on the complex pathogenic mechanisms of hidradenitis suppurativa and the relevant literature on the current treatment options for this condition. Expert commentary: There is increasing evidence supporting the role of Th17 cells and enhanced expression of IL-17 and IL-1β, which represent potential targets for therapy. Bacteria and biofilms are likely contributory but secondary drivers of inflammation. There is also evolving evidence to suggest the presence of systemic comorbidities associated with HS, which underlie the importance of better understanding the pathogenesis and treatment of this disease.