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IN-DEPTH REVIEW

Nutrition Education Toolbox for Hidradenitis Suppurativa

Jennifer M. Fernandez MD, RD1, Joi Lenczowski MD2, Jennifer L. Hsiao MD3, Vivian Y. Shi MD4

1University of Arizona, College of Medicine; Tucson, AZ, USA
2Virginia Commonwealth University, Department of Dermatology, Richmond, VA, USA
3University of California Los Angeles, Department of Medicine, Division of Dermatology, Los Angeles, CA, USA
4University of Arkansas for Medical Sciences, Department of Dermatology; Little Rock, AR, USA

Background
Emerging evidence suggests that diet
influences hidradenitis suppurativa (HS)
symptoms.1–4 Recent survey studies indicate
that up to 90% of HS patients have attempted
to manage HS through dietary changes, with
up to 65% of patients reporting that dietary
changes were beneficial.1,5 Price et al.
identified dietary modification to be the most
commonly self-employed complementary
alternative medicine (CAM) intervention
implemented by HS patients.5 Though
current evidence supporting dietary
recommendations in HS is low to moderate in
quality,6 patients still frequently express
interest in discussing dietary changes with
their healthcare providers. However,
providing nutrition education during clinic

visits can be time consuming, and physicians
may not feel equipped to do this. Referring
patients to a registered dietitian (RD) for HS
is often not feasible due to limited insurance
coverage for nutrition visits. Though dietary
changes are commonly implemented by HS
patients, there is currently no comprehensive
HS nutritional guide. Our goal is to provide
practical, cost-conscious nutrition
recommendations as an adjunct to
conventional medical treatments for HS.
Herein, we provide information in a handout
that was developed with input from HS
specialists, a registered dietitian, and a
culinary specialist.

Impact of diet
The proposed mechanism of dietary
involvement in HS is largely extrapolated
from the literature on acne given the similar
pathogenesis.7,8 Refined carbohydrates

ABSTRACT

Diet has been shown to influence disease activity in hidradenitis suppurativa (HS). Modification of
dietary intake is the most commonly used lifestyle intervention in HS, and patients frequently report HS
improvement after implementing dietary changes. Providing nutrition education may be perceived as
not feasible within the time constraints of an outpatient office visit, and many physicians may also not
feel equipped to do this. In addition, most insurances have limited coverage for nutrition visits. However,
dietary changes may be employed as a low-cost adjunctive treatment option that can be combined with
conventional medical treatment to mitigate HS symptoms. Though dietary modification has been
increasingly recognized as a commonly used and influential factor in HS management, there is no
comprehensive HS nutritional guide. Herein, we provide tools for both physicians and patients to
facilitate evidence-based nutrition education in HS through collaboration with dermatologists
specializing in HS, a registered dietitian, and a culinary specialist.

INTRODUCTION

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May 2021 Volume 5 Issue 3

increase insulin levels, and dairy increases
insulin and insulin-like growth factor-1 (IGF-
1).9,10 Subsequent hyperinsulinemia causes
a nuclear androgen repressor, forkhead box
protein O1 (FOXO1), to enter the cytoplasm,
activating mTORC1 (the kinase mammalian
target of rapamycin complex 1) signaling,
leading to increased sebaceous lipogenesis
and contributing to follicular occlusion.9,10
Increased androgenic signaling due to
exogenous hormones in dairy products and
lack of nuclear androgen suppression with
FOXO1 may increase the production of
keratinocytes and induce subsequent
follicular blockage in acne and HS.9 As such,
it may be beneficial for patients to avoid dairy
and refined carbohydrates.

Additionally, hyperglycemia due to excessive
carbohydrate consumption can increase
circulating inflammatory cytokines.11–13 An
imbalance of omega-6 to omega-3 fatty acids
can lead to production of prostaglandins,
thromboxanes, and leukotrienes through the
arachidonic acid pathway, and excessive
saturated fat intake can have inflammatory
effects by disrupting normal immune cell
function.12,14,15 High salt intake can also alter
immune activity and inhibit growth of
beneficial bacteria that are part of a healthy
gut microbiome.16,17 Dietary intake is
immediately modifiable with minimal side
effects, making diet an important target for
disease management. Physicians should
counsel patients that improvement in HS
symptoms after dietary changes may take
time and may require long-term dietary
adjustments. Given this, dietary interventions
may be more suitable for a more motivated
subset of patients.

Impact of weight, diabetes, and metabolic
syndrome
Obesity is associated with insulin resistance
and chronic low-grade inflammation due to
circulating cytokines such as tumor necrosis

factor (TNF) and interleukin (IL)-6.18 The
excessive adipocytes present with obesity
can perpetuate production of inflammatory
cytokines such as TNF that are also
implicated in HS pathogenesis.19 Obesity
correlates with increased HS disease
severity and is commonly observed in HS
patients.20 More than half of HS patients are
either overweight (27%) or obese (36%).20
Obesity likely contributes to increased HS
severity through inducing inflammation and
excessive friction.21 Weight loss of more than
15% is associated with a clinically significant
decrease in HS severity.22 Diabetes and
metabolic syndrome can also accompany
HS. Rates of diabetes mellitus in HS patients
range from 5% to 20%,23 and approximately
40% of HS patients have metabolic
syndrome.24 Obesity and diabetes can both
cause hyperinsulinemia, promoting
excessive lipogenesis and contributing to
follicular occlusion in HS.7

Factors affecting food choices
Many factors may contribute to food selection
in HS patients, such as limited mobility which
may affect the ability to go food shopping, low
socioeconomic status (SES), unemployment,
financial hardship, poor mental health, and
cultural preferences. HS is associated with
low SES and with high levels of anxiety,
depression, and loneliness and low self-
esteem.25 Characteristic symptoms of HS
including pain, malodorous discharge, and
itch are major contributors to physical
disability.26

Research shows that several of the diets
studied in HS may attenuate disease severity
including the Mediterranean diet, a brewer’s
yeast-free diet, and a dairy-free diet.7,27,28
Sample nutrition handouts for HS patients
incorporating recommendations based on

NUTRITION RECOMMENDATIONS

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these studies are provided in Figures 1, 2, 3,
and 4.7,9,10,27–30 While daytime fasting over a
prolonged period of time has been shown to
decrease the number of abscesses and
draining fistulas,3 persistent fasting is likely
impractical for most patients. Thus, a well-
balanced diet with an appropriate caloric
intake may serve as a better approach for HS
patients.

Foods to Avoid
Yeast
Diets restricting the intake of yeast have
shown positive results in HS, including
brewer’s yeast that leads to fermentation in
alcohol and baker’s yeast that causes baked
products to rise; these yeasts are each
comprised of a different strain of
Saccharomyces cerevisiae, a single-celled
fungal organism.4,28 In an initial study with a
small cohort, twelve HS patients followed a
wheat and brewer’s yeast-free diet for 12
months after surgical excision of HS lesions
and were instructed to avoid baked goods
(such as pizza, cake, bread, etc.), vinegar,
black tea, soy sauces, beer, wine, fermented
cheese, and mushrooms.28 All 12 patients
experienced regression of HS lesions, with
immediate reappearance of lesions upon
reintroduction of brewer’s yeast, beer, or
wheat and subsequent disappearance of
lesions after those agents were removed
from the diet again.28 A larger follow up study
evaluated 37 HS patients who followed a
yeast-free diet for six years after excision of
HS lesions, with 70% reporting improvement
in HS symptoms without other accompanying
treatment, and 87% reporting recurrence of
HS symptoms within a few days after
consuming a restricted food.4 Though the
sample sizes in these studies are small and
patients were also treated with surgery, the
results after implementation of a yeast-free
diet are promising.

Carbohydrates
Refined carbohydrates
Refined carbohydrates can lead to
hyperinsulinemia which may exacerbate
follicular occlusion.9,10,31 Refined
carbohydrates come from sweets, sugar-
containing beverages, many snack foods,
and refined grains such as white rice, white
bread, and pasta.

Grains
At least half of all grains consumed should be
whole grains such as 100% whole wheat
bread, whole-grain pasta, and brown rice.32

Added sugars
Dietary Guidelines for Americans 2015-2020
recommended that less than 10% of daily
calories come from added sugars, a major
dietary source of refined carbohydrates.32
Nearly 80% of added sugars are from
beverages, snacks, and sweets,32 so
replacing these items with healthier options
may significantly decrease intake of added
sugars. Sugar-sweetened beverages like
soda, juice, and sports drinks contain calories
but have minimal nutritional value. Fruit
drinks are often thought of as a healthy
option, but they frequently contain added
sugar. If fruit juice is consumed, it should be
“100% fruit juice”, and it should be consumed
in limited quantities (4-6 oz/day).32 Low-
calorie beverages without added sugars
should be encouraged. Seltzer water, with a
splash of 100% juice, or club soda with
wedges of lemons, limes, or oranges can be
a refreshing alternative to traditional juices
and sodas. Adding fresh fruit such as
raspberries or vegetables such a sliced
cucumber to water can also add a hint of
flavor. Unsweetened tea is a healthier
alternative for sweetened tea.

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Figure 1. Nutrition handout with recommendations for anti-inflammatory
foods, dairy intake, and healthy snack options.

Figure 2. Nutrition handout with recommendations for carbohydrate intake.

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Finding healthy and affordable snack options
can be challenging, especially when.
processed snacks, such as chips and
cookies, are cheap and readily available

Eating fruits or vegetables as a snack can
help patients reach the recommended daily
intake of these food groups. While nuts are
high in calories, they provide a source of
healthy, anti-inflammatory fats, and unsalted
nuts in ¼ cup portions make travel-friendly
and convenient snacks. Air-popped popcorn
or whole grain crackers with almond butter
are also healthy snack options. Cravings for
sweet treats can be satisfied with healthier
alternatives such as baked apple wedges,
sautéed banana slices, pear slices sprinkled
with crushed walnuts, fruit salads, or frozen
fruit puree popsicles.

Dairy
Dairy is defined as products made from the
fluid form of milk such as cheese, yogurt, and
cottage cheese. Dairy products contribute
many essential nutrients including calcium,
vitamin D, and vitamin B12, among others.32
In a cohort of 43 HS patients who followed a
dairy-free diet, 83% improved.7 HS patients
who eliminate dairy may consume
inadequate amounts of calcium and may
require supplementation. Other sources of
dietary calcium include sardines and salmon,
green leafy vegetables, soy products, beans,
and nuts.29 Soy products such as soy cheese
and soymilk, almond milk, and rice milk can
serve as dairy alternatives.

Foods to Consume
Anti-inflammatory foods and the
Mediterranean-style diet
The Mediterranean diet and increased intake
of omega-3 fatty acids are associated with
lower HS severity scores.27 Currently, there
is no clear definition of an anti-inflammatory
diet. However, the Mediterranean diet is
regarded as an anti-inflammatory diet and

has been shown to decrease risk of cancer,
cardiovascular disease, and diabetes, among
other conditions.33 A Mediterranean-style diet
is a plant-based diet high in fiber and omega-
3 fatty acids which have anti-inflammatory
effects. It is characterized by an abundance
of fruits and vegetables that contain
polyphenols that counteract inflammation.
Vegetables and fruits have a low caloric
density and are high in fiber, both of which
are important for weight control.
Unfortunately, only about 20% of Americans
consume the recommended amount of fruits
and vegetables.32

Major protein sources in the Mediterranean
diet include fish, nuts, and beans while
animal proteins such as red meat and dairy
are consumed in limited quantities. Olive oil
is the principal source of fat; saturated fat is
limited. In addition, whole grains are
emphasized over refined carbohydrates.
Fatty fish such as salmon, trout, or tuna are
high in omega-3 fatty acids and should be
consumed two times per week.

Other Considerations
Portion sizes
Excessive portion sizes can contribute to
overconsumption of calories, leading to
obesity. Serving sizes vary based on whether
a food is cooked (takes up less space) or raw.
Serving sizes also vary for different food
groups.32 For vegetables, one serving is
typically ½ cup of cooked vegetables or 1 cup
raw. A serving of fruit is ½ cup chopped fruit,
one small fist-sized piece of fruit, or ¼ cup
dried fruit. A serving of meat is typically 3-4
oz. A portion of dairy is 1 cup of milk or yogurt
or 1.5 oz of cheese. While measuring cups
and scales may be the most accurate way to
measure foods, patients may find it more

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Figure 3. Nutrition handout with general tips for healthful eating and portion
sizes.

Figure 4. Nutrition handout with tips for eating out.

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practical to use parts of the hand (such as
fingertip, palm, and clenched fist) to estimate
portion sizes (Figure 3).

Recommendations for eating out
While eating out can be a fun social
experience, portions can be excessive, and
food is often high in fat and sodium. To limit
excess calories, fat, and sodium, encourage
patients to order from the lunch menu as
portions tend to be smaller and cheaper than
the dinner menu. Ask for sauce on the side or
no sauce as sauce can often be high in
saturated fats. To avoid eating extremely
large portions, patients may consider splitting
an entrée. Alternatively, requesting a to-go
container when the order is placed and
putting half of the food in the container before
eating can help limit excessive consumption.
Avoid buffets as portion control is extremely
challenging in this setting. Choose water
rather than juice, soda, or alcohol to curb cost
and calories.

Food assistance options
Supplemental Nutrition Assistance Program
(SNAP), formerly called the Food Stamp
Program, is a government assistance
program that distributes benefits monthly
onto an Electronic Benefit Transfer (EBT)
card which can be used like a debit card.34 It
can be used at various grocery stores, dollar
stores, pharmacies, convenience stores, and
big-box stores (such as Walmart and Target),
among others.34 EBT cards allow purchase of
fruits, vegetables, meat, poultry, fish, dairy,
breads, and cereals, and other items.34 They
cannot be used for alcohol or prepared or hot
foods. Food pantries and food banks are also
sources of food distribution, and information
about location of food pantries can be found
at https://www.foodpantries.org/. As some
patients may not have access to the internet,
physicians may consider providing paper
handouts. Using coupons can also help save
money. Community Supported Agriculture

(CSA) programs are subscription-based
programs that local farmers participate in,
where consumers who purchase a
subscription receive a box of produce and
other farm goods such as eggs or meat
several times per month.

Insurance coverage
Approximately a third (31.5%) of HS patients
are insured by either Medicare or Medicaid,
which is a significantly higher proportion than
age-matched controls.35 For those with
diabetes or kidney disease, Medicare Part B
covers up to three visits per year with a
registered dietitian,36 and this can be
considered for motivated patients who meet
criteria. Medicaid nutrition benefits vary by
state, and states are not required by the
federal government to provide Medical
Nutrition Therapy (MNT) benefits, although
about half of states offer some nutrition
services benefits.37 Coverage for nutrition
visits with private insurances can vary
greatly, so patients should be encouraged to
contact their insurance provider to inquire
about coverage. Once insurance coverage
for MNT is established, the website hosted by
the Academy of Nutrition and Dietetics can
assist physicians and patients with finding a
registered dietitian in their area
(https://www.eatright.org/find-an-expert).

More research is needed regarding the
mechanism of diet in HS, but these studies
are difficult to conduct given the unique
dietary needs, preferences, and culinary and
cultural practices of each individual. These
studies may also require participation for an
extended duration to adequately evaluate the
impact of dietary modifications, which is
further complicated by a high risk of poor
dietary adherence. The benefit of restricting
total caloric intake versus restricting specific

CONCLUSION

https://www.foodpantries.org/
https://www.eatright.org/find-an-expert

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food groups or ingredients in HS is largely
unknown, and specific dietary guidelines for
HS are lacking. Nutrigenetics and
nutrigenomics are at the forefront of applied
nutrition research and can be incorporated
into future diet-related investigations for HS
patients.

Clinic visits between patients and
dermatologists can often be limited by time
constraints, and nutrition counseling from an
RD is often not covered by insurance, so
providing nutrition education to patients can
be challenging. However, efforts should be
made by HS physicians to address diet as
part of their treatment plan. A healthy and
well-balanced diet should be the foundation
of dietary counseling. Recommendations
should be tailored to patients of varying SES
with consideration of cultural preferences,
food costs, access, and preparation time. In
addition, being mindful of eating behaviors
and recognizing the tendency to eat when
under stress, or as a response to other
emotions, can help prevent unnecessary
calorie consumption. These strategies can be
incorporated into comprehensive treatment
plans to both help manage HS symptoms and
to promote overall health.

Conflict of Interest Disclosures: VYS is on the
Board of Directors for the Hidradenitis Suppurativa
Foundation, is a stock shareholder of Learn Health
and has served as an advisory board member,
investigator, and/or received research funding from
Sanofi Genzyme, Regeneron, AbbVie, Eli Lilly,
Novartis, SUN Pharma, LEO Pharma, Pfizer, Menlo
Therapeutics, Burt’s Bees, Galderma, Altus Lab,
GpSkin and Skin Actives Scientific. JLH has served as
an advisor for Novartis. There were no incentives or
transactions, financial or otherwise, relevant to this
manuscript.

Jennifer M. Fernandez and Joi Lenczowski have no
conflicts of interest.

Funding: None

Corresponding Author:
Vivian Y. Shi, MD
Associate Professor, Department of Dermatology
University of Arkansas for Medical Sciences
4301 West Markham, Slot 576
Little Rock, Arkansas 72205
Phone: 501-686-5110
Email: vivian.shi.publications@gmail.com

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