Hidradenitis Suppurativa (HS) is a chronic inflammatory skin condition characterized by the recurrent appearance of painful, deep-seated nodules and abscesses. This disorder primarily affects hair follicles and associated apocrine glands, often leading to the formation of tunnels, known as sinus tracts, beneath the skin. The established link between excess body weight, particularly obesity, and the severity of HS is a major focus in disease management. This relationship raises the question of whether weight loss can fully resolve the condition.
Understanding Hidradenitis Suppurativa
HS lesions typically develop in areas where skin rubs against skin, known as intertriginous regions, such as the armpits, groin, inner thighs, and buttocks. The painful lumps often resemble boils, but they are rooted deeper and can persist for weeks or months, sometimes rupturing to leak pus and foul-smelling fluid.
The underlying process involves follicular occlusion, where hair follicles become blocked, followed by rupture and a profound inflammatory response. This is not simply a bacterial infection. Clinicians use the Hurley staging system to categorize disease severity. Stage I involves isolated abscesses without sinus tracts or scarring. Stage II includes recurrent abscesses with sinus tracts and scarring. Stage III is the most severe, presenting with diffuse involvement, interconnected sinus tracts, and extensive scarring across an entire area.
How Adipose Tissue Drives HS Activity
Excess adipose tissue, or body fat, functions as an active endocrine organ that contributes significantly to systemic inflammation. This tissue releases signaling molecules called adipokines, which worsen the inflammatory state of HS. Patients with HS often show an imbalance, with elevated levels of pro-inflammatory adipokines like leptin and resistin, and suppressed levels of the anti-inflammatory adipokine, adiponectin.
This dysregulation fuels the chronic inflammation driving HS lesion formation. Obesity also exacerbates mechanical factors that trigger flares. Increased body mass leads to larger skin folds, increasing skin friction and moisture retention in areas like the groin and underarms. This mechanical stress promotes follicular occlusion and rupture, adding a physical component to the disease activity.
Obesity is also closely linked to metabolic conditions like insulin resistance, which can influence the severity of follicular diseases. Insulin resistance can elevate androgen activity, potentially worsening the pathology of the hair follicle unit. The connection between increased weight and HS activity is two-fold: a systemic inflammatory effect and a local mechanical stress effect.
Weight Reduction and Disease Severity
Weight loss, particularly in individuals with obesity, is strongly associated with a reduction in HS disease severity and flare frequency. Studies indicate that losing 15% or more of total body weight yields substantial improvement in symptoms. This often manifests as a decrease in painful nodules and a regression in Hurley staging, sometimes moving patients from Stage II to a milder Stage I.
Bariatric surgery provides compelling evidence, as the resulting massive weight loss is frequently followed by significant improvement or even remission of HS in many patients. Weight loss is considered a management strategy that can achieve remission, but it is not a guaranteed cure, as it does not eliminate the underlying genetic predisposition. Rapid weight loss can sometimes lead to excess loose skin, which may increase skin-on-skin friction and temporarily worsen symptoms in some individuals.
Comprehensive Management Beyond Weight Loss
While weight loss is a powerful tool, effective management of HS requires a multidisciplinary approach combining lifestyle changes with medical and procedural therapies. Smoking cessation is highly recommended, as tobacco use is a major independent factor that exacerbates disease severity. Patients are also advised to wear loose-fitting clothing to minimize friction and use proper wound care techniques for draining lesions.
Pharmacological treatments are essential, with options ranging from topical and oral antibiotics, such as clindamycin and rifampicin for moderate disease, to hormone therapies like spironolactone for women. For moderate-to-severe cases, biologic medications, such as the tumor necrosis factor (TNF) inhibitor adalimumab, target the systemic inflammatory pathways driving the condition. When the disease has caused irreversible damage, procedural interventions like deroofing or wide surgical excision are utilized to remove sinus tracts and fibrotic tissue. These procedures may be needed even after successful weight reduction.