Hidradenitis suppurativa (HS) is a chronic inflammatory skin disorder marked by deep-seated, inflamed nodules in the apocrine gland-bearing areas of the body, commonly the axillae and inguinal and anogenital regions.1,2 It is a prevalent but under-recognized disease, accounting for 0.006-4.1% of the population, and typically manifests between the second and third decades of life, with an average age of onset ranging between 20-27 years. Women are three times more affected by HS than men.3 Despite a large array of therapeutic options available, the course of the illness is usually chronic and relapsing. Surgical excision with secondary healing is often indicated, and wide surgical excision is considered the only curative treatment, although even this method is not a permanent solution.4

In order to improve the quality of life in patients impacted by this chronic and debilitating disease, it is important to increase one’s understanding about HS and its treatment beyond the traditional therapies. Integrative dermatology is a holistic approach to treatment that incorporates traditional and complementary alternative medicine.5 Some of the lifestyle factors to consider include nutrition, smoking, substance use, physical activity, sleep, and stress. Essentially, these are modifiable lifestyle adaptations that may impact the severity of disease. Integrative approaches to treatment can be beneficial for patients who have had limited results with traditional methods or are hesitant to use pharmacological interventions. There is evidence that other dermatological disorders have responded to integrative dermatology.5 For instance, a review conducted in 2020 found evidence that increased alcohol consumption is associated with increased rates of skin cancer, acne, and psoriasis.5 Despite the rising interest in integrative approaches, quality data supporting their practice are not robust, particularly relating to HS. Thus, the purpose of this review was to assess and synthesize the data pertaining to lifestyle factors that may help to optimize HS management.


A literature search was completed by two authors (M.P and C.S) on PubMed, EMBASE, Google Scholar,, and Cochrane Library databases. The literature was assessed for five lifestyle factors associated with hidradenitis suppurativa (psychological stress, mechanical stress, sleep, smoking, and substance use). The following search terms were used: “(lifestyle factors) and (hidradenitis suppurativa)”; “(integrative dermatology) and (hidradenitis suppurativa)”; “(stress) and (hidradenitis suppurativa)”; “(smoking) and (hidradenitis suppurativa)”; “(sleep) and (hidradenitis suppurativa)”; “(alcohol) and (hidradenitis suppurativa).” Literature reviews and systematic reviews without meta-analysis were excluded. Non-English articles without a translated section were excluded. The search included all articles published without a time period restriction due to the limited data on the subject matter. Literature results were gathered and organized into Covidence, a web-based software platform to organize references for reviews. Literature on weight loss/nutrition/diet were not included due to the abundance of data on the topic and a general, solidified consensus by practitioners on the effects of weight/nutrition/diet on HS. The authors sought to add a novel integrative medicine perspective to HS beyond nutritional interventions.


Our literature search yielded 779 results, of which, after duplicates and full-text screening, 50 were included in the final review. Table 1 lists a summary of the included studies organized by lifestyle factor. The results will be discussed in the context of each modifiable lifestyle factor. There was a total of nine studies on psychological stress, eight on mechanical stress, five on sleep, twenty on smoking, and eight studies on substance use.

Table 1.
Author (Year) Study Type/ Sample Size Study Objective HS Severity Results Limitations
Psychological Stress
Chiricozzi (2018)6 Cross-sectional questionnaire/ 86 hidradenitis suppurativa (HS) patients

100 obese individuals

85 control subjects
Assess the presence of alexithymia in patients with HS Not applicable The mean Toronto Alexithymia Scale (TAS)-20 score was significantly higher in the HS patient cohort (55.37 ±13.42) than in the control group (40.96±10.47) (p < 0.001) Cross-sectional design
Esmann (2011)7 Interview/ 12 HS patients Assess the psychosocial impact of HS Not applicable HS negatively impacts self-worth, intimate relations, communication, and work. It also leads to increased stigmatization Small study sample

Descriptive analysis
Frings (2019)8 Questionnaire/ 110 HS patients Assess the psychological burden in HS Hurley Staging Significant correlation between Hospital Anxiety and Depression Scale and Visual Analogue Scale (VAS) (for pain) (p = 0.009), between Skindex-29 and Sartorius score (symptoms: p = 0.024; emotions: p = 0.019), as well as between Skindex-29 and VAS (symptoms: p = 0.000; emotions: p = 0.001) Small study sample
Gielin (2020)9 Case-control/ 71 HS patients and 213 controls Assess the link between traumatic events and the development of HS Not applicable Childhood emotional traumatic events (odds ratio (OR) 5.03, p < 0.05) were significantly associated with the development of HS Recall bias

Small study sample
Keary (2020)10 Structured interview/ 12 HS patients Assess the psychological distress in HS Not applicable HS patients commonly experience shame and pain and have adapted coping mechanisms to deal with their symptoms Small sample size

Descriptive analysis
Kirby (2017)11 Cross-sectional, multicenter survey/ 154 HS patients Investigate resilience, depression, and health-related quality of life (HRQOL) in HS patients Not applicable The resilience score was significantly associated with depressive symptoms (regression coefficient a = −0.21; p < 0.001), and the depressive symptoms score (c = 0.637; p < 0.001) was significantly associated with lower HRQOL (c′ = 0.644; p < 0.001) Cross-sectional design
Kouris (2016)12 Questionnaires/ 94 HS patients Evaluate quality of life, depression, anxiety, loneliness, and self-esteem in patients with HS Not applicable HS patients presented with significantly higher anxiety (6.41 ± 3.31 vs. 5.00 ± 1.59, p < 0.001), depression (5.45 ± 2.79 vs. 4.16 ± 1.54, p < 0.001), loneliness and social isolation scores (42.86 ± 8.63 vs. 35.57 ± 6.17, p < 0.001) and lower self-esteem scores (18.91 ± 1.79 vs. 19.77 ± 2.53, p = 0.008) than controls Small sample size

Self-reported diagnoses
Matusiak (2010)13 Questionnaires/ 54 HS patients Assess the psychophysical aspects of HS Not applicable Advancement of the disease is the most important factor negatively influencing patients’ well-being (P < 0.01). The anogenital location appears to impair the HS patients’ quality of life most of all (P < 0.05), but the occurrence of lesions on uncovered skin plays a large role in the stigmatization level (p < 0.05) Small study sample
Tzur (2020)14 Population-based retrospective review/ 4,191 HS patients

20,941 controls
Association between bipolar disorder and HS Not applicable Higher bipolar disorder HS patients compared with controls (0.7 vs. 0.1%,) Retrospective design
Mechanical Stress
Boer (2015)15 Case study/ 1 HS patient Resolution of HS by dietary measures Not applicable A 33-year-old female with chronic HS experienced resolution of the induration of her lesions on her inner thighs and lower abdomen corresponding to the location of her waist band, but persistent lesions on her buttocks after a 32 kg weight loss One patient

No controls/interventions
Boer (2016)16 Case study/ 1 HS patient Elucidate role of mechanical stress in HS Not applicable 33-year-old woman with HS had superficial nodule and follicular papules in area of mechanical stress by bra edge One patient

No controls/interventions
Boer (2017)17 Case series/ 14 HS patients with lesions in areas exposed to Describe possible Koebner phenomenon in HS Not applicable All patients were obese with mean BMI of 35.8 and had ectopic HS lesions at the sites of friction of the convex abdomen (waistband) No controls/interventions
De Vita (2018)18 Case study/ 1 HS patient Elucidate role of mechanical stress in HS Not applicable 54-year-old man without a history of HS developed chronic, recurrent, inflammatory nodules, cysts, and depressed scars at the location of a giant abdominal hernia One patient

No controls/interventions
de Winter (2012)19 Case study/ 1 HS patient Elucidate role of mechanical stress in HS patients Not applicable 44-year-old man without a previous history of HS had recurrent, inflammatory deep-seated nodules, abscesses and fistulas on the amputation stump of his left leg, at the site of his lower leg prosthesis One patient

Lack of intervention

Case study design
Dufour (2010)20 Case study/ 1 HS patient Possible influence of mechanical stress on the development of HS Not applicable Infant developed HS-like lesions in inguinal naevus comedonicus after mechanical stress in the area One patient

No controls/interventions
Rondags (2017)21 Case study/ 1 HS patient Elucidate role of mechanical stress in HS Not applicable 28-year-old man with a history of HS developed small ulcers with yellowish-brown discharge and sinus tract formation as well as a dark erythematous plaque on his right foot after wearing a new, rigid pair of tight-fitting work shoes One patient

No controls/interventions
Von Der Werth (2004)22 Cross-sectional questionnaire/ 156 HS patients Describe natural history of HS Not applicable 16/110 (16%) patients reported tight clothing and friction as an aggravating factor of HS and 11/110 (11%) reported loose clothing as a relieving factor of HS Recall bias
Cohen (2021)23 Retrospective study/ 4,417 HS patients and 22,085 controls Determine the association of HS and obstructive sleep apnea (OSA) Not applicable Patients with HS have a 1.60 OR of having OSA (95% CI 1.36-1.86; p < 0.001) and a 1.32 OR of having a non-OSA sleep disorder (95% CI 1.12-1.57; p < 0.001) Lack of data on severity of HS
Kaaz (2018)24 Cross-sectional questionnaire/ 108 HS patients and 50 controls Pain and itch sleep implications in HS patients Hidradenitis Suppurativa Score (HSS)

Hidradenitis Suppurativa Severity Index (HSSI)

Hurley’s Staging
Mean± standard deviation The Athens Insomnia Scale (AIS) and Pittsburgh Sleep Quality Index (PSQI) scores among patients with hidradenitis suppurativa vs. controls were assessed as 5.4±4.3 vs. 5.5±3.4 and 6.5±3.6 vs. 3.1±1.9 points, respectively. The presence of itch and pain had a significant impact on the frequency of insomnia. Cross-sectional design
Kelly (2021)25 Prospective study/ 36 HS patients and 31 psoriasis patients Formal sleep studies to assess OSA prevalence in HS Hurley Staging 50% HS patients and 34% psoriasis patients had a high probability of OSA, as assessed by the Berlin and STOP-Bang questionnaires.

Six patients with HS (37%) and six psoriasis patients (43%) were positive for sleep apnea based on overnight sleep studies.
Small study sample
Vossen (2017)26 Cross-sectional/ 211 HS patients Prevalence and characteristics of pruritis in HS patients Not applicable 121/211 (57.3%) of patients had pruritus based on a numerical rating scale (NRS, 0 – 10) with a mean NRS score of 6.1 ± 2.0 Cross-sectional design
Wertenteil (2018)27 Retrospective cohort analysis/ 19,945 HS patients OSA incidence in HS Not applicable OSA incidence among patients with HS was 3·5% (n = 695/19 945) vs. 2·5% (n = 7400/296 170; p < 0.001) in patients without HS.

The overall odds of a new OSA diagnosis among patients with HS were 1·41 [95% confidence interval (CI) 1.30–1.53] vs. without HS 1.45 (95% CI 1.33–1.57)
Retrospective design
Akdogan (2018)2 Case control/ 40 HS and 40 control Smoking and its risk with HS Hurley Staging

HS Physicians Global Assessment (PGA)
Smoking associated with a 14.87-fold increase in the risk of HS (p = 0.001, 95% CI 2.82—78.56) Small sample size
Deilhes (2020)28 Retrospective review/ 51 HS patients who smoked Smoking cessation program (SCP) vs. smoking reduction program (SRP) Not applicable 48 patients followed up for 11.6 months, with 70% of patients attending the SCP. 1/3 stopped smoking and 44% reduced consumption (mean decrease 2.4 cigarettes per day). Among quitters, 93% attended the SCP. Lack of controls

Descriptive analysis
Denny (2017)3 Retrospective review/ 198 patient smokers and non-smokers Assess patient factors that increase response to medical therapy Not applicable Non-smokers/former smokers had a 2.634 (95% CI = 1.301-5.332, p = 0.007) times increased odds of having improvement in their disease compared to current smokers, regardless of amount smoked Study design

Lack of controls
Dessinioti (2017)29 Retrospective review/ 133 patients with HS Association between smoking and HS severity Hurley Staging

Number of affected areas in the body
Smoking causes no change in Hurley staging (OR = 1.31, 95% CI: 0.37–4.61), but increases number of affected body areas (OR: 3.56, 95% CI: 1.27–9.96) Small sample size

Retrospective design
Dessinioti (2018)30 Retrospective review/ 186 patients with HS Association between early-onset HS and smoking Hurley Staging

Number of affected areas in the body
Early-onset HS (<17 years old) is associated with fewer smokers than adult-onset HS (p < 0.001) Recall bias

Small non-smokers sample size
Foolad (2021)31 Cross-sectional review/ 761 patients with HS Characterize patients with HS at University of California Medical Center Not applicable There was a prevalence of about 38% current or former smokers in the cohort, and 57.7% of never smokers Lack of confounder analysis

Data from online database
Garcovich (2021)32 Cross-sectional review/ 870 pediatric patients with HS List risk factors for hospital-based pediatric patients with HS Hurley Staging 23.9% of the cohort were smokers which is higher than the referenced general population of 11.8% Cross-sectional design

Small sample size

Generalizability limitations
Garg (2018)33 Retrospective review/ 7,860 HS patients Incidence of HS among tobacco smokers Not applicable Incidence of HS was 0.20% among tobacco smokers and 0.11% among nonsmokers (p < 0.001) Cross-sectional design
Iannone (2021)34 Retrospective cohort/ 36 patients with moderate-severe HS Evaluate the effects of smoking on response to antibiotic therapy for HS mSartorius, acne inversa severity index (AISA), DLQI Smoking was positively correlated with AISA (Spearman's rho = 0.51, p = .036) and DLQI (0.47, p = 0.061) in patients being treated with clindamycin and rifampicin. Small sample size

Retrospective design
Killasli (2020)35 Cross-sectional registry/ 1,724 pregnancies with HS, 13,538 patients overall Study the prevalence of lifestyle factors that negatively affect health and pregnancy in HS pregnant patients Not applicable Smoking was reported in 41% of pregnant women with HS. 13% of women in the reference group were smokers. Cross-sectional design

Missing variables for some patients
Kjaersgaard (2021)36 Prospective cohort/ 23,930 Danish blood donors Association of remission rates of self-reported HS with smoking Not applicable Smoking was statistically associated with the development of self-reported HS (HR = 1.72, 95% CI: 1.15-2.5). Active smoking was also statistically associated with remission rates. (HR = 0.49, 95% CI: 0.32-0.76) Self-reported diagnosis
Kromann (2014)1 Retrospective Questionnaire, mean follow-up 22 years/ 212 HS patients Long-term prognosis and clinical course of HS based on risk factors Not applicable 92.2% of HS patients smoked tobacco. 40% (35/88) nonsmokers reported remission vs. 29% (17/59) active smokers reported remission Small sample size

Self-reported information
Liakou (2021)37 Cross-sectional study/ 290 HS patients Assess association between active smoking and HS as well as smoking and HS disease severity Hurley Staging

IHS4 score system
Active smoking statistically significant risk factor for higher stage of disease (OR 1.38, 95% CI: 1.11-1.65) Small sample size

Cross-sectional design
Macklis (2021)38 Cross-sectional online survey/ 591 patients with HS Determine lifestyle modifications that are associated with HS improvement Hurley staging Tobacco cessation showed improvement of HS in 17% of patients. The most significant improvement in subjective and Hurley staging of HS was seen with smoking cessation. Recall bias

Selection bias
Omine (2020)39 Retrospective case series/ 58 HS patients Assess the factors associated with HS severity and to compare characteristics of HS patients in East Asia and Western countries Modified Sartorius Score Smokers had a Sartorius Score of 48 compared to 57 in never smokers (p = 0.53). Ex-smokers had a Sartorius Score of 38 compared to 57 in never smokers (p = 0.35) Self-reported information on age of disease onset and comorbidities

Fewer mild cases because site is a referral site for severe cases
Revuz (2008)40 Two case-control studies/ 67 self-reported HS patients, 200 control 302 medically-assessed HS patients and 900 control Prevalence of HS in French population and associated factors Not applicable Strong association with current smoking in self-reported (OR = 4.16, 95% 95 % CI: 2.99-8.69) and in medically assessed (OR = 12.55, 95% CI: 8.58-18.38) populations Self-reported diagnoses

Study design
Sartorius (2009)41 Cross-sectional/ 251 HS patients Hidradenitis Suppurativa Score (HSS), BMI, and smoking habits on disease severity Hidradenitis Suppurativa Score Median HSS for smokers was 41, former smokers 27, and nonsmokers 22 Cross-sectional design

Small sample size
Schrader (2014)4 Retrospective review/ 864 HS patients Disease-related factors associated with HS Hurley Staging HS severity was associated with smoking pack-years (OR 1.02; p = 0.001) Self-reported data
Simonart (2010)42 Case series/ 2 HS patients Improvement HS lesions with tobacco cessation Not applicable 24-year-old woman with smoking history, HS refractory to antibiotics and zinc gluconate. Lesions improved 2 months after smoking cessation, no abscess/nodule recurrence

37-year-old woman with smoking history and HS refractory to antibiotics, isotretinoin, and zinc gluconate. HS lesions improved 3 months after tobacco cessation, in remission
Small sample size

No controls
Tzellos (2015)43 Meta-analysis/ Active smoking: 3,997 HS patients, 432 controls

History of smoking: 2,472 HS patients, 732 controls
Cardiovascular disease risk factors in HS patients Not applicable HS significantly correlated with active smoking (OR 4.34, 95% CI 2.48–7.60, p < 0.001) and history of smoking (OR 6·34, 95% CI 2.41–16.68, p < 0.001) Meta-analysis of observational studies
Substance Use
Garg (2018)44 Cross-sectional review/ 32,625 HS patients Assess the prevalence of substance use disorder (SUD) in patients with HS Not applicable Compared to patients without HS, SUD was significantly more prevalent in patients with HS. Prevalence of SUD in HS was 4.0% compared to 2.0% in non-HS patients. Alcohol comprised 47.9% of SUD cases, opioids 32.7% of cases, and cannabis 29.7%. HS patients had an increased chance of 50% of having SUD compared to non-HS patients (95% CI 1.42-1.59; p < 0.001). SUD could not be accurately diagnosed

Cross-sectional design
Lesort (2019)45 Prospective case-control study/ 641 patients (503 HS patients and 138 psoriasis patients) Assess prevalence and justifications for using cannabis Not applicable Prevalence of cannabis use in HS patients= 34% vs. prevalence in psoriasis patients= 11.6% (p < 0.001) After multivariate analysis, HS patients were 185% more likely to use cannabis than psoriasis patients (OR = 2.85; 95% CI 1.51- 5.64). Close to 69% of patients in the cohort of HS patients started using cannabis before disease onset. Study design
Patel (2019)46 Cross-sectional review/ 24,666 HS patients Measure mental disorders and cost burden associated with HS Not applicable The prevalence of mental health disorders was 34.27% for inpatients with HS vs. 20.05% for patients without HS. HS was associated with significantly higher odds of mental health disorder (OR 2.53, 95% CI 2.42-2.63) Generalizability due to hospitalized patients

Potential for missing data
Shlyankevich (2014)47 Retrospective case-control study/1,730 HS patients and 1,730 controls Measure the prevalence and comorbidities of HS Not applicable Having a drug dependence was associated with higher odds of having HS in univariate analysis (OR 17.2, 95% CI 7.99-37.1) but this association was lost with multivariate analysis. Alcohol dependence was associated with higher odds of having HS compared to controls in multivariate analysis (OR 0.25, 95% CI 0.087 - 0.73) Ascertainment bias for detecting comorbidities

Limited generalizability due to study sample belonging to one academic facility
Revuz (2008)40 Cross-sectional case-control study/ 67 HS subjects and 200 controls Describe the prevalence of HS and associated factors Not applicable Univariate analysis did not show an association between HS and alcohol consumption or drug use. Causal relationship not established due to nature of study design
Theut (2018)48 Cross-sectional questionnaire of Danish blood donors/ 500 HS patients Estimate prevalence and characterize patients with HS Not applicable There was a significant difference in wine and spirit consumption among respondents with HS. Blood donors with HS drank wine significantly less frequently than blood donors without HS (p = 0.02) but spirits/liqueur significantly more frequently (p < 0.001). Limited external validity
Phan (2020)49 Meta-analysis/ 62,248 cases and 96,615,486 controls Perform a meta-analysis to assess the association between HS and substance abuse Not applicable HS patients had significantly higher odds of having a substance use disorder (OR 2.84, 95% CI: 2.33–3.46, p < 0.00001), and alcohol abuse (OR 1.94, 95% CI: 1.43–2.64, p < 0.0001). Significant study heterogeneity
Wehner (2020)50 Cross-sectional study using an electronic health record database/8,539 HS patients Characterize the medications prescribed for HS patients Not applicable 18.1% of patients received an opiate prescription during an HS encounter as compared with 8.5% of psoriasis patients (p < 0.001). Cross-sectional design

HS diagnosis not validated from the dataset

Psychological Stress

The studies revealed that psychological stress may be a cause as well as a result of HS. As such, it is important for dermatologists to understand the impact of stress on disease flares, as managing psychological conditions may offer disease remission in select patients. There were nine studies on psychological stress. Seven studies were cross-sectional surveys, one was a case-control study, and one was a population retrospective review.6–14 The studies were observational but showed strong associations, thus resulting in moderate-quality evidence. However, these studies are important to consider because designing a high-quality randomized clinical trial for psychological stress and HS can be met with inherent challenges associated with studying stress factors. One of the proposed mechanisms by which psychological well-being plays a role in HS flares was systemic inflammatory process involved in psychiatric conditions.9,51 According to previous studies, the hypothalamic-pituitary axis (HPA) is a potent regulator of inflammation and can be disturbed in childhood through different processes, such as traumatic events.9 Interestingly, depression and other psychiatric states have also been closely linked to inflammation by altering the HPA axis.9,51 To assess the link between traumatic events and the development of HS, a case-control study of 17 HS patients and 213 controls was completed. Gielen et al. found that childhood emotional traumatic events were significantly associated with the development of HS (OR 5.03, p <0.05).9

On the contrary, the disease itself may be a cause of patients’ psychological stress. The stress induced by patients’ appearance may then play a role in exacerbating the disease. As such, it is important to manage all patient comorbidities. Quality of life is more commonly impaired with HS than other inflammatory cutaneous disorders.1,12,22 Kouris et al. found that patients with HS had significantly higher anxiety scores than patients without HS (6.41 ± 3.31 vs. 5.00 ± 1.59, p < 0.001).12 Similarly, they scored higher in depression scales (5.45 ± 2.79 vs. 4.16 ± 1.54, p < 0.001) and in loneliness and social isolation scores (42.86 ± 8.63 vs. 35.57 ± 6.17, p < 0.001). Moreover, their self-esteem scores were significantly lower than healthy controls (18.91 ± 1.79 vs. 19.77 ± 2.53, p = 0.008).12 These findings are in accordance with the findings in other studies.8 For example, the number of lesions on exposed skin plays a vital role in the stigmatization level of patients. However, involvement of different areas of the body affects patients differently. For instance, in a questionnaire study, analysis of respondents revealed that even involvement of the uncovered areas of the body significantly impacts quality of life.13

More rare psychological pathologies, such as bipolar disorder and alexithymia (the inability to identify and describe emotions experienced by one’s self), have been observed in HS patients.6,14 In one cross-sectional questionnaire, the mean score for the Toronto Alexithymia Scale (TAS) was 55.37 compared to 40.96 in the controls (p < 0.001).6 In a separate study, bipolar disorder was present in 0.7% of patients with HS compared to 0.1% prevalence in patients without HS.14 Importantly, there have been studies assessing coping strategies for HS patients with negative psychosocial impacts from HS. Two sets of interviews and focus groups of 12 HS patients revealed that these patients felt “unattractive,” particularly with many/large scars, helpless from limited daily activities caused by the painful lesions, stigmatized and embarrassed by visible scars, and worried other people may find them contagious. Further, the psychological burden was centered around three main themes: shame, pain, and coping mechanisms.7,10 The interviews revealed that social support was the most beneficial coping strategy, as patients who were acquainted with others who shared their diagnosis valued their understanding of their symptoms.10 Patients may benefit from the Hidradenitis Suppurativa Foundation (, which provides a valuable forum and supportive community for HS patients.7 However, online support groups may be more suitable for individuals who have longstanding disease. Newly diagnosed patients may find the exposure to the potential severity of HS through the support groups to be distressing. Cognitive-behavioral therapy (CBT) may be a well-suited therapy for HS patients, as it increases individuals’ compassion for themselves and reduces feelings of shame, although it has not been specifically studied in HS patients.10

In their survey of 143 HS patients, Kirby et al. established that patients with higher resilience levels had a smaller decrease in their health-related quality of life (HRQOL) scores as depressive symptoms increased. The authors proposed that resilience can be taught through online videos, self-guided books or readings, telephone calls with individuals or groups, or in-person small group sessions with exercises and discussions. Hence, there may be a role for resilience training programs for HS patients.11

Mechanical Stress

Various case reports have reported mechanical stress as an inciting factor for HS flares, especially in high-friction areas, whether from clothing or skin-skin contact. A total of eight studies on mechanical stress were found. Seven were case studies, and one was a cross-sectional study.15–22 The evidence is limited by the low-quality evidence of case reports and cross-sectional studies. It is widely documented that HS is more prevalent in obese patients. Still, the role of friction as an independent environmental factor in the pathogenesis of HS has been implicated in only a few case studies and series. Mechanical stress independent of obesity has only been studied in the form of case reports and case series.

Several case reports have described the development of recurrent HS lesions in friction-bearing areas, suggesting that mechanical stress itself can be an inciting factor for HS.15–19,21 Case reports have documented lesions arising around the band of wired brassieres, on the feet of a patient with tight-fitting work shoes, waistbands, and from leg prostheses.

Moreover, there was a report of a 4-month-old child that developed HS-like lesions in an inguinal nevus comedonicus after mechanical stress of the region.20 HS caused by mechanical stress in atypical areas not characterized by apocrine sweat glands may be caused by mechanical friction and a warm, humid, occlusive microclimate favorable to bacteria.19 To minimize mechanical friction and pressure in HS patients, ideal undergarments include sports bras or camisole tanks with built-in bras that lack thin straps, tight elastic, and metal wires. Loose-fitting underwear (seamless or laser-cut underwear lacking elastic bands) made from gentle fabrics are favorable for patients with HS. In one questionnaire, 16 of 110 (16%) patients reported tight clothing and friction as an aggravating factor of HS and 11 of 110 (11%) reported loose clothing as a relieving factor of HS.22 Men should be encouraged to opt for loose-fitting boxers rather than tight briefs. Education about appropriate undergarment styles and fabrics can empower patients to choose clothing options that reduce friction and irritation, decreasing the likelihood of HS flares.


Observational studies have shown increased sleep disturbances in HS patients, likely due to the pain and pruritus. In addition, poor sleep can contribute further to the inflammatory state of HS. Of the five studies, two were cross-sectional, one was a prospective study, and two were retrospective studies.23–27 Sleep is a fundamental physiological process governed by homeostatic sleep drive and circadian rhythm. Since skin plays a role in core body temperature control and thermoregulation, it contributes to proper sleep activity, onset, and awakenings. Sleep quality can be disturbed by chronic inflammatory dermatoses such as atopic dermatitis, plaque psoriasis, prurigo nodularis, chronic spontaneous urticaria, and HS.24,52 The pain, pruritus, and unpleasant odor caused by HS lesions may also amplify sleep disturbance.

A study in The Netherlands found that 121 of 211 HS patients (57.3%) had pruritus based on a numerical rating scale (NRS, 0 – 10), with a mean NRS score of 6.1 ± 2.0. The eosinophilic granulocytes may explain the increased pruritus in HS patients and a perineural infiltrate in the affected skin. In turn, these patients reported decreased quality of sleep and activities of daily living in the 5-D itch scale questionnaire.26 Using the Athens Insomnia Scale (AIS) and Pittsburgh Sleep Quality Index (PSQI) questionnaires on 108 HS patients and 50 control patients, Kaaz and colleagues found that itch and pain had a significant impact on insomnia frequency, and pain significantly affected sleep quality, sleep duration, and daytime dysfunction.24

Sleep disturbance in the form of obstructive sleep apnea (OSA) has a higher prevalence in HS patients than in healthy controls.25 OSA is an independent risk factor for the development of cardiovascular disease, increasing the risk of morbidity and mortality in HS patients. In a small study, Kelly et al. used the Berlin, STOP-Bang and Epworth Sleep questionnaires as well as overnight sleep studies to assess the prevalence of OSA in HS patients and found that the probability of OSA in HS patients is higher than that of the general population (50% in HS patients, versus 10% of males and 3% of females in the general population).25 However, this comparison does not control for the confounder of weight in HS populations. In a population-based analysis, Werteneil et al. found an increased incidence of OSA in HS patients, 3.5% (n = 695/19 945) vs. healthy controls 2.5% (n = 7400/296 170; p < 0.001).27 Lastly, Cohen et al. also found an increased incidence of OSA in HS patients vs. health controls (OR= 1.60, 95% CI 1.36-1.86; p < 0.0001). In their study, Cohen et al. also found an association between other sleep disorders besides OSA and HS. Specifically, there was a 32% increased chance that patients with HS had a non-OSA sleep disorder (95% CI 1.12-1.57; p < 0.001).23 While observational studies can not determine causation, authors have proposed that HS and sleep disorders are associated through pro-inflammatory states. Additional interventional studies investigating the presence and role of OSA in HS patients are required to establish the temporal association between this modifiable cardiovascular risk factor and HS.


Observational studies have shown strong associations between smoking and an increased risk of HS.1,2,33,36 Although the studies discussed have been observational in nature, the strong associations result in moderate-quality evidence. Smoking may contribute to the pathophysiology of HS through follicular occlusion, inflammation, and dysregulated immunity. Nicotine, polyaromatic hydrocarbons, arsenic, and dioxin-like compounds in tobacco smoke activate keratinocytes and cells of the immune system via nicotinic acetylcholine receptors.28 Skin samples from HS patients have shown a significantly thicker epidermis in the presence of nicotine in vitro compared with controls and an increased expression of acetylcholinesterase receptors surrounding the follicular infundibulum.29 Further, alkaloids such as nicotine stimulate the growth of Staphylococcus aureus, which consequently enhances the expression of choline acetyltransferase, the rate-limiting enzyme in the synthesis of acetylcholine, which may play a role in the pathway of infundibular hyperkeratosis and follicular occlusion via autocrine and paracrine signaling of the acetylcholine receptors.33 Various inflammatory interleukins (IL’s) such as IL-36α, IL-36β, and IL-36γ are increased in active smokers, contributing to HS exacerbations.53

Numerous studies indicate that a high percentage of HS patients, approximately 70-90%, currently smoke or have previously smoked cigarettes.1,25,29,51 Akdogan et al. investigated 40 patients with HS and 40 matched controls and found smoking was associated with a 14.87-fold increase in the risk of HS (95% CI 2.82—78.56). Active cigarette smoking increased the likelihood of HS, which was further increased by the length of time smoking.2 Among 7,860 patients with HS, Garg et al. showed that the incidence of HS was doubled among tobacco smokers compared to nonsmokers. Tobacco smokers diagnosed with HS were most commonly aged 18–39 years, women, white, and those with body mass index (BMI) ≥ 30.33 Additionally, a Danish study suggested that tobacco smokers may be less likely to achieve remission, or the absence of inflammatory lesions for at least 6 months, than non-smokers.1 In another population of Danish blood donors, active smoking was associated with lower remission rates (HR = 0.49, 95% CI 0.32-0.76) as well as the development of HS (HR = 1.72, 95% CI 1.15-2.50).36 A meta-analysis of observational studies found that HS was significantly correlated with active smoking (OR 4.34, 95% CI 2.48–7.60, p < 0.001) and with a history of smoking (OR 6.34, 95% CI 2.41–16.68, p < 0.001).43

Although smoking has been extensively studied as a trigger for HS, its association with the clinical severity of the disease has been less clear.54 A study comparing the differences in the epidemiology of HS in Western countries and East Asia did not find an association between tobacco smoking and disease severity.39 Dessinioti et al. found that smoking did not affect the severity of HS through Hurley staging, but smoking did increase the number of affected body areas in HS patients, with an increased risk for current or former smokers to have more than two body areas affected compared to non-smokers.29 However, early-onset HS was associated with less frequent smokers when compared to adult-onset HS.30 In contrast, Liakou and colleagues, as well as a study of Dutch patients with HS by Schrader et al. did, however, conclude that active smoking and increased pack-years may be associated with more severe HS.37 Further, Sartorius et al. showed that according to the Hidradenitis Suppurativa Scoring (HSS), smokers had more severe HS compared with former smokers and non-smokers.41 In a survey study, 17% of respondents indicated that their HS improved upon smoking cessation. Although this was a small proportion reporting severity improvement compared to other interventions, these patients had the most subjective and Hurley staging improvement in their HS compared to other lifestyle interventions.38

Deilhes et al. conducted a retrospective review investigating the benefits of a smoking cessation program (SCP) combining behavioral and pharmacological treatments on 51 HS patients (20 males, 31 females). All patients were daily smokers with an average of 13 pack-years and 13.8 cigarettes per day. Forty-eight patients followed up after a mean time of 11.6 months, with 70% of patients attending the SCP. One-third continuously stopped smoking and 44% reduced their consumption, with a mean reduction of 2.4 cigarettes per day. Among quitters in this time period, 93% attended the SCP.28 Similarly, HS patients who attended a smoking cessation program in an interdisciplinary intervention study by Touhouche et al. decreased their mean number of cigarettes per day.55

There are also other HS populations at risk for increased smoking habits, such as pregnant women and the pediatric population. In one study on Swedish pregnant women, 41% of the 1,724 pregnancies belonged to smokers. This is compared to only 13% in the reference population who were smokers.35 The pediatric population must also be regarded when considering smoking as a risk factor for their HS. Interestingly, Garcovich et al. found that in a cross-sectional review of 870 pediatric patients with HS, 23.9% of the cohort were smokers, which is higher than the referenced general population (11.8% of the general pediatric population are smokers).32

Interestingly, smokers are less likely to respond to first-line therapies for HS, including oral antibiotics, topical antibiotics, intralesional corticosteroids, or antibacterial washes, creams, and lotions.3 A recent study published by Iannone et al. revealed that smoking seems to be a predictive factor for poor response to clindamycin and rifampin therapy. There was a positive correlation between acne inversa severity index (AISA) and smoking (Spearman’s rho= 0.57, p=0.36).34 A case series by Simonart et al. suggested that smoking cessation has decreased the severity of HS in two women, aged 24 years and 37 years, as well as helped them achieve remission and may do so in other patients with HS.42

Factors increasing smoking cessation success in HS patients included motivation, level of nicotine dependency, access to interventions, and psychological comorbidities such as depression and anxiety.28 A multidisciplinary intervention including social services, nutrition, psychology, and pharmacological treatments such as nicotine replacement and varenicline may aid in establishing quitting goals in this population.28

A rare finding, Foolad et al.'s chart review on HS patients from the University of California Medical Center found that more than half of their cohort were never smokers (57.7%). These findings are contrary to other evidence in the literature regarding HS and smoking. Importantly, their study was a descriptive analysis from a single center. Although the majority of their HS patients were never smokers, they did not test for an association between smoking and HS.31

Substance Use (Illicit Drugs and Alcohol)

There is evidence that substance use disorders are more prevalent in patients affected by HS. While the eight studies described associations between HS and SUD, they failed to answer whether substance use affects HS disease state, severity, or flares.40,44–50 Additionally, the quality of the evidence is low because some studies have shown minor or no associations. As alluded to previously, patients with HS often endure chronic pain, which can lead to anxiety and depression. For instance, studies have shown that these patients score higher on anxiety and depression scales.8,12 These psychiatric conditions may lend themselves as precursors for substance use disorders (SUD) in these individuals. For example, a cross-sectional analysis of HS patients revealed that the prevalence of SUD in HS patients compared to non-HS patients was significantly different (4% in HS patients vs. 2% in non-HS patients, p < 0.001). SUD cases were from alcohol (47.9%), opioids (32.7%), and cannabis (29.7%).44 Similar findings were seen in a French cohort, where the prevalence of cannabis use among HS patients was 34% compared to 11.6% in psoriasis patients (p < 0.001). Interestingly, the majority of the patients in the HS cannabis use cohort had begun to use cannabis before disease onset, indicating that cannabis may be implicated in disease pathogenesis.45 Patel et al. found that HS was two times more likely to be associated with a primary/secondary diagnosis of mental health disorder, including SUD, than patients without HS.46

Some studies found conflicting evidence regarding alcohol and drug dependence in patients with HS. Shlyankevich et al. found that there were significantly lower odds of having alcohol dependence in HS patients compared to non-HS patients.47 Additionally, Revuz et al. did not find a significant difference in alcohol intake between patients with HS and non-HS patients.40 Riss et al. found a difference in wine and spirits intake among Danish patients with HS compared to non-HS patients, but there was no difference in beer intake.48 Specifically, HS patients drink significantly less wine than non-HS patients but significantly more hard liquor.

In their meta-analysis, Phan et al. documented an association between substance-related disorders, alcohol abuse, and HS. Similar to the findings by Garg et al, the most cited substances were alcohol, opioids, and cannabis. The authors hypothesized that the increased association between substance-related disorders and HS may be largely due to the pain that these patients experience.49 The pain these patients experience also serves as an explanation behind the increased opiate prescriptions in HS patients in a retrospective cross-sectional study. The finding of increased opiate prescriptions in these patients lends a focus on the poor management of these patients and serves as an argument for increased treatment strategies to alleviate flares.50


This review presents several lifestyle factors associated with HS that may be worth investigating and modifying for patients to achieve enhanced disease control and quality of life. These include adapting lifestyle behaviors to better control psychological stress, mechanical stress, sleep quality, smoking habits, and substance use.

Psychological Stress: Practical Recommendations

Psychiatric conditions such as depression are hypothesized to cause an inflammatory state, which could worsen the cutaneous inflammation in HS, regardless of medication regimen.9 However, there is no strong quality evidence suggesting that control of psychiatric conditions improves HS flares, as may be suggested by the inflammatory hypothesis. Regardless, a large proportion of HS patients suffer from a psychiatric condition. Therefore, clinicians may consider screening for anxiety and depression during a dermatology visit and facilitate an interdisciplinary partnership with a psychiatrist, psychologist, or primary care provider.

Mechanical Stress: Practical Recommendations

It is important to consider the role that mechanical stress plays on HS severity. Case reports have reported that the friction induced by clothing and other objects may play a critical role leading to HS exacerbations. Clinicians can screen for disease activity in body locations susceptible to friction and advise patients to modify their choice of clothing to help control flares, in favor of loose undergarments.

Sleep: Practical Recommendations

Since skin plays a role in core body temperature control and thermoregulation, it contributes to proper sleep activity, onset, and awakenings. Increased sleep disturbances including OSA were observed in HS patients. Therefore, sleep quality measures can be assessed for each patient, as this can negatively impact the quality of life for HS patients and is a pathway that increases the inflammatory state. In the case of suspected OSA, a referral to diagnose and treat this potentially serious condition would be important.

Smoking: Practical Recommendations

There is strong evidence that smoking is associated with increased odds of HS.2,3 Smoking has also been associated with reduced response to HS treatment.2,3,28,33 Assessment for smoking status is recommended in each HS patient, and referrals to smoking cessation programs should be offered when appropriate.

Substance Use Disorders: Practical Recommendations

Although there is no evidence of SUD being a trigger for HS, HS patients are more likely to suffer from SUDs than non-HS patients.47 Consequently, it is important for dermatologists to understand that this may be a comorbidity and screen for such disorders, whether it is through specific SUD questionnaires or a review of systems.

Our review has several limitations which are inherent to the studies included. First, a meta-analysis of these studies could not be completed due to the broad objective of the study and the paucity of specific studies on the matter with common variables. There is a large body of evidence on the effects of nutrition and weight on HS. However, the purpose of this review was to provide the scientific community with an overview of the less-frequently discussed lifestyle behaviors that are important in HS. Many of these studies are cross-sectional in design and rely on observational methods, which limits the extent of causation between lifestyle and HS.1,4,9–11,14,23,28–31 The optimal method to determine causation would be with a randomized-controlled trial, which may be challenging to conduct due to the variables in question. Additionally, several included studies relied on questionnaires for their results, which makes the study susceptible to errors in self-reported diagnoses, recall bias, and selection bias.9,12,22,30,36,38 Lastly, several studies were limited by their small sample sizes.8,10,14,25,29

This review highlights how an integrated multidisciplinary care model for HS is needed to optimally manage HS symptoms and comorbidities. Additionally, our work features other lifestyle factors beyond weight and diet that are infrequently discussed as factors for HS disease severity. Addressing these lifestyle behaviors may lead to an increased quality of life for HS patients and improve HS symptoms and individuals’ comorbidities.


HS patients have increased odds of having anxiety, poor sleep, and substance-related disorders. In addition, the data suggest that minimizing mechanical stress and advocating for smoking cessation may help with HS flares. Our work is particularly important because it features lifestyle factors beyond weight and diet that are infrequently discussed as exacerbating or affecting HS disease. Clinicians are encouraged to screen for psychological comorbidities, substance-related disorders, and sleep disorders to provide patients with an integrated multidisciplinary care model for HS to optimally manage symptoms and comorbidities. There is an opportunity for additional cohort studies and larger clinical trials on the association between HS and lifestyle factors such as psychological stress, mechanical stress, sleep, smoking, and substance use.


The authors have no financial or personal conflicts of interest that may influence the work or reduce transparency. Funding was not received for this project.