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  • Presentation

Treating Hidradenitis Suppurativa by Addressing Insulin Resistance and Metabolic Dysfunction

Description

The speaker argues that hidradenitis suppurativa (HS) should be viewed as a disease closely linked to insulin resistance and metabolic dysfunction, with systemic inflammation and hyperinsulinemia forming a vicious cycle that worsens disease. HS patients often have normal fasting glucose and A1c despite significant insulin resistance, so the speaker recommends checking fasting insulin and calculating HOMA-IR rather than relying on A1c. Management should address both skin inflammation and metabolic drivers, especially obesity, smoking, low physical activity, and chronic inflammation. The speaker describes practical interventions including biologics for HS inflammation, smoking cessation support with nicotine replacement or varenicline, encouraging any doable physical activity, and using GLP-1 agonists for weight and metabolic control. Metformin is presented as a useful, generally safe option for hyperinsulinemia, with guidance on dosing, monitoring renal function and B12, and awareness of rifampin interaction; berberine is mentioned as an alternative for those who cannot tolerate metformin. Dietary strategies emphasized include reducing carbohydrates modestly, favoring a Mediterranean-style pattern, avoiding ultra-processed foods, and using a longer overnight fast rather than framing it as intermittent fasting. Overall, the goal is to interrupt the cycle between insulin resistance and inflammation to improve HS outcomes.

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Conclusions

  • Hidradenitis suppurativa appears closely linked to metabolic dysfunction and insulin resistance, and in some patients may be an independent risk factor for insulin resistance.
  • A normal or near-normal HbA1c does not rule out insulin resistance in HS, so fasting glucose, fasting insulin, and HOMA-IR are better screening tools.
  • HS-related systemic inflammation and insulin resistance likely reinforce each other in a vicious cycle that worsens disease burden.
  • Treating the inflammatory component of HS with biologics may also help reduce hyperinsulinemia.
  • Smoking cessation is an important and actionable way to improve insulin resistance and HS outcomes.
  • Increasing physical activity, even modestly, can help lower circulating insulin and should be encouraged in realistic, patient-centered ways.
  • Weight loss and metabolic therapy, including GLP-1 agonists, can improve HS for some patients, especially after substantial weight reduction.
  • Metformin is presented as a generally safe and useful off-label treatment for hyperinsulinemia in HS, with extended-release dosing favored for tolerability.
  • Patients who cannot tolerate metformin may benefit from berberine, though evidence and product quality are less certain.
  • Dietary changes such as reducing carbohydrate intake, emphasizing a Mediterranean-style pattern, limiting ultra-processed foods, and extending the overnight fast may help improve insulin resistance and potentially HS outcomes.
  • Overall, better management of insulin resistance is expected to improve HS outcomes and reduce long-term cardiometabolic risk.
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