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Vol. 113. Núm. 6.
Páginas T627-T631 (Junio 2022)
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[Translated article] RF – Usefulness of Zinc Gluconate and Other Nondrug Treatments for Managing Hidradenitis Suppurativa
FR – Utilidad del gluconato de zinc y otros tratamientos no farmacológicos en el manejo de la hidrosadenitis supurativa
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L. Serra-García, D. Morgado-Carrasco
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danielmorgado@yahoo.com.ar

Corresponding author.
Departamento de Dermatología, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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L. Serra-García, D. Morgado-Carrasco
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Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by inflammatory nodules, abscesses, recurrent furuncles, and fistulas in the axillae, groin, perianal, or inframammary regions. It significantly affects quality of life and can cause depression and anxiety.1 Treatment is complex and often unsatisfactory. Treatments used include antibiotics, topical or systemic corticosteroids, classical immunosuppressants, tumor necrosis factor α (TNFα) inhibitors (e.g. adalimumab), antiandrogens, antidiabetics such as metformin, and surgical procedures. Nonpharmacological interventions such as dietary supplements can be indicated, although evidence supporting their utility is scarce (Table 1).2

Table 1.

Nonpharmacological Treatments for Hidradenitis Suppurativa.

Agent  Authors  Intervention  Indication  n  Evidence  Results 
Dietary supplements
Zinc  Brocard et al., 2007  Zn gluconate (90mg/d PO)  Mild-to-moderate HS (Hurley stage I–II)  22  Pilot study  Complete and partial response observed in 8 (36%) and 13 (59.1%) out of 22 patients 
  Hessam et al., 2016  Zn gluconate (90mg/d PO) and topical 2% triclosan 2 times/d  HS without active treatment or treatment in the preceding 4 wk  54  Uncontrolled retrospective study  Significant decrease in HS severity in 43 of 54 (79.6%) patientsImprovement in quality of life in 40 of 54 (74%) patientsGastrointestinal adverse effects in 12 patients (22%)Treatment discontinuation in 5 patients, dose reduction in 4 patients 
  Molinelli et al., 2020  Zn gluconate (90 mg/d)+nicotinamide (30mg/d) PO for 90 d  Mild-to-moderate HS (Hurley stage I–II) previously treated for 12 wk with minocycline (100mg/d, PO)  92  Controlled retrospective study  Significant decrease in flare number and duration, improved quality of life, and increased disease-free survival in 47 treated patients versus untreated control group 
Vitamin B12  Mortimore and Florin, 2010  Intramuscular vitamin B12, 1000μg/14 d for 6 wk, and monthly thereafter  Inflammatory bowel disease associated with HS or similar skin lesions (perianal fistulae, inflammatory nodules)  12  Case series  Complete or partial response in 8 of 12 patients 
Vitamin D  Guillet et al., 2015  Vitamin D in drinkable ampoules (100,000 IU) according to levels of 25-OH-vitamin D3  HS of any stage with vitamin D deficiency  44  Pilot study  Vitamin D supplementation decreased the number of nodules by 75% in patients with vitamin D deficiency 
Dietary interventions
Mediterranean diet  Barrea et al., 2019  Adherence to Mediterranean diet evaluated using PREDIMED scale  HS of any stage  82  Cross-sectional case–control study  HS severity was inversely proportional to the level of patient adherence to the Mediterranean diet 
Yeast-free diet  Cannistrà et al., 2013  Surgery and yeast-free diet  HS of any stage  12  Prospective pilot study  All patients showed stabilization and reduction in skin lesions at 12 moLesion recurrence in all patients who resumed consumption of yeast or wheat 
  Colboc et al., 2016  Yeast-free diet for 3 mo  HS of any stage with medical treatment  20  Uncontrolled prospective study  Pain, inflammation, suppuration, and flare duration improved in 50% of patients with good adherence to dietPatients with poor adherence reported less improvement in HS 
Lifestyle modificationsa
Overweight and obesity  Kromann et al., 2014  Weight loss  HS of any stage with bariatric surgery  249  Uncontrolled retrospective study  After bariatric surgery with significant weight loss, complete and partial remission was observed in 17 (48.6%) and 7 (20%) patients, respectively, out of 35 patients with HS 
  Thomas et al., 2014  Weight loss  HS and morbid obesity  Patient  An isolated case in which, after bariatric surgery with significant weight loss, the symptoms of HS, which had been refractory to various treatments, resolved 
Laser hair removal
Nd:YAG laser  Tierney et al., 2009  4 monthly Nd:YAG laser sessions  Moderate-to-severe HS  22  Prospective randomized controlled study  After 3 mo of treatment, reductions in HS severity were observed: 65.3% in all anatomical areas, 73.4% in the inguinal area, 62% in the axillary region, and 53.1% in the inframammary area 
  Mahmoud et al., 2010  4 monthly Nd:YAG laser sessions  Moderate HS with bilateral and symmetrical lesions  22  Prospective randomized controlled intra-patient (right-left) study  72.7% improvement on the treated side versus 22.9% on the control side 
  Xu et al., 2011  2 monthly Nd:YAG laser sessions  Moderate HS  20  Prospective randomized controlled intra-patient (right-left) study  An average improvement of 31.6% was observed in all anatomical regions compared to the control side 
IPL  Highton et al., 2011  2 sessions per wk for 4 wk  Moderate-to-severe HS with bilateral symmetric involvement  18  Prospective randomized controlled intra-patient (right-left) study  Significant improvement in HS lesion severity on the treated side at 3, 6, and 12 mo 
  Piccolo et al., 2014  4 IPL sessions at intervals of 15–20 d  Mild-to-moderate HS  Case series  Patients with HS showed a complete response after finishing treatment 
Alexandrite laser  Koch et al., 2013  6 laser sessions separated by 6–8 wk  Moderate HS  Retrospective study, review of medical records  The HS patient showed complete resolution of the lesions in the groin area, without requiring systemic antibiotic treatment 
Diode laser  Sehgal et al., 2011  6 laser sessions separated by 3–4 mo  Bilateral moderate HS affecting the axillae  Patient  After 6 sessions, the patient showed an objective improvement in HS lesions 
a

Other recommendations include quitting tobacco, avoiding shaving, and improving skin hygiene and care.

Abbreviations: HS, hidradenitis suppurativa; IPL, intense pulsed light; Nd:YAG: neodymium-doped yttrium aluminum garnet; PREDIMED, prevention with Mediterranean diet; Zn, zinc.

Source: Hendricks et al.2

A recent retrospective study, which included 92 patients with mild-to-moderate HS successfully treated with oral tetracyclines, evaluated the utility of oral zinc gluconate (ZnG) (90mg/d) and nicotinamide (30mg/d) as maintenance treatment for 90 days in 47 patients versus 45 untreated control patients. Significant decreases were observed in the treated versus the control group at weeks 12 and 24 in the following parameters: lesion severity, according to the International Hidradenitis Suppurativa Severity Score System (4.0 and 4.7 versus 6.2 and 7.8, respectively); quality of life according to the Dermatology Life Quality Index (2.9 and 3.5 versus 7.5 and 10.6, respectively); pain (mean visual analog scale score of 2.0 and 2.4 versus 7.5 and 10.6, respectively); and mean duration of flares (3.8 and 4.9 d versus 5 .6 and 8.9 d, respectively). Mean disease-free survival was also significantly longer in the treated group (20.4 d versus 5.4 d in the control group). All these differences were statistically significant (P<0.005). Reported adverse effects consisted of nausea in 2 patients, neither of whom discontinued treatment.3

Two previous studies also support the utility of ZnG in HS. The first pilot study4 included 22 patients with HS refractory to conventional treatment, treated with 90mg/d ZnG. All individuals showed an improvement, either partial (63.6%) or complete (36%). Adverse effects were observed in only 3 patients. Another study5 evaluated the efficacy of ZnG and topical 2% triclosan in 66 patients with mild-to-moderate HS, and reported a significant improvement at 3 months in disease severity, the number of inflammatory nodules and flares, and in quality of life. Gastrointestinal adverse effects were observed in 22 individuals, of whom 5 discontinued treatment. The beneficial effects of ZnG in HS and in other dermatoses may be explained by its anti-inflammatory activity: it inhibits neutrophil chemotaxis, activates natural killer cells and phagocytes, regulates the expression of integrins in keratinocytes, and modulates the production of proinflammatory cytokines, such as TNFα and interleukin 6.4 Nicotinamide also has anti-inflammatory and antioxidant properties and decreases the accumulation of free radicals.

Management of HS is complex and nonpharmacological interventions can be particularly useful. The combination of ZnG and nicotinamide is a low-cost and well-tolerated alternative, and may be useful as a maintenance treatment or as an adjunct to conventional therapy.

Conflicts of Interest

The authors declare no conflicts of interest.

References
[1]
S.R. Goldburg, B.E. Strober, M.J. Payette.
Hidradenitis suppurativa: epidemiology, clinical presentation, and pathogenesis.
J Am Acad Dermatol, 82 (2020), pp. 1045-1058
[2]
A.J. Hendricks, P.A. Hirt, S. Sekhon, A.R. Vaughn, H.A. Lev-Tov, J.L. Hsiao, et al.
Non-pharmacologic approaches for hidradenitis suppurativa – a systematic review.
J Dermatol Treat, 0 (2019), pp. 1-8
[3]
E. Molinelli, V. Brisigotti, A. Campanati, C. Sapigni, A. Giacchetti, C. Cota, et al.
Efficacy of oral zinc and nicotinamide as maintenance therapy for mild-moderate hidradenitis suppurativa: a controlled retrospective clinical study.
[4]
A. Brocard, A.-C. Knol, A. Khammari, B. Dréno.
Hidradenitis suppurativa and zinc: a new therapeutic approach. A pilot study.
Dermatol Basel Switz, 214 (2007), pp. 325-327
[5]
S. Hessam, M. Sand, N.M. Meier, T. Gambichler, L. Scholl, F.G. Bechara.
Combination of oral zinc gluconate and topical triclosan: an anti-inflammatory treatment modality for initial hidradenitis suppurativa.
J Dermatol Sci, 84 (2016), pp. 197-202
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