Episode 2: HS, Microbiomes, and Whole-Body Healing

Medscape

22-05-2025

This transcript has been edited for clarity. For more episodes, download the Medscape app or subscribe to the podcast on Apple Podcasts, Spotify, or your preferred podcast provider.
Ginette A. Okoye, MD: Hello. I am Dr Ginette Okoye. Welcome to the Medscape InDiscussion podcast series on hidradenitis suppurativa (HS). Today we'll discuss the gut and skin microbiome and how they relate to HS with our guest, Dr Tamia Harris-Tryon. Dr Harris-Tryon is an associate professor in the departments of dermatology and immunology at UT Southwestern Medical Center in Dallas, Texas.
Her research focuses on how the immune system, the microbiome, and the skin barrier all work together or sometimes against each other in chronic skin conditions such as HS. Thank you for joining us today, Dr Harris-Tryon, and welcome to the Medscape InDiscussion podcast.
Tamia Harris-Tryon, MD, PhD: Thanks so much, Ginette.
Okoye: I have been excited for this conversation today because certainly there's increasing interest in the role of the gut and skin microbiome and skin diseases, and this interest isn't just among healthcare professionals — it's among our patients, too. Our patients are taking probiotics, especially those who are more interested in holistic care and those who are on antibiotics.
I would love for us to try to empower dermatologists and other healthcare providers to understand the science here so we can help our patients make informed decisions about this aspect of their care. Thank you for being willing to guide us through that conversation.
Why don't we start by you telling us your connection to HS?
Harris-Tryon: My connection to HS pre-dates my connection to the microbiome. I trained at Hopkins in dermatology. Dr Okoye was my attending, and we saw a lot of patients with HS in the practice there. I think what struck me is how much suffering there was and how little knowledge there was concerning what was causing all these festering wounds in the armpit. We were putting people on biologics, but only one third of people were responding to them. These are some of the best medicines we have. Some people would respond, but even then, I would call the response partial.
People weren't going back to their normal lives and a normal high quality of life. They were still suffering. It became clear that we needed to learn significantly more about HS and try to make a difference in our patients' lives.
Okoye: Absolutely. I agree with that. Do you see patients with HS now? And how do you work in your research on the microbiome into your care of these patients?
Harris-Tryon: I spend about 80% of my time running my basic science lab. The focus is on the skin microbiome and the immune system. But when I am in clinic, I see patients at both our public hospital and also in my private practice. I see patients with HS, and when I see those patients with HS, what I want to impart to them is that this is a whole-body condition, and that if we can do things to strengthen their immune system through modifying behaviors in their life, we can make a meaningful impact in their disease.
Every medicine I prescribe — I still prescribe a lot of medicines — they'll all work significantly better if we can also make some changes in lifestyle management, smoking cessation, nutrition practices, and increasing physical activity in their daily lives. If we can do those things all together in concert and take an integrated approach to their health, we'll make significant gains and get people, hopefully, into durable remission with their HS, and they can go back to a high quality of life every day.
Okoye: I love that goal. You mentioned an integrative approach. How do you manage that with your patients?
Harris-Tryon: The way that I approach a lot of integrative health questions now with my patients with HS is to help them understand that the skin microbiome is out of balance. In HS, bacteria are growing and existing in people's armpits and groins, buttocks, and under the breast, which we never see in patients who don't have HS. The lens that I take toward it is, how do we get that balance restored?
One of the first things we talk about is diet. Diet is such a hot-button issue. It can be so sensitive for people. I focus more on things we can add back into the diet.
And then some major things that we need to take away. The one major thing I say that we should reduce is high-sugar foods. In medicine, we also often call these 'high glycemic index foods' — sweetened juices, sodas, things like that, and sweetened tea here in the south. We love our sweet tea.
To partner with my patients, I often say we don't have to get rid of those entirely. Cut back sugary drinks to maybe once a day if you're having them many, many times a day. And then if you're having a sweetened drink once every day, maybe cut them back to once a week.
We talk about risk reduction, and sugar is the first place I start. In partnering with that, too, when people are thinking about diet, they're often thinking about restriction. I also try to emphasize that we can add some yummy things back in. What's your favorite vegetable that you enjoy eating? Maybe being intentional about adding those to the diet every day. If they're already there every day, maybe we can add them to every meal. And placing sweet drinks as a dessert and as a treat after a meal, not as the main focus of your nutrition, and understanding that skin and nutrition go hand in hand.
The last piece is also fats in the diet. Modern diets are sometimes low in fats. I emphasize that the skin is the largest organ of the human body. It needs a lot of fats to function optimally. Making sure you get those nutrients is going to make a good impact in the skin.
Okoye: It must be a different conversation to have a quote-unquote diet conversation with a patient, where you're saying, you can have more fat. I think that's a nice way of having what could be a fraught conversation. Your nutrition recommendations are related to your thoughts and research about the microbiome.
Let's take a step back and teach us a little bit about the microbiome and how it relates to those recommendations.
Harris-Tryon: I was fortunate to do my postdoctoral fellowship in a gut microbiome lab here at UT Southwestern, Lora Hooper's lab. If you're in a gut microbiome lab, you start to realize that microbiome in the gut and nutrients in the diet, they go hand in hand.
Every time you consume something, your body's going to do some of the work of digesting that food and extracting the nutrients from that food. But the microbes are also doing their part. The easiest example is fiber in the diet. If you have any plant-based food, you have a salad today, or even if you have wilted spinach today, cooked vegetables, our body can't digest all of that spinach. We just don't have the enzymes to do that. And that's not bad. It doesn't limit us because in our small intestine and the large intestine, we have a series of microbes that can do the digestion for us.
They can digest plant polysaccharides, the big fiber molecules. There are species of bacteria that do that work very well, way better than we do. When you give those microbes the food that they need, they grow and expand. The populations that digest fiber expand. It turns out that the microbes that digest fiber make all sorts of small molecules that are highly beneficial for our immune system, our brain, and our skin. Those things working together in concert help strengthen our immune system and help it help strengthen our skin barrier.
Okoye: These bacteria, do they exist from birth, or do they change depending on what you eat throughout your lifetime? Can you change them? Can you adjust your microbiome?
Harris-Tryon: It's been shown in mouse studies and human studies, large population studies from all over the globe, that what you eat will drive your microbiome. Some of the original studies were done in groups of human populations that shift their diet significantly with seasons. During the seasons when you had a high fiber-rich diet, your gut microbiome expands to be full of microbes that digest that food. During the seasons when you don't eat that same nutrient, those microbes go down, and the microbes that metabolize what you are now eating will go up. We know that's true, and it happens over weeks, not over months. It can happen even faster, too. If you change your diet and microbial communities, we expect to see a shift in the gut.
To answer your second question, babies are somewhat sterile at birth. Their skin microbiome gets colonized by their method of delivery. If you're born vaginally vs by C-section, the baby's gut gets populated again. If you are getting breast milk, that's going to tune you to have a certain microbiome. Formulas, which we've tuned over time to be a lot like breast milk, are going to have an impact on the microbes that respond to that nutrient early in life.
Okoye: Are there data showing the types of microbes that tend to occur in patients with HS in terms of the gut and the skin?
Harris-Tryon: Yes, there have been some papers. It hasn't been entirely definitive what microbes are associated with HS in the gut, but we know that there are decreases in fiber-fermenting microbes. We know that in the populations that tend to get HS, we see fewer of those fiber-fermenting bacteria.
Okoye: So that's what's driving your recommendation to increase fiber, vegetable, and fruit intake in patients with HS.
Harris-Tryon: Yes, increasing vegetables and fruits and lowering the sugars. Every single interaction you have in your life will have a tuning effect on the microbiome. For example, we know that our HS patients smoke more. We know that there are specific species, such as Porphyromonas species, that are more associated with smoking.
These links are known. It's diet, and also other exposures such as smoking, that have a big impact on the oral microbiome. Microbes that grow in your mouth will also impact microbes that end up in your gut.
Okoye: How does a high sugar diet affect the microbiome?
Harris-Tryon: I think it's twofold. If you have a high-sugar diet, you also probably have a low-fiber diet. It's the two things together. We don't exactly know the mechanisms, but if you have high sugars, you'll get high amounts of insulin. We know as dermatologists that we see a lot of rashes that come downstream of that. My lab is trying to dissect some of these questions right now on the bench. What exactly is changing? I have less data for that, and fewer direct links to the microbiome. That is part of my practice as a physician and clinical experience. If I lower those sugars, patients do better.
Okoye: And there are lots of other good reasons to decrease sugar in the diet anyway.
Harris-Tryon: I emphasize that to my patients for acne and HS, this is the organ we can see. But all these changes, we have decades of medical literature saying that this is good for your heart, your liver, your kidneys. It's very affirming for me as a physician to be able to motivate people to make whole-health system changes to their life that impact the organ they can see every day, which is their skin.
Okoye: When you talk to patients in a nonjudgmental, relationship-affirming way, they will often identify those foods themselves as foods that tend to flare their disease. This is fantastic. I think it will help inform some of our conversations with patients, so we are not just arbitrarily saying decrease sugar, increase fiber, have more fruits and vegetables, but we can explain to them why. Especially if they are showing interest in more integrative care or they're asking about dietary changes or probiotics.
Harris-Tryon: I've had so many patients who say, my HS was terrible. I decided to drop my soda consumption every single day and my skin cleared up. When they come with those stories, it's very affirming to me that this practice is something people get a lot of benefit from.
Okoye: I think it's important to note that this is part of the practice. So yes, we can still treat with antibiotics, we could still treat with biologics, but why not also incorporate this into our care? It'll help the patient's overall health.
When I think about foods, I always think about the impact of public health factors that we know impact food choices. What are your thoughts on public health interventions or systemic interventions that we, as a field, should think about for patients with HS when it comes to their microbiome?
Harris-Tryon: I think on a systems basis, this is critically important. We have a lot of data on what makes populations thrive and healthier. This includes access to nutrient-dense foods that are affordable and accessible. They've done some studies to show that it's not necessarily more expensive to have a diet that has nutrient-dense foods, but access is an issue. How do people access the grocery store? How do you physically get to that grocery store so that you can get the groceries that you need? That's a major issue here in Dallas. Our food pantries are helping to fill some of that gap with a lot of education and a lot of access to food. 'Food is medicine' programs are allowing physicians to shift their practice so that you can start prescribing foods, so that we can write prescriptions for foods that we know are nutrient-dense and fiber-rich, that can have an impact on health.
I think that's a major one. I was fortunate to be at this meeting last week, talking about heart health. The American Heart Association has talked about all of these different metrics that help with hypertension.
Many of those help with other things too that we see in dermatology. Making sure our patients know that sleep and stress are going to modify their immune system and gut microbiome, and disease. Allowing people to live in walkable, safe communities so that they can get the exercise that they need and the steps that they need, because that is also a component of how you optimize metabolism, which ends up having a big impact, a positive impact, on skin.
All these issues are systems issues. They're public health issues. Addressing them will help with HS. Again, to come back to smoking, whatever we can do to encourage smoking cessation is also going to allow all the medicines we prescribe for HS to work better. It is so clear that patients who smoke are at a higher risk of developing HS.
All these are big public health interventions we can make to have an impact on our patients.
Okoye: So, at a systems level, zooming out, there is work to be done. Clearly, you already led with the things that we could do one-on-one with patients to help them and ultimately their families. Because often we see women of childbearing age with HS. They may be preparing food for their children and their family. We could have an exponential impact that way.
Harris-Tryon: One other thing I try to encourage my patients to do is to use less packaged foods; they're foods of convenience. They are part of everyone's diet, but I think it's just being conscious of that. Foods that are shelf-stable, by definition, are missing some nutrients that we need to make them shelf-stable. Some nutrients we need aren't shelf-stable. I have that conversation as well with my patients.
Okoye: What are your thoughts on probiotics? Do you think they have a role in the management of HS and other inflammatory conditions?
Harris-Tryon: We talked about my stepwise approach. First, cut back on the sugars. Next, focus a lot on what we need to add back those fibers, fats, and healthy proteins. I always say, if people still want to talk about it, then we move on to probiotics.
My approach to probiotics is also supported by a lot of other microbiome scientists, who focus on fermented foods. There are so many fermented foods that are ancient in human history, and we know that a lot of the microbes in those foods are beneficial to all aspects of human health.
If you take yogurt, probably the most easily and readily available fermented food, it often has Lactobacillus species in it. Those are beneficial microbes. And they make a lot of products that are good for the immune system. They often also have Bifidobacterium species in them.
We know that when you're eating the fermented food, in the case of yogurt, you're getting the live microbes. If you turn over any container of yogurt at your grocery store, they will list the live active cultures. They'll actually list the species that are in there.
These foods are also approved by the US Food and Drug Administration. We've had them in our history as humans for millennia, so we know they're safe. We know that humans have been eating them with benefit for a long time, and they're also well-controlled. We know what active species are in them. So, for all those reasons, I think it's great to start with a fermented food such as yogurt.
You can eat other foods that are ancient, such as kimchi, sauerkraut, kefir, yogurt drinks, all these foods, we know are full of microbes that have now been shown with all of our scientific tools to be very beneficial. But for millennia, humans have been eating them.
Okoye: Our ancestors already knew. Are there any other fermented foods we could mention?
Harris-Tryon: Ginette, you and I are both from the Caribbean region. My family's from Guyana. We have drinks such as fly, mauby, and ginger beer. Those are just from the region my family happens to be from.
I know in West Africa, even their fufu and these other pounded grains, they have to be fermented. My lab is full of people from all over the world, and so I often ask questions about their fermented food practices. Bamboo shoots are often fermented in many parts of the world.
Some of the people in my lab point out that dosa dough is fermented. I didn't know that, and I love dosa. The dough is made and then left overnight to ferment. I'm not sure what species are in that. I was saying we should study that in the lab.
I do think one thing that microbiome has helped me align with is, how you feel is important. If you eat some of these things and your stomach or your digestion is upset, you don't have to eat things just because they're fermented. I think it is important to center on how you feel after you eat, and that's also what microbiome science has helped me understand. Thinking about the skin, too — if your skin reacts negatively after a few days of something, move away from it. And if your digestion reacts negatively after a few days, move away from it.
I can't tolerate a lot of fermented drinks if I drink too much of them. I don't drink too many fermented drinks if they have too much gas in them, too much carbon dioxide.
Many other fermented foods, I tolerate well. There have been so many fermented foods throughout human history. Remember to always align with how you feel after you consume something.
Okoye: I think that's important to follow up on those recommendations to patients, so they don't feel like they failed. For example, I tried kombucha, and I felt terrible. Okay, then try something else. And I think it's always nice to tell people to think about their people — where are from, and what have they been eating for millennia?
Harris-Tryon: Yes. A beneficial diet is the Mediterranean diet. One way that you can understand how the Mediterranean diet might be used differently throughout the world is through the website https://www.oldwayspt.org.
They've created food pyramids that reflect Mediterranean-style diets, not just from the Mediterranean, but from the African continent, Asia, and the Americas, so that everybody can have access to that.
Okoye: This has been fascinating. Do you have any parting words for us?
Harris-Tryon: Your skin is telling you something about your health, is probably my parting word. It shouldn't be itchy. It shouldn't be inflamed. It shouldn't be red. It does need care, but that care doesn't always involve a 15-step, highly astringent regimen that's expensive. I think it involves taking care of your body through making mindful choices of what you're ingesting. Get good movement several times a week; the body needs that for its metabolism. As dermatologists, we love a great moisturizer for a reason because the skin needs lipids, both in the diet, and if your skin is dry, you want to add a little bit more lipid to it. If you feel like your skin is oily, then you can shift away from that, too. But I do think trying to find a skin balance where your skin is not inflamed is an important part of health.
Okoye: Today, we've talked to Dr Harris Tryon about the gut microbiome in HS. Some key takeaways from my perspective include the fact that what you eat changes your gut microbiome, and that change can happen within days or weeks. And that encouraging our patients to have a higher fiber, lower sugar diet can sway their microbiome toward the types of bugs that we believe are more beneficial for inflammation in the skin.
Thank you for joining us. Please take a moment to download the Medscape app to listen and subscribe to this podcast series on Hidradenitis Suppurativa. This is Dr Ginette Okoye for the Medscape InDiscussion podcast.
Microbiota and Maintenance of Skin Barrier Function
Evaluating Dietary Considerations in Hidradenitis Suppurativa: A Critical Examination of Existing Knowledge
Role of Dietary Fiber in the Recovery of the Human Gut Microbiome and Its Metabolome
Mediterranean Diet Intervention Alters the Gut Microbiome in Older People Reducing Frailty and Improving Health Status: The NU-AGE 1-Year Dietary Intervention Across Five European Countries
Population-Level Gut Microbiome and Its Associations With Environmental Factors and Metabolic Disorders in Southwest China
Seasonal Variation in Human Gut Microbiome Composition
Dynamics and Stabilization of the Human Gut Microbiome During the First Year of Life
Skin and Gut Microbiome in Hidradenitis Suppurativa: A Systematic Review
Cigarette Smoking as a Triggering Factor of Hidradenitis Suppurativa
Probiotics in Hidradenitis Suppurativa: A Potential Treatment Option?
Oldways Cultural Food Traditions