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Medscape
22-05-2025
- Health
- Medscape
Episode 1: Joint Pain in Paradise: A Closer Look at Arthritis and HS
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'm Dr Ginette Okoye. Welcome to the Medscape InDiscussion podcast series on hidradenitis suppurativa (HS). Today we'll be discussing the diagnosis and treatment of arthritis in HS with our guest, Dr Rebecca Manno. Dr Manno is a board-certified rheumatologist specializing in autoimmune and inflammatory conditions such as rheumatoid arthritis (RA), lupus, vasculitis, and scleroderma. She practices at Comprehensive Orthopaedic Global in the US Virgin Islands and is an adjunct assistant professor of medicine at Johns Hopkins University. Thank you for joining us today, and welcome to the Medscape InDiscussion podcast. Rebecca Manno, MD, MHS: Hi. Thank you so much for having me. This is such a pleasure. Okoye: Well, I am particularly excited to have you because, as you know, patients with HS often report joint symptoms and arthritis and arthropathy. I would love to get the definitions of those from you; they're known comorbidities of HS, and they contribute to the quality-of-life impact. But the joint symptoms haven't been well characterized, and they're often described by people like me, dermatologists. I don't think we quite have the expertise that you have in describing the joints, examining the joints, and knowing which imaging tests to record. I'm thrilled to have this conversation so you can help us all get better at this. Why don't you tell us a little bit about how you came to develop an expertise in HS. Manno: This story starts with a little bit of background on my personal career journey. I did my medical training, including rheumatology fellowship, at big academic centers in Baltimore, Maryland. And I joined the faculty in the Division of Rheumatology at Johns Hopkins in 2011. Throughout all of this, as with many of us who trained at big academic centers, you have access to every specialist and subspecialist in medicine that you can imagine. This makes it easy to stay in your rheumatology lane or whatever your specialty is. It made it easy to stay in my RA, lupus, vasculitis, gout lane, because for anything that expanded beyond your specialty, there's somebody right down the hallway who can help. Five years ago, I made a big career and life change and moved to the Virgin Islands, where I am currently the only full-time rheumatologist. I went from a big academic center with a huge medical infrastructure and an infinite number of providers and specialists to the opposite of the spectrum. The Virgin Islands is an amazing, close, tight-knit community, but we do have limited resources, especially when it comes to healthcare. Specifically, in our Virgin Islands territory, we have very, very limited dermatology access in general. Most of the HS is cared for either by primary care doctors or surgeons. So really, the way that I started having a referral pathway for HS patients was from my surgical colleagues. I had a conversation with one of our outstanding surgeons. He said, 'Rebecca, I just don't want to operate on this person again. I know that there are these medications out there, and we probably can do better for him. Would you see this patient and see if you can help?' And I said, absolutely. This opened the door to conversations and collaborations in our medical community here between rheumatology, surgery, and the primary care doctors and dermatology when we have some help there as well, about how to best take care of these patients. Okoye: Wow. That's, that's an amazing example of this kind of cross-specialty care for patients. After this episode, you may have several dermatologists interested in coming to the Virgin Islands to help you. Manno: Absolutely. Okoye: When you've been seeing patients with HS who have joint symptoms, what are the most common symptoms you've encountered, and which joints are more commonly affected? Manno: When I see patients with HS and arthritis in my clinic, there are two pathways or two scenarios. The first pathway is a patient who may be referred to me specifically for HS. Let's talk about that scenario first. When that patient is referred to me for HS I'm looking at their skin, but I'm a rheumatologist, so I'm going to start talking to them about their joints, whether they like it or not. I'm going to ask them about joint pain, swelling, stiffness, and striking inflammatory symptoms. And it is certainly a large proportion of these patients who do have joint symptoms; it can be a spectrum. The next step then is evaluating that, so if there is obvious synovitis or swelling on exam. I'll go down the path of evaluating them for a defined rheumatic disease. Do they have undiagnosed RA? Do they have undiagnosed axial spondyloarthritis? And sometimes I find those things, and then sometimes I don't. Yet on my exam of this patient who was sent to me for something that doesn't have to do with their joints, there is synovitis on exam. In those patients, it tends to be in the small joints of the hands. So the proximal interphalangeal (PIP) joints, sometimes the metacarpophalangeal (MCP) joints, enthesitis, and tendonitis, especially in the elbows and knees. Large joint arthritis is less common, but I've certainly seen it in the knees and ankles as well. In general, if these patients do not have a defined rheumatic disease that I can attribute their inflammatory arthritis to, and it's associated with the HS, it tends not to be a destructive arthritis. I have seen some exceptions to that rule. The second scenario would be a patient referred to me for joint pain — a typical rheumatology consult. We get these all the time, patients with joint pain. And then I uncover an HS diagnosis. These are patients in whom, truthfully and regrettably, I probably would have missed the HS diagnosis 5 years ago in Baltimore because HS is not a comorbidity in rheumatology we typically ask about. In our history or in our review of systems, when we're working up an inflammatory arthritis or joint pain, we're good at asking about psoriasis, skin manifestations of lupus or dermatomyositis, ulcers for pyoderma, and erythema nodosum for sarcoidosis. But we don't ask about HS. And I realized that when I started asking about it — and we'll be looking for it on our physical exam as well — but I recognize that if I didn't ask about it, a lot of patients may not tell me about it. They are embarrassed. They think that it's not relevant to what we're talking about. If I don't ask about it, and then I find it on physical exam, I say, why didn't you tell me about this? And they're like, oh, well, that's nothing. You see how patients may not bring that to the forefront, and that could be whatever subspecialist they're seeing, either because they're ashamed, they're embarrassed, or they don't think that you can help with it. They're worried that you're going to be judging them for something. That was eye-opening to me as well. Okoye: What I heard there is rheumatologists should be asking more about HS symptoms, and certainly dermatologists should be asking more about joint symptoms. Now that I have a captive rheumatologist, I have so many questions, one of which is, what are the typical symptoms you'll find in enthesitis or tendonitis? Manno: With enthesitis and tendonitis, it tends to be pain with active resistance. For example, let's talk about epicondylitis, which is an enthesitis or a tendonitis. It's really common, and it doesn't have to be indicative of a systemic inflammatory disease. Typically, that's your tennis elbow or your golfer's elbow — anything where you apply resistance to the insertion point of the tendon. For example, lifting your coffee cup or a gallon jug of water, when you're applying resistance to that tendon at the insertion point, it is going to elicit pain. It's a good way to try to differentiate that pain from arthritis. Arthritis will be painful, even with a passive range of motion. Okoye: For a dermatologist who hasn't had your training, how would you describe a quick joint exam? Manno: I think there are a couple of ways. First would be asking the questions. Even before laying hands on the patient, the doctor should ask questions about their joint symptoms. I think this is a space that is wide open for investigation. Similar to 'how now' with psoriasis and psoriatic arthritis, there are several simple screening instruments to use if patients are experiencing inflammatory joint symptoms, which should then prompt the referral to rheumatology. I think the same could be said for something similar for HS in the future. Start even just with a simple question: 'Do you have joint pain?' Because patients will sometimes say no, they're all right. Then you're done. When they say yes, the question is which joints and how long does it last? And is there swelling associated with it? The question of which joints, that's going to help to direct your physical exam, especially as a dermatologist, because I don't expect you to do the head-to-toe joint exam. How long? If they say, oh, I had a pain in my knee for 5 minutes last week, that's okay. It's better. We're done. But if the answer is, I have had this pain in my hands and in the morning, I can no longer hold my coffee cup because my hands are so stiff now, the focus of the exam is going to be on the hands and the small joints. Then you can ask, is there swelling associated with it? The patient may say, no, there's no swelling, or they'll say yes, there absolutely is. That also helps you to really pay close attention to those joints where if there has been swelling. Especially if they say that there's been swelling in a large joint, such as the knee, you can ask: Has it been large enough to where someone has drained fluid out of your knee? Something like that. We'll get a better sense of how long this has been going on and how severe. Then, when moving to the physical exam, admittedly, some of the more subtle synovitis, especially in the small joints of the hands and the wrists that I have seen in HS, can be more subtle. But I have absolutely seen the more robust, synovial hypertrophy — thickening of the joints and the small joints of the hands and in the feet with these patients. Certainly, looking at the joints that are the most affected is important. Does it look swollen? Are you seeing normal landmarks palpating it? Do you feel any fluid? Is it tender when you push on the joint itself, or is it not tender when you push on the joint and it's tender when you push somewhere else, like on a tendon insertion point? A quick and easy exam that we often teach medical students and our fellows to quickly look for synovitis in the MCPs or in the metatarsophalangeal joints (MTPs) is what's called an MCP squeeze or an MTP squeeze, where you just squeeze across two through four of the MCPs or one through five on the MTPs. If you do that and patients don't have synovitis or pain, it should elicit nothing. But if there is synovitis there, then patients will say, that's painful. So that's a good screening test instead of going joint by joint in the small joints of the hands, where it can be tricky, or in the feet. Okoye: Super high yield. I agree with you that there's room in HS for this type of screening tool. I hope you might be willing to work with a dermatologist to create that. Manno: Yes. Okoye: Let's move on to treatment. What are your go-to treatment options for patients with both HS and arthritis? Manno: Nonsteroidal anti-inflammatory drugs (NSAIDs) absolutely have a role to help acutely with the pain and the inflammation of arthritis. Many of the patients that I see are younger, so we aren't dealing with as many of the other comorbidities that may negate the use of NSAIDs, but of course we have to use them carefully given other medications they're using or if there's renal insufficiency and so on. I like NSAIDs quite a bit. I like topical NSAIDs, especially for the hands or for the knees. They can be very effective. They are not going to be as effective for other joints, such as the shoulders, for example. And then systemic NSAIDs if that's appropriate for the patient. I do find that the biologics, if we are using them to treat their HS, also treat the arthritis, which certainly can be effective. And if there is a clearly defined inflammatory arthritis, methotrexate can be helpful as well. I have not seen improvement in the joint symptoms or, if there is an inflammatory arthritis associated with the HS, with antibiotic regimens alone. Okoye: That makes sense. Let's go back to the NSAIDs. Are you referring to NSAIDs over the counter, such as ibuprofen, or are you referring to prescription NSAIDs? Manno: It depends on the specific patient scenario. I will often use the COX2 inhibitors for two reasons. One, there is slightly better gastric protection. Some patients tolerate them a bit better, and they have a longer duration of action. Ibuprofen only lasts about 4-6 hours. Patients are taking it multiple times throughout the day or are not taking it. Whereas naproxen and many of the COX2 inhibitors are once-a-day or twice-a-day drugs, which are easier for patients to take. Okoye: You mentioned methotrexate. Do you combine methotrexate and biologics in some patients? Manno: Absolutely. Certainly, if they have a defined inflammatory arthritis that is independent of the HS, then methotrexate in combination, especially with the tumor necrosis factor (TNF) alpha inhibitors, may give us additional benefit, especially for peripheral arthritis. This has not been studied in terms of if it's just HS-associated, but methotrexate in general can give a nice benefit for inflammatory arthritis of the small joints. Of course, we have to be careful, depending on our patient population, if we have young women who are considering pregnancy, and so on. We have to ask all of those right questions. But methotrexate in combination especially with the TNF-alpha inhibitor can be a nice combo for inflammatory arthritis. Okoye: That's interesting, because we use low-dose methotrexate around a range of 10 mg/wk for people whom we believe have anti-adalimumab antibodies or anti-infliximab antibodies. What's the range of the doses you're using for arthritis? Manno: For inflammatory arthritis, we will usually use doses between 15 and 25 mg/wk. Okoye: Okay, so a little bit higher. That's great. Dermatologists are quite comfortable with methotrexate, so that's certainly something we can add. You mentioned topical NSAIDs. I'm not as familiar with that group of drugs. Can you tell us a bit more about those and which ones you prefer? Manno: Diclofenac gel, which used to be prescription only, is now available over the counter, although some insurance companies will still pay for it if you write it as a prescription. It can be kind of expensive if purchased over the counter. It got its FDA approval for osteoarthritis of the hands and the knees because of the absorption; the joints are so close to the skin, which helps with easy absorption. I find it can be highly effective. I'll tell patients to apply it two to three times a day as needed. It is a little bit easier when you're in a warm climate, and so your knees may be exposed more, and you're not wearing long pants all of the time. It can be a great additional tool. And then it doesn't cause the gastrointestinal (GI) upset that we can see with NSAIDs. Okoye: Back to the bigger picture question here: Do you think the joint disease in HS is HS of the joints, or do you think patients with HS are more likely to have other inflammatory types of arthritis? Manno: I think this is a fantastic question, and I think this is the question that we should really have some good research agendas moving forward on. I think both are true. The data that do exist, especially in the dermatology literature, show us that patients with HS have an increased risk of also having another autoimmune disease. We know that's true in autoimmune diseases in general. If you've got one, you're allowed to have as many as you darn well please. So, those data are very clear that there is an increase in prevalence of RA and axial spondylarthritis in patients with HS. I think there's no doubt that you can have more than one, but it should be very clearly defined. If we're going to call it 'RA and HS,' it should be very, very clearly defined. This is where serologies and even classification criteria can be very helpful. Now, I know classification criteria are not diagnostic criteria, but they give us some boundaries when we're thinking about how to consider the different organ manifestations of an inflammatory process. Do I think that our HS patients are at higher risk for having these inflammatory processes? The data that we already have say yes, but there's a second scenario as well: the HS patients that don't have serologies, have an inflammatory arthritis, and have robust systemic inflammation. Now, on the one hand, you could call these patients 'seronegative RA,' and they would meet criteria for seronegative RA. Technically, yes, these patients don't have antibodies. They have hypogammaglobulinemia; they have a sedimentation rate and a C-reactive that's through the roof. They have anemia of chronic inflammation. You could call these patients 'seronegative RA,' but when you treat the HS, the arthritis improves. And now it gets complicated, because many of the treatments we're using for the HS also treat inflammatory arthritis. I'm going to share a case with you. I fully recognize this is a case of 'N of 1.' This is quite an extreme case, but I've seen several other instances that are in this similar neighborhood. I had a young man with terrible HS: stage 3, multiple sites, multiple locations. He responded partially to TNF-alpha inhibitors and steroids. We struggled to have consistent medical therapy for him for a lot of reasons, mostly access to medications and care. Ultimately, we sent him off-island to the United States, and he had multiple surgical procedures by a very skilled plastic surgeon; he was in the hospital for about a month and had multiple excisions and skin grafts. He did extremely well. Let me tell you, when I first met this young man, he clearly had advanced HS, but he also had a raging inflammatory arthritis. He had synovitis of the small joints of his hands and his wrists, where he was developing contractures at his PIP joints. He had developed some deformity of his fifth PIP on both hands. He had joint pain to the extent that he wasn't able to work. It wasn't just the skin; it was the joint symptoms too. When we sent him off-island, he had extensive surgical interventions. When he came back a couple of months later, I saw him. His arthritis was gone. His inflammatory markers were normal. His labs looked great. He was not on medical therapy. And he continues to do well today. Now, I'm not saying that this surgical intervention is the way to go about it, but if this was all seronegative RA from the beginning, it should not have improved with this type of intervention. That is an extreme example, and perhaps it is an outlier, but I think that it is telling us something about the robust inflammatory process of HS that goes beyond just the skin. Okoye: It tells us about this idea that we're starting to develop now, which is that HS tissue itself drives the inflammation. So, by debulking so-called HS, you decrease systemic inflammation, and that is telling with your patient. Wow, there's lots of work to be done in this area. Do you do serologies in these patients? Which ones? Manno: I will check serologies to look for a concurrent rheumatic disease because if they have the inflammatory arthritis and they're anti-cyclic citrullinated peptide (CCP) high titer positive, I'm going to call that RA with HS. I am going to check the antinuclear antibodies (ANA), and I will probably check double-stranded DNA if there are some joint symptoms associated with it as well. I want to know those things too, especially if I'm thinking about a biologic, and which ones to choose safely. And then I'll check serologies based on any other specific signs or symptoms. If they're having any GI issues, I will work them up for inflammatory bowel disease. and I will check anti-saccharomyces antibodies. I will check anti-neutrophil cytoplasmic antibody (ANCA), specifically perinuclear ANCA, which can be seen in inflammatory bowel disease as well. And of course, I'll have a GI workup for them too. But in general, unless I'm going down a path that they have an additional rheumatic disease, their serologies are going to be negative. But they will have hypogammaglobulinemia with immunoglobulin G levels that can be 2500 or 3000; they're polyclonal on serum protein electrophoresis. But it is just another example of how inflammatory they are. Okoye: What do you think is the role of exercise or physical therapy for the joint symptoms in HS? Manno: I think there is an important role for it. We know so much about the role of exercise in many of our rheumatic diseases that involve the musculoskeletal system, such as RA, dermatomyositis, and axial spondyloarthritis. We consider exercise to be just as important a part of the prescription as the disease-modifying antirheumatic drug or their biologic agent, and the data strongly support that. And it starts with some education for the patients who think, Am I going to make this worse? Especially when they're dealing with a musculoskeletal problem like arthritis, and I would say even with HS patients, because they're worried about moving too much. From an arthritis standpoint, I can say definitively, no, you are not going to make it worse. Now, I'm not going to recommend that they go join a CrossFit gym and do really high-impact exercise that is high velocity. Things that are not high impact can still be extremely beneficial. It just means that they should be slow, controlled movements. Absolutely, exercise is key. The goal of exercise is to increase strength and muscle mass, which will help with overall body composition. Weight management is important, but it's body composition. We want our patients not to be undermuscled, which is what they are. We want them to gain muscle. I think something important, with our HS patients, is giving them an exercise prescription. I'll start with something very simple: find out what they like to do. They'll say, well, I like to go walking. Great. I want you to walk for 15 minutes once a week, and at the end of your walk, you're going to do 10 air squats, or you're going to do 10 step-ups. Okoye: Very specific. Manno: Very specific, and you're going to do that for a month, and then you're going to increase it to twice a week. Simple and specific, so it's achievable. The other thing that I will do is refer our patients to a physical therapist for a home-based resistance exercise program, which can be supervised for some time by the therapist and then can be translated into something at home. Okoye: Wow, Dr Manno, I have to go back and listen to this podcast to finish taking my notes for my patients. This has been enlightening, and I don't think that this resource exists anywhere else yet, so I really appreciate all you do for patients with HS. And I thank you for coming on the podcast. Manno: I thank you for inviting rheumatology to the conversation about HS. We are definitely, as a community, happy to be here and be a part of this. Thank you for all that you're doing as well. Okoye: Today, we talked to Dr Manno about the diagnosis and treatment of arthritis in HS. 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 Ginnette Okoye, for the Medscape InDiscussion podcast. Association between Hidradenitis Suppurativa and Inflammatory Arthritis: A Systematic Review and Meta-Analysis Comorbidities and Quality of Life in Hidradenitis Suppurativa Prevalence of Musculoskeletal Symptoms in Patients With Hidradenitis Suppurativa and Associated Factors: Cross-Sectional Study Diagnostic Delay in Hidradenitis Suppurativa: Still an Unsolved Problem Improving Hidradenitis Suppurativa Management: Consensus Statements From Physicians and Patients' Perspectives Management of Lateral Epicondylitis: A Narrative Literature Review 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee Efficacy and Safety of Topical NSAIDs in the Management of Osteoarthritis: Evidence From Real-Life Setting Trials and Surveys Methotrexate and Its Mechanisms of Action in Inflammatory Arthritis Hidradenitis Suppurativa and Rheumatoid Arthritis: Evaluating the Bidirectional Association
Medscape
22-05-2025
- Health
- Medscape
Episode 2: HS, Microbiomes, and Whole-Body Healing
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 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
