Hidradenitis suppurativa: a review of hormonal and metabolic interventions

Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by abnormal keratinocyte proliferation, follicular obstruction, and rupture of hair follicles predominantly in intertriginous zones. Sex hormones and metabolic dysregulation contribute to the multifactorial pathogenesis of HS. Sex hormones were originally implicated in HS due to its female predominance and symptom fluctuations during menstruation, pregnancy, and menopause. Hormonally driven HS involves end-organ androgen hypersensitivity and local androgen dysregulation. Additionally, metabolic comorbidities, such as obesity, insulin resistance, type 2 diabetes mellitus, polycystic ovary syndrome, and metabolic syndrome, are highly prevalent in HS and contribute to disease severity through chronic inflammation and adipokine dysregulation. The complex hormonal and immunometabolic interactions underlying HS provide avenues for therapeutic management. For patients with hormonal involvement and/or metabolic comorbidities, various interventions, including lifestyle modification, topical and systemic hormonal therapies, and metabolic therapies, serve as useful initial or adjunctive treatment options. Understanding these interventions and the patient populations they benefit remains essential, particularly during this period of robust biologic therapy development, given the high prevalence of these comorbidities and the continued need for multi-modal therapy in HS. This review provides a comprehensive overview of current hormonal and metabolic therapeutic strategies, detailing their mechanisms of action, clinical efficacy, benefits, risks, and limitations.