Microbiome Health and Hidradenitis Suppurativa
The human microbiome - the trillions of microorganisms living on and inside the body - is emerging as an important area of HS research. This page explores what the microbiome is, why it may matter in HS, and what the current science says about microbiome-based approaches.
The gut-skin axis: how gut microbiome dysbiosis may contribute to systemic inflammation and altered skin microbiome in HS
Medical Disclaimer: Microbiome-based therapies for HS are not currently guideline-recommended treatments. This page is for educational purposes only. Always discuss any new dietary, probiotic, or microbiome intervention with your dermatologist or healthcare provider.
What the Microbiome Is
The human microbiome refers to the trillions of microorganisms - bacteria, fungi, viruses, and other microbes - living on and inside the human body. Far from being harmful, the vast majority of these microorganisms are either beneficial or neutral, and many are essential for normal immune function, digestion, and skin health.
These microbial ecosystems influence immune function and inflammation throughout the body. When the balance of these communities is disrupted - a state known as dysbiosis - it can contribute to increased inflammation and altered immune responses.
Key Microbiome Sites
Gut microbiome
The largest and most studied microbial community, containing trillions of bacteria that regulate immune function, metabolism, and systemic inflammation.
Skin microbiome
The community of microorganisms living on the skin surface, which helps maintain the skin barrier and modulates local immune responses.
Oral microbiome
The microbial community of the mouth, which can influence systemic inflammation and has been studied in connection with various inflammatory conditions.
Healthy microbiome diversity (left) versus dysbiosis (right): reduced species diversity and overgrowth of specific bacteria are associated with increased inflammation.
Why the Microbiome Matters in HS
Researchers increasingly believe the microbiome may influence HS development and disease activity through several interconnected mechanisms.
Altered Skin Bacterial Communities
Studies have found that HS lesions contain altered bacterial communities compared to healthy skin, with a higher proportion of certain species associated with inflammation and tissue damage.
Biofilm Formation
Bacteria in HS tunnels and lesions form biofilms - structured protective communities that are significantly more resistant to antibiotics than free-floating bacteria, complicating treatment.
Immune Responses to Microbes
The immune system's response to bacteria in HS lesions may drive much of the chronic inflammation. Dysregulated immune recognition of skin bacteria is an active area of HS research.
Gut-Skin Axis
Gut microbiome imbalance may contribute to systemic inflammation that worsens HS. Studies have found reduced gut microbiome diversity in HS patients, similar to patterns seen in other inflammatory conditions.
Shared Inflammatory Pathways
HS shares inflammatory pathways with conditions like inflammatory bowel disease and psoriasis, both of which have established microbiome connections, suggesting the microbiome may play a similar role in HS.
Antibiotic Resistance Patterns
The polymicrobial nature of HS lesions and biofilm formation help explain why single-antibiotic approaches often have limited effectiveness, and why combination regimens tend to work better.
Bacterial biofilm formation in an HS hair follicle: the protective matrix blocks antibiotic penetration and triggers an immune response in surrounding tissue. This is one reason combination antibiotic regimens and antiseptic washes are used in HS management.
Emerging Research
Several research areas are being explored that aim to rebalance microbial ecosystems that may influence HS. These approaches are in varying stages of investigation.
Probiotic Therapies
Targeted probiotic supplementation to restore beneficial bacterial populations in the gut and potentially influence systemic inflammation. Research is exploring which specific strains may be most relevant to HS.
Currently no HS-specific probiotic protocol is established. General gut health probiotics are being studied.
Microbiome Restoration
Approaches including fecal microbiota transplantation (FMT) and targeted microbiome modulation are being investigated for inflammatory conditions. For HS specifically, these remain experimental and are not guideline-recommended.
FMT for HS should only be explored within formal clinical trial settings.
Dietary Interventions
Anti-inflammatory dietary patterns - including high-fiber diets, fermented foods, and reduced ultra-processed food intake - are being studied for their ability to improve microbiome diversity and reduce systemic inflammation in HS patients.
Dietary changes are the most accessible and lowest-risk microbiome intervention currently available.
Bacterial Biofilm Disruption
Antiseptic washes (such as chlorhexidine and benzoyl peroxide washes) are already used in HS management partly because they can disrupt surface biofilms. Research is exploring more targeted biofilm-disrupting agents.
Antiseptic washes are currently the most established microbiome-related intervention in HS care guidelines.
Lifestyle Factors That Influence the Microbiome
Improving microbiome diversity is an area of active scientific investigation. Several modifiable lifestyle factors have been shown to influence the composition and diversity of the gut and skin microbiome.
Diet
A diet rich in diverse plant foods, fiber, and fermented foods supports microbiome diversity. Reducing ultra-processed foods, refined sugars, and alcohol is associated with healthier microbiome composition.
Antibiotic Exposure
Antibiotics - commonly used in HS treatment - can significantly disrupt gut microbiome diversity. Probiotic support during and after antibiotic courses may help partially restore balance.
Stress
Chronic psychological stress is associated with reduced gut microbiome diversity and increased intestinal permeability. Stress management may therefore have indirect microbiome benefits.
Sleep Quality
Poor sleep quality and disrupted circadian rhythms are associated with altered gut microbiome composition. Consistent, quality sleep supports microbiome health as part of an overall anti-inflammatory lifestyle.
Environmental Exposures
Smoking, environmental pollutants, and certain medications beyond antibiotics can negatively affect microbiome diversity. Reducing exposure where possible supports overall microbiome health.
Physical Activity
Regular moderate physical activity is associated with greater gut microbiome diversity. Exercise-induced changes in microbiome composition may contribute to its anti-inflammatory effects.
Important Perspective
Why Microbiome Research Is Promising
- Provides a biological rationale for the known benefits of anti-inflammatory diets in HS
- Helps explain why combination antibiotics outperform single-drug approaches
- Supports the use of antiseptic washes as adjuncts to systemic treatment
- Opens potential new therapeutic targets beyond current biologic and antibiotic approaches
- Connects HS to a broader understanding of inflammatory disease mechanisms
Why Caution Is Still Warranted
- Microbiome research is promising but still evolving - most findings are associative, not causal
- No microbiome-specific treatment protocol has been validated for HS in large clinical trials
- Commercial microbiome tests and personalized microbiome therapies vary widely in quality and evidence
- Experimental approaches like FMT carry real risks and should only be pursued in clinical settings
- Patients should approach microbiome therapies carefully and seek guidance from qualified healthcare professionals
The most evidence-supported microbiome-related actions currently available to HS patients are: following an anti-inflammatory diet rich in fiber and diverse plant foods, using antiseptic washes as directed by your dermatologist, and discussing probiotic support with your provider if you are on long-term antibiotics. These are safe, accessible, and consistent with current HS management guidelines.
Frequently Asked Questions
Can improving my gut microbiome help my HS?
Research suggests a connection between gut microbiome health and systemic inflammation, which plays a role in HS. However, there is currently no established protocol for treating HS through microbiome interventions. Dietary changes that support microbiome diversity - such as increasing fiber and reducing ultra-processed foods - are generally safe and may offer broader anti-inflammatory benefits, but should be discussed with your healthcare provider.
What is a biofilm and why does it matter in HS?
A biofilm is a structured community of bacteria encased in a protective matrix that adheres to surfaces - including the walls of HS tunnels and lesions. Biofilms are significantly more resistant to antibiotics than free-floating bacteria, which helps explain why single-antibiotic approaches often have limited effectiveness in HS. Combination antibiotic regimens and antiseptic washes are partly aimed at disrupting these biofilm communities.
Should I take probiotics for HS?
Probiotic research for HS specifically is still in early stages. While probiotics are generally safe for most people, there is not yet sufficient clinical evidence to recommend specific probiotic strains or formulations for HS management. Some patients explore probiotics as part of a broader anti-inflammatory lifestyle approach. Always discuss supplementation with your dermatologist or gastroenterologist before starting.
What lifestyle factors most affect the microbiome in HS?
Diet is one of the most significant modifiable factors influencing microbiome diversity. A diet rich in fiber, fermented foods, and diverse plant foods tends to support a healthier microbiome. Antibiotic exposure (common in HS treatment) can disrupt the gut microbiome, which is one reason some clinicians recommend probiotic support during antibiotic courses. Chronic stress, poor sleep, and smoking are also associated with reduced microbiome diversity.
Is fecal microbiota transplantation (FMT) a treatment for HS?
Fecal microbiota transplantation (FMT) is an experimental approach being investigated for various inflammatory conditions. For HS specifically, FMT is not a guideline-recommended or approved treatment. It remains in the research phase for HS and should not be pursued outside of clinical trial settings. Discuss any interest in experimental therapies with a qualified gastroenterologist or dermatologist.
Medical References
- [1]Ring HC, et al. The follicular skin microbiome in patients with hidradenitis suppurativa and healthy controls. JAMA Dermatol. 2017;153(9):897-905. PubMed
- [2]Alikhan A, et al. North American clinical management guidelines for hidradenitis suppurativa. J Am Acad Dermatol. 2019;81(1):76-90. PubMed
- [3]Jemec GBE. Hidradenitis suppurativa. N Engl J Med. 2012;366(2):158-164. PubMed