Nutrition Health Review

November–December 2023

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Natural Versus Artificial Food Dyes

By Sarabeth Lowe, MPH Ms. Lowe is a Communication Specialist at the University of Delaware Disaster Research Center. Although food dyes have been used since ancient times, they have long been a subject of controversy.1–4 Recently, they have entered the spotlight again, as the United States (US) Food and Drug Administration (FDA) begins to roll out a timeline and plan to help food manufacturers transition from artificial, or synthetic, dyes to natural alternatives.3,5–7 This spring, US Health Secretary, Robert F. Kennedy, Jr., brought this issue to the forefront of public health and the news media when he announced his plan to remove nine chemicals—all petroleum-based, synthetic food dyes—by the end of 2026.6–9  His efforts dovetail into a broader political, social, and industry movement toward less processed foods.6,9–15 In January 2025, the FDA announced its plan to remove Red No. 3 from food and ingested drugs more than three decades after the synthetic coloring was first found to cause cancer in male laboratory rats.11,16–18 At the same time, more than two dozen state legislatures are pushing to restrict the use of artificial dyes.6,19,20 This is a pervasive issue in public health and the food industry. According to a Wall Street Journal analysis of a federal database detailing food and beverage ingredients, more than one in 10 products contain at least one artificial dye.11 This topic has also spurred debate among researchers and experts over a relatively simple question: Are these color additives safer than natural ones? This article will provide a broad overview of food dyes, compare natural and artificial colorants, and explain the pros and cons of their use. Here is what you should know. What Are Food Dyes? Food dyes fall under the umbrella term “color additives,” which the FDA describes as substances that can impact the color of food, drugs, or cosmetics.21 In more general terms, food dyes are chemical substances developed to enhance the appearance of food by imparting artificial color.15 They are used for various reasons, including enhancing and brightening hues, correcting natural variations, and offsetting color loss due to environmental exposures.22 Food dyes are nearly integral to the US food system. The first synthetic organic dye was discovered in 1856, followed by decades of similar discoveries. These early dyes, which were used in foods, drugs, and cosmetics, were first produced from byproducts of coal processing.1–3,23,24 Many of those coloring agents were not safe and contained poisonous materials, such as lead, arsenic, and mercury. Eventually, the FDA’s 1938 Federal Food, Drug, and Cosmetic Act was enacted. Among other safety measures, this law requires the FDA to approve all color additives and new uses for listed color additives before they could be used in foods.21–24  These rigorous standards still exist today. When evaluating the safety of a substance and whether it should be approved, the FDA considers the:21 Composition and properties of the substance Amount that would typically be consumed Immediate and long-term health effects Availability of analytical methods for determining its purity and acceptable levels of impurities Artificial versus Natural Dyes Research shows that the color of foods plays a significant role in how consumers select them.1,3,25–28 There is also a significant link between color and taste.29 For example, since oranges are orange, we expect orange-colored drinks to be orange-flavored.27 This is why food colorants are popular in the food industry.  Artificial dyes are chemically or physically modified colorants that can be used to yield desirable characteristics for manufacturing, such as high purity, stability, brightness, a wide range of shades, uniformity, and reproducibility in production.1,25–27,30 As science and technology have advanced, more have been developed, but there is lingering controversy about the safety of these dyes. Several studies have shown a small but significant association between these dyes and health outcomes.24,31–34 There have also been concerns about the potential for synthetic dyes to cause cancer, but there is more nuance to this claim. Research shows that some synthetic dyes may contain cancer-causing contaminants.24,35,26 For example, benzidine, a manufactured chemical and carcinogen, has been found in food dyes. However, these contaminants are present in such low levels that the FDA permits their use.1,3,24,26,35 With the exception of the now-banned Red No. 3, there is currently no conclusive evidence that artificial food dyes cause cancer.1,24,35,37  Due to longstanding and recent concerns around the potential risks of synthetic food dyes, there has been greater industry and consumer interest in natural alternatives.1–4,20,27,30 Unlike their artificial counterparts, which are created via chemical synthesis, natural food colorants originate from natural sources.1,3,6,21,22 Until the mid-20th century, these dyes were collected directly from plant tissue, animal cells, microorganisms, or minerals.1 With modern technology, however, scientists can extract certain naturally occurring chemical compounds from these sources and purify, stabilize, and standardize them.1 Notably, they are still minimally processed. These compounds can be used directly or chemically modified to produce a whole range of colors. The names of these dyes are likely more familiar than artificial ones. Some of the most common sources for natural food colorants have been paprika, turmeric, beets, and grape skin extract.1,21 However, there is a limited body of research on the safety of naturally-sourced alternatives when used as color additives.6 Pros and Cons It might seem like a simple choice to transition from artificial to natural food dyes. Both options come with trade-offs, and several factors need to be considered. Cost and scalability. Natural dyes are significantly more expensive than artificial dyes for several reasons. The effort required to source the dyes, use natural materials to create them, and process and stabilize the dyes increases the overall cost of these dyes.1,25,26,30 Color appeal and reproduction. Both artificial and natural food dyes can provide a wide range of colors, but recreating the exact same shade from batch to batch is more difficult with the latter. Some experts argue that artificial food dyes can create more vibrant colors or enhance more muted hues. This is an important factor to consider because color is important in identifying medications and can impact sales of

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Sarcoma Awareness Month

Sarcoma is a group of rare cancers where cancerous cells form in the bones or soft tissues. About 25 percent of bone and joint cancers are diagnosed in indviduals younger than 20 years of, age while soft tissue cancers are more frequently diagnosed in individuals aged 55 years or older.1 The American Cancer Society estimates that roughly 13,520 new cases of soft tissue sarcoma will be diagnosed in 2025, equating to 7,600 cases among male individuals and 5,920 cases among female individuals. It is estimated that 5,420 people, will die from soft tissue sarcoma in 2025.2  Risk Factors for Sarcoma Individuals with certain inhertied disorders, including Li-Fraumeni syndrome, neurofibromatosis type 1, nevoid basal cell carcinoma syndrome, Gardner syndrome, Werner syndrome, and tuberous sclerosis, have an increased risk of dveeloping sarcoma. History of radiation therapy, long-term lymphedema of the arms or legs, exposure to certain chemicals (eg, arsenic, vinyl chloride), human herpesvirus 8 infection, and human immunodeficiency virus (HIV) infection are other risk factors of sarcoma.3  Symptoms Soft tissue sarcoma often presents as a painless lump or swelling, commonly found on the arms or legs. In the abdominal area, sarcoma may be asymptomatic until it increases in size. As sarcoma grows, it puts pressure on nearby organs, nerves, and muscles, which can lead to pain and difficulty breathing.3 Diagnosis and Treatment A biopsy is typically done to diagnose soft tissue sarcoma. After the biopsy, further testing might be conducted on the biopsy sample; these tests can include immunohistochemistry, which checks for antigens in the tissue to help diagnose cancer; flow cytometry, which measures the number and characteristics of cells; and molecular profiling, which looks for genes, proteins, and other molecules that might be indicative of cancer.3  Soft tissue sarcoma is commonly treated with surgery to remove the tumor. Examples of surgical procedures include Mohs micrographic surgery, which preserves normal tissue; wide local excision, which removes the tumor along with some surrounding healthy tissue; limb-sparing surgery, in which a tumor in the arm or leg is removed without amputating the limb; or amputation, which involves removing part or all of the limb. Small, low-grade tumors might only require surgical intervention, whereas larger, higher-grade tumors might require chemotherapy or radiation therapy, either before surgery to shrink the tumor and reduce the amount of tissue that needs to be removed or after surgery to eradicate any remaining cancer cells. Targeted therapy and immunotherapy may also be used to treat sarcoma.3  Sources American Association for Cancer Research. Sarcoma awareness month. Accessed 20 May 2025. https://www.aacr.org/patients-caregivers/awareness-months/sarcoma-and-bone-cancer-awareness-month/ American Cancer Society. Key statistics for soft tissue sarcomas. Revised 16 Jan 2025. Accessed 20 May 2025. https://www.cancer.org/cancer/types/soft-tissue-sarcoma/about/key-statistics.html National Cancer Institute. Soft tissue sarcoma treatment. Updated 2 Jun 2023. Accessed 20 May 2025. https://www.cancer.gov/types/soft-tissue-sarcoma/patient/adult-soft-tissue-treatment-pdq 

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What is Multiple Myeloma? A Guide for Patients and Care Partners

Multiple myeloma (MM) is a complex hematologic malignancy (blood cancer) characterized by the proliferation of malignant plasma cells and abnormal production of monoclonal antibodies (M protein). Overproduction of these plasma cells can cause end-organ damage.1 These plasma cells are found in the bone marrow.2 The cause of MM is unknown, but some risk factors have been identified. MM develops primarily in older adults, with the median age at diagnosis being 70 years. Men are 1.4-times more likely to have MM than women.1 MM risk is twice as high in Black/African American individuals, compared to White individuals, whereas Asian/Pacific Islander individuals have a lower risk. Additionally, Black/African American individuals are much more likely to be diagnosed below the age of 50 years, compared to White individuals. Having a first-degree relative with MM can also increase the risk of MM, especially among men and Black/African American individuals.2 Other risk factors include genetic alterations, environmental exposures, obesity, and alcohol consumption.1 As per the International Myeloma Working Group, the diagnostic criteria for MM are as follows:3  Clonal bone marrow plasma cells of 10 percent or greater or biopsy-proven bony or extramedullary (outside the bone marrow) plasmacytoma (tumor formed by myeloma cells) and at least one of the following: Hypercalcemia (serum calcium >1mg/dL higher than the upper limit of normal or >11mg/dL) Renal insufficiency (creatinine clearance <40mL/minute or serum creatinine >2mg/dL) Anemia (hemoglobin >20g/L below the lower limit of normal or hemoglobin <100g/L) Bone lesions Clonal bone marrow plasma cells of 60 percent or greater Involved:uninvolved serum free light chain ratio of 100 or greater One or more focal lesions on magnetic resonance imaging (MRI) MM can lead to renal damage, platelet dysfunction, hyperviscosity (high blood viscosity), cytopenia (decrease in mature blood cells, eg, anemia, leukopenia, thrombocytopenia), and bone loss.1 Additional complications and symptoms include infection, bone pain, fatigue, venous thromboembolism, and peripheral neuropathy.1,2    Diagnosis and staging In brief, the diagnostic process for MM includes a history and physical exam, blood tests, urine tests, bone marrow biopsy and aspiration, immunohistochemistry (IHC) and/or flow cytometry and fluorescence in situ hybridization (FISH), and imaging tests, typically 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). Blood tests can measure levels of red blood cell, white blood cells, platelets, antibodies, M protein, and free light chains. Urine tests can identify the levels of total protein, M protein, and light chains in the urine.4 Bone marrow aspiration and biopsy are necessary for determining the proportion of abnormal plasma cells,1 as samples collected from these procedures are used in IHC, flow cytometry, and FISH. IHC and flow cytometry identify myeloma cells in the bone marrow, and FISH detects chromosomal, or cytogenetic, abnormalities in myeloma cells, which aids in determining prognosis. FDG-PET/CT scans are used to show the location of the myeloma as well as any bone damage.4 The Revised International Staging System (R-ISS) and second revision of the ISS (R2-ISS) are often used to determine disease stage, which helps with risk stratification. R-ISS is divided into three stages:5 Stage I: ISS Stage I (serum beta-2 microglobulin <3.5mg/L, serum albumin ≥3.5 g/dL) and standard-risk cytogenetic abnormalities measured by interphase FISH. Stage II: neither Stage I nor III Stage III: ISS Stage III (serum beta-2 microglobulin ≥5.5mg/L) and high-risk cytogenetic abnormalities [ie, presence of del(17p) and/or translocation t(4;14) and/or translocation t(14;16)] measured by interphase FISH or serum lactate dehydrogenase (LDH) above the upper limit of normal  The R2-ISS assigns points to each risk factor based on their impact on overall survival. ISS Stage III is worth 1.5 points; ISS Stage II, presence of del(17p), serum LDH above the upper limit of normal, and t(4;14) are worth 1 point; and 1q gain/amplification is worth 0.5 points. Staging works as follows:6 Low-risk: score of 0; none of the risk factors listed above are present. Low-intermediate–risk: score of 0.5 to 1  Intermediate-high–risk: score of 1.5 to 2.5 High-risk: score of 3 to 5 Treatment options vary based on patient characteristics, risk factors, and disease status (newly diagnosed or relapsed/refractory). The best way to understand whether a certain treatment option is right for you is to discuss it with your healthcare team. Conclusion MM is a rare and serious form of cancer that primarily affects older individuals. If you are diagnosed with MM, speak to your healthcare team about the treatment possibilities that fit best with your situation. Sources Albagoush SA, Shumway C, Azevedo AM. Multiple myeloma. In: StatPearls. StatPearls Publishing; 2025. Updated 30 Jan 2023. Accessed 11 Apr 2025. https://www.ncbi.nlm.nih.gov/books/NBK534764/ Padala SA, Barsouk A, Barsouk A, et al. Epidemiology, staging, and management of multiple myeloma. Med Sci (Basel). 2021;9(1):3.  Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol. 2014;15(12):e538–e548. National Comprehensive Cancer Network. NCCN guidelines for patients: multiple myeloma, 2025. 2024. Accessed 11 Apr 2025. https://www.nccn.org/patients/guidelines/content/PDF/myeloma-patient.pdf Palumbo A, Avet-Loiseau H, Oliva S, et al. Revised International Staging System for multiple myeloma: a report from International Myeloma Working Group. J Clin Oncol. 2015;33(26):2863–2869.  D’Agostino M, Cairns DA, Lahuerta JJ, et al. Second revision of the International Staging System (R2-ISS) for overall survival in multiple myeloma: a European Myeloma Network (EMN) report within the HARMONY Project. J Clin Oncol. 2022;40(29):3406–3418. Erratum in: J Clin Oncol. 2022;40(34):4032.  

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The Importance of Bone Density for Women: Why Early Scans Matter

By Emily Socolinsky Coach Emily is the Owner and Head Coach of Fivex3 Training located in Baltimore, Maryland. Bone density, an often overlooked element of women’s health, plays a critical role in our overall wellbeing and quality of life as we age. Unlike cardiovascular fitness or muscle tone, which tend to receive more attention in discussions of women’s health, bone strength quietly underpins everything from our ability to move freely to our resistance against fractures and long-term disability. The gradual and often silent decline of bone density, particularly in women, makes early education and screening, such as bone density dual-energy X-ray absorptiometry (DEXA) scans as early as 50 years of age, a vital part of preventative health care. Bone mineral density (BMD) refers to the amount of bone mineral (hydroxyapatite) in bone tissue. It is measured using a DEXA scan, which evaluates the strength of bones and the likelihood of fractures. These scans yield two types of results: T-score and Z-score. T-score compares your bone density to that of a healthy young adult. A T-score of –1.0 or above is normal. A score between –1.0 and –2.5 indicates osteopenia, a condition where BMD is below normal and may lead to osteoporosis. A score of –2.5 or lower signals osteoporosis, a disease characterized by fragile bones and an increased risk of fractures. Z-score compares your bone density to the average of someone your age, sex, and weight. A Z-score significantly below average (<–2.0) may indicate that something other than aging is causing abnormal bone loss and should prompt further investigation. For women, bone density is at its peak between the ages of 20 and 29 years. During this decade, the bones are the strongest and densest they will ever be. However, this window is fleeting. Beginning around the age of 30 years, bone mass naturally starts to decline. The loss is slow and steady at first, often going unnoticed. By the time women are in their 40s, the rate of bone loss begins to accelerate, especially in the years leading up to menopause. Women may begin to show signs of osteopenia even without symptoms. Around the age of 50 years, women begin to enter menopause, and estrogen levels drop dramatically. Because estrogen is a key hormone in maintaining bone mass, this hormonal shift leads to a rapid decrease in bone density, increasing the risk for osteoporosis. For women in their 60s and beyond, without intervention, the risk of osteoporosis rises sharply. By this time, many women may experience fractures or learn that they have low bone mass only after an injury has occurred. The Role of Menopause and Hormonal Changes Estrogen plays a central role in bone remodeling, the process by which bones continually rebuild themselves. During menopause, the sharp decline in estrogen disrupts this balance, tipping the scale toward bone resorption (breakdown) rather than bone formation. This is why women are at a far greater risk of osteoporosis compared to men, especially after menopause. Conditions like early menopause, surgical removal of ovaries, or amenorrhea (lack of menstruation due to underweight or high physical stress) can bring on early bone loss. Additionally, medications such as corticosteroids, certain thyroid treatments, and even some cancer therapies can reduce bone density.  Why Get a Bone Scan by 50 years of age? Many health organizations recommend women begin routine DEXA scans at 65 years of age or earlier if risk factors are present. However, by this age, substantial bone loss may have already occurred. Detecting changes in bone density by 50 years of age allows women to take early action, including: Implementing strength training. Resistance and weight-bearing exercises stimulate bone formation. Women who lift weights, especially heavy weights such as the compound barbell movements (squats, deadlifts, and presses), tend to maintain or even improve their bone density. Supplementing wisely. Adequate intake of calcium and vitamin D is essential. Vitamin D helps the body absorb calcium and maintain healthy levels in the bloodstream. Women with vitamin D deficiency (<30ng/mL) are at greater risk of bone loss and fractures. Addressing lifestyle risks. Smoking, excessive alcohol consumption, and very low bodyweight all increase the risk of osteopenia and osteoporosis. Identifying these factors early can allow for lifestyle interventions that preserve bone mass. Monitoring medication impact. Some medications may affect bone density. Early scans can help track bone loss in women undergoing treatment for other conditions. By the age of 50 years, most women are entering perimenopause or are already in menopause. This period is critical for assessing health risks, and adding a bone scan to routine checkups can uncover issues before a fracture occurs. It should be viewed as essential as mammograms or colonoscopies. Real-World Evidence: Case Studies in Strength Below are real-world case studies of five women between the ages of 50 and 75 years and the analysis of their bone scans during the time they implemented strength training into their lifestyle. All five women had a DEXA scan, which is calculated as bone mineral content or mass divided by the projected area of a bone in a 2D image. These scans measured two-dimensional spaces, areal BMD (aBMD). An areal unit has no mass because area is a two-dimensional measurement of surface. It is calculated as cm² or m². Density, by definition, is mass per unit volume. Therefore, an areal unit, lacking mass, cannot have density. In regards to aBMD, the focus is on mass per unit area, such as grams per square centimeter (g/cm²). This differs from volumetric BMD (vBMD), which is mass per unit volume (eg, g/cm3). While vBMD, obtained from 3D imaging techniques like micro-computed tomography (microCT), is a true measure of density, a DEXA scan which measures a two-dimensional space (aBMD), is an extremely valuable indicator of bone health and fracture risk even if it is not a true measure of density. Case study 1: MS, a 75-year-old postmenopausal woman. MS has been training at Fivex3 since December 2019. Due to the COVID-19 pandemic, there was a 2.5-month period from mid-March to

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Artificial Intelligence in the Doctor’s Office

By Sarabeth Lowe, MPH Ms. Lowe is a Communication Specialist at the University of Delaware Disaster Research Center. Welcome to the second edition of Health Literacy Highlights, a new NHR column where I explore topics related to finding, understanding, and utilizing health information. This column is meant to empower you with the skills you need to apply to what you already know and how to use it to maintain and protect your overall health and well-being. In this installment of Health Literacy Highlights, I will be discussing the use of ambient artificial intelligence (AI) in healthcare. If you’ve visited your doctor recently, this scenario might sound familiar: You call the doctor’s office only to find that the next available appointment, whether its with a specialist or a primary care physician, is months out. You schedule the appointment, and you wait for the day to arrive. You wait for your name to be called in the waiting room. Finally, you’re waiting for the doctor in the exam room.  When you finally meet with the doctor, the conversation is brief and feels rushed. To make matters worse, their eyes are mostly glued to their computer screen, making the exchange feel impersonal and brusque. Even so, you know that you should not take it personally. After all, the doctor needs to move along to their next patient. Still, you leave feeling a little slighted, maybe even snubbed, after the interaction. Of course, this is not the desired scenario for the doctor, either.  Its no wonder that patient and physician burnout have become a serious issue in public health.1–6 According to the Association of American Medical Colleges, the United States will face a physician shortage of up to 86,000 physicians by 2036.7,8 Luckily, there is help—and hope—on the horizon.  AI is transforming the US healthcare system.6,9–12 As these tools continue to evolve and improve, many healthcare providers and experts agree that this innovative technology will play a critical role in shaping a more positive future. At the same time, enthusiasm for this technology is growing because they feel confident that leveraging these tools is finally a reality.13–18 Numerous tools have come onto the scene, including AI-powered chatbots, automated appointment scheduling, and computer-aided diagnosis algorithms. One, however, has emerged as a particularly effective tool for addressing patient-physician communication and burnout: ambient AI. What Is Ambient AI? Ambient AI, which I will refer to as AAI, is a subset of AI that focuses on creating intelligent systems—machines capable of recognizing and responding to their environment—that can solve problems in real-time and at scale.19,20 It uses ambient listening technology (ALT) and a combination of different AI-powered tools, including machine learning, data analytics, and natural language processing, to capture, process, and interpret conversations in near-real time. You can think of AAI as having a medical scribe in the room that never needs training, never burns out, and never interrupts. In clinical settings, healthcare providers use a recording device to “listen” in during their appointments, with the patient’s consent. AAI then analyzes this doctor–patient dialogue and converts it into structured medical documentation.21  Unlike other types of AI, where the user must ask a specific question or provide explicit context or details, ALT does not require a particular prompt or manual input. As the term “ambient” describes, this technology is non-intrusive and exists in the background. It only activates when the device perceives a context cue, such as a patient entering an exam room or an ID badge getting scanned. In short, AAI is designed to work behind the scenes without human intervention and be responsive, proactive, and intuitive.  How It Works and What to Expect AAI is more than just a recording technology. It does not just hear; it listens. AAI captures clinical context and transforms it into clean, usable medical documentation. It is able to identify symptoms, medications, diagnoses, and treatment plans. AAI accounts for all of this information and context—extracted from the raw, unedited dialogue between you and your doctor—and turns it into a high-quality, comprehensive note that fits neatly into your electronic health record (EHR).20,21 It is even able to recognize the nuances of conversation, such as pauses, voice inflection, and words per minute, and include those details in the digital record. According to Freed, a technology company behind a popular medical AI scribe tool that more than 20,000 physicians have used, here is what happens behind the scenes: Recording. A context cue will wake the ALT device, such as a tablet, smartphone, or ceiling microphone, which will be passively capturing audio from the room. Speech-to-text conversion. During the appointment, the ALT system will use automatic speech recognition to convert the conversation into text. This technology is able to account for multiple speakers. Speaker ID and context detection. ALT will use advanced diarization (a fancy term for “who said what”) to identify the speakers (eg, patient, doctor, nurse, etc.).21 It also identifies clinical context, including symptoms, conditions, medications, and treatment plans, during this time. Structuring the note. After the conversation is recorded and transcribed, the system will organize it into a structured format, such as a Subjective, Objective, Assessment, and Plan (SOAP) note. Instead of just transcribing the dialogue, ALT is able to transform the information into a usable clinical note.  Clinician review and handoff. Before this documentation is finalized and added to your EHR, the note is handed back to your provider, who will review the note, make any needed edits, and sign off to confirm its accuracy. AAI is able to complete these steps within minutes or seconds, depending on the system.21  This entire process, from the start of the appointment to writing up clinical documentation and submitting it to your Electronic Health Record (EHR), is time- and labor-intensive for healthcare providers and requires meticulous attention to detail. Research indicates that primary care physicians spend approximately 36 minutes on EHR documentation for each patient. All of this extra time spent on clerical and administrative tasks, which can add up to hours of additional

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Hidradenitis Suppurativa

Hidradenitis Suppurativa: Risk Factors, Comorbidities, and Treatment

Hidradenitis suppurativa (HS) is a chronic skin disorder characterized by abscesses and scarring around clogged hair follicles, which appear as cysts, blackheads, and nodules.1 While the exact causes of HS are unknown, it is believed to be caused by hormonal imbalance, trapped bacteria in hair follicles, and an over-active immune system.2 HS commonly appears in areas such as the armpits, groin, buttocks, and breasts.1  Risk Factors There are several risk factors associated with developing and worsening of the condition. Many patients with HS are overweight and/or smoke cigarettes,3–7 which can worsen symptoms.1 The condition is three times more prevalent in women and occurs more frequently in Black individuals.8,6,7  Smoking. A study by Revuz et al3 published in the Journal of the American Academy of Dermatology analyzed risk factors for HS among 302 participants and found that smoking is a primary risk factor for this skin disease. Among the study controls, smoking was notably more prevalent, with over 70 percent of patients with HS reporting smoking.9 The researchers discovered that smoking is a strong trigger for HS3,5 because it disrupts immune function and sweat gland activity.10,5 In a study conducted by Sartorius et al,11 smokers were found to have stronger disease severity compared to non-smokers, as assessed by the Modified Hidradenitis Suppurativa Score (HSS) which evaluates the number of affected body areas and the extent of skin affected by the lesions, and whether the lesions are broken up by areas of normal skin. A total of 115 patients were scored, with primary factors such as body mass index (BMI) and tobacco use considered as overall risk factors.12,11 Cigarettes’ various chemicals, including nicotine, benzopyrene, and arsenic-like substances can negatively impact receptors in hair follicles and sebaceous glands causing the skin to thicken and block pores.12,13 Tobacco also directly affects how much sweat the body produces, thereby clogging the sweat glands and further contributing to more severe cases of HS.12,14  Obesity. Multiple studies looking at HS and obesity have reported a strong link between BMI and increased disease severity.3,11,15–17 In turn, the literature indicates that HS is notable more common among people with obesity than among those who do not have obesity.15,18 Revuz et al3 discovered that overweight is a primary risk factor for HS; the researchers discovered that each small increase in BMI led to a higher risk of HS, suggesting that overweight and obesity are significant risk factors.3,9  Research also indicates that obesity and HS are closely linked, with contributing factors such as sweat retention and disrupted hormone regulation serving as triggers for HS. Sweating and skin-to-skin contact causes shearing which can lead to hair follicles becoming blocked. Keratin hydration within sweat glands is stimulated by skin-to-skin contact, reducing the diameter of the follicular orifice and leading to pore clogging. Obesity also impacts hormonal metabolism, leading to an excess of androgens, which can cause hair shafts to thicken, thereby contributing to pore clogging.19,20,5 Rates of obesity are higher among patients with HS compared to the general population;21 however, researchers have not yet identified a specific association.12 A study conducted by Wright et al22 analyzed 2,384 patients with HS and discovered that the participants’ baseline BMIs were significantly higher compared to the control subjects, with the most differences reported among women compared to men.  Common Misconceptions Because of the areas of skin it affects, HS is often mistaken for acne, folliculitis, or a sexually transmitted infection; however, HS is neither contagious nor caused by poor hygiene.23,24 Many myths surrounding the causes of HS include false beliefs that it is caused by poor hygiene, antiperspirant use, or chemical hair removal.10 A study published in the journal Archives of Dermatology examined whether shaving, chemical hair removers, deodorants, and talcum powder used in the armpit and groin regions are directly linked to the development of HS. Forty patients with matched controls were analyzed, and no significant differences were observed with the various products in either patients with HS or patients without HS.25 Comorbidities Psychiatric disorders. Patients with HS are likely to experience depression.15,26–30 Compared to other skin conditions, individuals with HS often experience more severe depression, with strong links between higher depression levels and the severity of both the disease and its associated inflammation.15,26,30 Other psychiatric conditions such as anxiety, schizophrenia, and bipolar disorder have also been reported in patients with HS.15,29  Substance use disorder. Due to the pain and emotional distress often experienced by patients with HS, the literature suggests these patients are at increased risk for substance use disorders, particularly with alcohol and opioids.31 A study looking at 32,000 patients with HS found the prevalence of substance use disorder to be 4.0 percent, in comparison to 2.0 percent in the control group.31,32 A separate study which looked at 20,000 patients with HS found the one-year incidence of chronic opioid use among opioid-naive patients with HS was 0.3 percent, twice the amount of the control group. Overall, the researchers found that patients with HS were at 1.5 times increased risk of chronic opioid use.33,31  Treatment Options Mild cases of HS can be treated with topical clindamycin 1%. Numerous clinical trials have reported the efficacy of this treatment. A total of 30 patients with recurrent HS participated in a trial with the control group experiencing significant improvement in reducing the number of abscesses, inflammatory nodules, and pustules, compared to the placebo group.34,35 For patients with severe HS, systemic antibiotics such as doxycycline taken once or twice daily, minocycline taken once or twice daily, or tetracycline taken twice daily, have proven to be effective.34,35 Other options for refractory cases include tumor necrosis factor (TNF)-alpha inhibitors. Clinical trials have demonstrated effectiveness in reducing HS symptoms and preventing the development of new lesions, with participants experiencing at least a 50-percent reduction in abscesses and inflammatory nodules, and no new abscesses or draining fistulas.37 Surgery to remove lesions is appropriate for patients with either Stage II or III HS, particularly for cases involving lesions over considerable areas of the body. Surgical options include local destruction, electrosurgery, and photodynamic

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