Metabolic Syndrome and Hidradenitis Suppurativa (Acne Inversa): What Your Internist Should Know

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Language: en
Category: Treatments
Published: 2026-05-21
Last updated: 2026-05-21
Last editorially reviewed: 2026-05-21
Next scheduled review: 2027-05-21

Author: Dr. rer. nat. Dennis Alexander Kwiatkowski (Biochemist, Scientific Writer and Pharma Expert)
Scientific editor: Dr. rer. nat. Dennis Alexander Kwiatkowski
Reviewer qualifications: Biochemist, Scientific Writer and Pharma Expert
Review scope: Scientific literature, clinical guidelines, sources, and editorial clarity
Clinical reviewer: No independent clinical review
Tags: Acne Inversa, Hidradenitis Suppurativa, HS, Treatments, metabolic syndrome, cardiovascular risk, diabetes, high blood pressure, dyslipidemia, comorbidities, screening
Metabolic syndrome occurs about four times more often in HS patients than in comparable controls, with measurable cardiovascular consequences. This article explains its components, the increased mortality risk, and which screening tests are important.

Medical disclaimer: This website is for general educational information only and does not replace medical advice, diagnosis, or treatment. Please speak with qualified medical professionals about symptoms or treatment decisions.

Article

Hidradenitis suppurativa (HS) is usually discussed as a skin disease. The cardiovascular and metabolic dimensions of the condition receive less attention in patient education and routine clinical care, even though some of the strongest comorbidity data in the HS literature relate to exactly this area. Patients with HS are roughly four times more likely to have metabolic syndrome than comparable controls, show increased rates of each individual component (obesity, diabetes, high blood pressure, dyslipidemia), and have nearly double the cardiovascular-related mortality.

This article addresses the metabolic dimension of HS directly: what the evidence shows about the increased cardiovascular risk, why this matters for life expectancy rather than just current quality of life, which screening tests are appropriate, and how the care pathway between dermatology, cardiology, and internal medicine should work for patients with pronounced HS. It is intended for patients who want to understand why their HS provider (or their internist) should be paying attention to factors beyond the skin.
For educational purposes only. Cardiovascular and metabolic management requires individual assessment by a primary care physician or internist. This article describes general principles and which screening tests may reasonably be requested.

Key Takeaways

- Metabolic syndrome — a cluster of obesity, high blood pressure, dyslipidemia, and impaired glucose metabolism — occurs about four times as often in HS as in comparable controls.
- HS patients have roughly double the risk of cardiovascular death and increased rates of major cardiovascular events (heart attack, stroke) compared with the general population.
- The increased risk is not explained by obesity alone; the chronic systemic inflammation caused by HS itself independently contributes to cardiovascular risk.
- Screening for components of metabolic syndrome in HS patients is recommended by current guidelines and is often underutilized.
- Treatment of the components of metabolic syndrome follows standard pathways (lifestyle, medications where indicated); some HS treatments may have an indirect metabolic benefit by reducing systemic inflammation.

What Metabolic Syndrome Actually Is

Metabolic syndrome is a clinically defined cluster of cardiovascular risk factors that, when they occur together, identify patients at substantially increased risk for cardiovascular disease and type 2 diabetes. The diagnostic criteria most commonly used in Europe (International Diabetes Federation, with similar definitions from NCEP-ATP III) require central obesity plus at least two of the following:

- Central obesity: waist circumference exceeding ethnicity-specific thresholds (for European populations: >94 cm in men, >80 cm in women)
- Elevated triglycerides: ≥150 mg/dl (1.7 mmol/l) or specific treatment for this abnormality
- Reduced HDL cholesterol: <40 mg/dl (1.03 mmol/l) in men, <50 mg/dl (1.29 mmol/l) in women, or specific treatment
- Elevated blood pressure: systolic ≥130 mmHg or diastolic ≥85 mmHg, or treatment for previously diagnosed hypertension
- Elevated fasting glucose: ≥100 mg/dl (5.6 mmol/l) or previously diagnosed type 2 diabetes

The diagnosis identifies a state of metabolic dysregulation. Each component independently contributes to the risk of cardiovascular and metabolic disease; their co-occurrence amplifies risk beyond what any single component would predict on its own. Roughly 25% to 30% of adults in Western populations meet the criteria for metabolic syndrome; prevalence increases with age.

What the HS-Specific Evidence Shows

The literature on metabolic syndrome in HS is consistent and extensive.

Overall prevalence of metabolic syndrome. A frequently cited Danish study of 358 HS patients reported roughly a fourfold higher likelihood of metabolic syndrome compared with matched controls. Several subsequent studies across different populations have confirmed a substantial increase, with point estimates ranging from roughly two- to fourfold depending on the study population.

Prevalence of individual components.

- Obesity: roughly 2.5-fold higher likelihood in HS populations (2024 meta-analysis, OR 2.48).
- Type 2 diabetes: roughly 2.8-fold higher likelihood (OR 2.78 in the same meta-analysis).
- High blood pressure: elevated in HS populations, with reported odds ratios typically around 2.
- Dyslipidemia: elevated, with both raised triglycerides and reduced HDL contributing.

Cardiovascular events and mortality. A population-based cohort study (n=5,964 HS patients) showed roughly double the risk of major cardiovascular events and 1.7- to 2-fold higher cardiovascular-related mortality compared with controls.

Independent effect beyond BMI. Several studies have shown that the metabolic and cardiovascular risk in HS is not fully explained by obesity alone. Even after adjusting for BMI, HS independently contributes to cardiovascular risk — a pattern consistent with chronic inflammation as an independent risk factor, similar to the well-documented cardiovascular risk associated with chronic inflammatory conditions such as rheumatoid arthritis and psoriasis.

The 2021 evidence-based screening recommendations from the US and Canadian Hidradenitis Suppurativa Foundations explicitly list metabolic syndrome, obesity, dyslipidemia, type 2 diabetes, high blood pressure, and cardiovascular disease among the comorbidities for which screening is recommended in HS patients.

Why This Matters More Than It Sounds

Three reasons why the metabolic dimension deserves attention rather than being dismissed as an incidental finding.

Mortality is increased. Roughly double the cardiovascular-related mortality is not a minor finding. For a 30-year-old patient with moderate-to-severe HS, the cardiovascular trajectory over the next 40 years is just as significant as the trajectory of the skin disease. Lifetime cardiovascular events contribute substantially to the overall burden of HS, which is poorly captured by skin-focused outcome measures.

The risk is modifiable. Unlike many comorbidity associations, the components of metabolic syndrome are amenable to specific interventions — lifestyle changes, medications for hypertension and dyslipidemia, blood glucose management, smoking cessation. The increased risk is not fixed. Active management leads to a measurable reduction in cardiovascular events.

The inflammation argument has therapeutic implications. If chronic inflammation contributes to cardiovascular risk in HS, effective treatment of the inflammation may reduce cardiovascular events. This has been documented for rheumatoid arthritis and psoriasis, where biologic therapy has been shown to reduce cardiovascular event rates beyond what is explained by management of traditional risk factors alone. For HS, data on cardiovascular outcomes from biologic therapy are still emerging, but the parallel is plausible.

Screening gaps are real. Several audit studies have shown that HS patients are screened for cardiovascular and metabolic comorbidities less consistently than would be appropriate given the elevated risk. Responsibility for screening falls between specialties — dermatology focuses on the skin, internal medicine sees the patient less often or not at all — and patients often fall through the gaps.

The Biological Connection

The mechanistic explanation linking HS to metabolic and cardiovascular disease is becoming increasingly well characterized.

Chronic systemic inflammation. HS leads to sustained elevation of inflammatory markers (CRP, IL-6, TNF-α, IL-1β, IL-17). Chronic systemic inflammation is a well-documented factor in atherosclerosis through effects on endothelial function, lipoprotein metabolism, plaque stability, and thrombogenic factors. The same inflammatory profile that drives HS at the skin level produces measurable cardiovascular effects.

Adipose tissue inflammation. Obesity in HS is associated with particularly inflammatory adipose tissue that generates an additional cytokine burden driving both HS activity and metabolic dysfunction. The relationship is bidirectional: obesity contributes to inflammation, and inflammation contributes to metabolic dysfunction.

Insulin resistance. Chronic inflammation produces insulin resistance through the effects of TNF-α and other cytokines on insulin signaling. Insulin resistance in turn contributes to obesity, dyslipidemia, hypertension, and atherosclerosis — mechanistically linking the components of metabolic syndrome together.

Shared risk factors. Several modifiable risk factors are shared between HS and metabolic syndrome: obesity, smoking, lack of physical activity, certain dietary patterns. These shared factors contribute to both conditions and explain part (but not all) of the comorbidity association.

Vascular effects. Some research points to direct effects of HS-related inflammation on vascular health, including measurable endothelial dysfunction in HS patients independent of traditional cardiovascular risk factors. This is consistent with the pattern observed in other inflammatory conditions.

The overall picture: HS contributes to cardiovascular risk both through shared risk factors (obesity, smoking) and through systemic inflammation independent of those factors. Both pathways are addressable.

Appropriate Screening Tests

Recommended screening measures for metabolic and cardiovascular comorbidities in HS patients, based on current guidelines and clinical practice:

Annually (or at appropriate intervals):

- Blood pressure measurement
- Weight, height, BMI calculation
- Waist circumference
- Fasting lipid profile (total cholesterol, LDL, HDL, triglycerides)
- Fasting glucose or HbA1c
- Symptom review for cardiovascular symptoms (chest pain, exertional dyspnea, palpitations)

Initial baseline assessment (especially for patients with moderate-to-severe HS):

- Complete cardiovascular risk assessment using validated tools (SCORE, Framingham, or local equivalents)
- Assessment of family history of cardiovascular disease
- Smoking status and cessation progress
- Sleep history (sleep apnea is more common in HS and contributes to cardiovascular risk)

Additional assessment where indicated:

- ECG for patients with symptoms or specific risk factors
- Echocardiography for specific indications
- Referral to cardiology for high-risk patients or specific findings

This screening is appropriately performed by the primary care physician rather than the dermatologist — the dermatologist's role is to flag the need for screening and communicate the elevated risk profile to the primary care provider. In Germany, routine health check-ups (Gesundheits-Check-up) under statutory health insurance provide a framework for this screening, and HS patients should make sure to use these proactively rather than relying on episodic, disease-focused visits.

What Treatment Looks Like

Management of the components of metabolic syndrome in HS patients follows standard pathways.

Lifestyle Interventions

The foundation of all metabolic syndrome management. Specific approaches:

- Weight management for patients with elevated BMI, covered in the companion article on weight and HS.
- Smoking cessation, covered in the companion article on smoking. The combined cardiovascular benefit of cessation plus the HS-specific benefit make this one of the most rewarding interventions.
- Physical activity, to the extent the disease state allows, with the dual benefit of cardiovascular protection and metabolic improvement.
- Dietary patterns consistent with anti-inflammatory and cardioprotective principles. The Mediterranean dietary pattern has the strongest evidence for combined metabolic and cardiovascular benefit.
- Sleep optimization, particularly recognizing and treating sleep apnea when present.

Medications for Individual Components

Specific medications for components of metabolic syndrome are managed by primary care physicians and internists according to standard guidelines. A brief summary of what HS patients should know:

High blood pressure. Treated with standard antihypertensive agents (ACE inhibitors, ARBs, calcium channel blockers, thiazides) according to general guidelines. ACE inhibitors and ARBs have specific advantages in patients with diabetes or proteinuria. There are no HS-specific considerations for the choice of antihypertensive agent.

Dyslipidemia. Statins remain the first choice for elevated LDL cholesterol or for cardiovascular primary prevention in patients with increased risk. There is no HS-specific contraindication to statins. The reduction in cardiovascular events from statin therapy is well documented and applies to HS patients with elevated risk.

Type 2 diabetes. Metformin is the first choice, with additional benefits in cases of PCOS overlap and possible direct anti-inflammatory effects relevant to HS. GLP-1 receptor agonists (semaglutide, liraglutide) and SGLT2 inhibitors (empagliflozin, dapagliflozin) offer both glycemic control and additional cardiovascular benefits. The companion articles on weight loss and PCOS cover these in more detail.

Aspirin for primary prevention is no longer routinely recommended; the decision depends on individual cardiovascular risk and bleeding risk. This is a decision made in primary care.

Treating HS Itself

Effective HS treatment may indirectly benefit metabolic and cardiovascular outcomes by reducing systemic inflammation. Direct evidence in HS is limited, but parallels with psoriasis and rheumatoid arthritis suggest that effective biologic therapy may reduce cardiovascular event rates beyond what would be predicted from skin improvement alone. This is an additional rationale for consistent treatment of pronounced HS rather than chronic suboptimal management.

The Problem of Integrated Care

A patient with pronounced HS and metabolic syndrome frequently sees:

- A dermatologist focused on the skin disease
- A primary care physician managing primary care
- Possibly an endocrinologist for diabetes
- Possibly a cardiologist for cardiovascular risk
- Possibly a gynecologist or other specialists

Each specialist tends to focus on their own domain. The bigger picture — chronic inflammation driving both skin and cardiovascular disease, multiple modifiable factors affecting both, shared therapeutic goals — often falls through the cracks.

What helps here:

- Active coordination by one provider (usually the primary care physician) who holds the overall picture
- Explicitly bringing up the HS dimension in primary care visits, including any biologic therapy and current disease activity
- Explicitly bringing up the cardiovascular dimension in dermatology visits, including current cardiovascular medications and any cardiac symptoms
- Asking specialists to coordinate — via shared electronic records or summary letters, where possible
- Annual integrated review in primary care, where all conditions are considered together rather than separately

Patients who advocate for this integration tend to receive better coordinated care than those who passively accept fragmented specialist contacts.

Specifically in Germany

The German care context for metabolic screening in HS:

- Gesundheits-Check-up (general health check-up) is available under statutory health insurance every 3 years for adults aged 35 and older, as well as once between ages 18 and 34. This is the appropriate framework for routine metabolic and cardiovascular screening. HS patients should make sure to use it.
- Primary care physician coordinates standard cardiovascular and metabolic care.
- Specialist referrals to endocrinology, cardiology, or other relevant specialties are arranged by the primary care physician as needed.
- DMPs (Disease Management Programs) exist for type 2 diabetes, coronary artery disease, and other chronic conditions; HS patients with these conditions can enroll for structured follow-up care.

The system supports the integrated screening described in this article — what is often missing is the patient's active awareness that this screening is warranted given their comorbidity profile.

Frequently Asked Questions

Should I see a cardiologist as part of my HS care?

Not routinely, but if you have specific symptoms (chest pain, dyspnea), known cardiovascular disease, or a substantially elevated cardiovascular risk on standard assessment, referral to cardiology through your primary care physician is appropriate. Most patients can be adequately managed in primary care.

Will treating my HS lower my cardiovascular risk?

Possibly. The evidence is suggestive but not definitively specific to HS. The parallel with psoriasis and rheumatoid arthritis — where effective biologic therapy reduces cardiovascular events — supports the expectation that effective HS treatment has cardiovascular benefits beyond skin improvement. This strengthens the rationale for active HS treatment rather than chronic suboptimal management.

Are biologics safe from a cardiovascular standpoint?

Generally, yes. The biologics approved for HS (adalimumab, secukinumab, bimekizumab) have favorable cardiovascular safety profiles in the indication populations studied. TNF inhibitors have been extensively studied in cardiovascular contexts in rheumatology and dermatology. In patients with specific advanced cardiovascular conditions (e.g., NYHA class III/IV heart failure), there are particular considerations with TNF inhibitors, and these should be assessed individually.

Does it matter that my CRP is elevated?

C-reactive protein (CRP) is a marker of systemic inflammation that is often elevated in HS, particularly during flares. Persistently elevated CRP is associated with cardiovascular risk independent of traditional factors. Active HS treatment that lowers CRP may indirectly reduce cardiovascular risk. CRP is a useful biomarker but is not, in itself, a treatment target in HS management.

Should I take a statin because of my HS?

Statin therapy is determined by cardiovascular risk assessment, not by the HS diagnosis alone. If your overall cardiovascular risk calculation supports statin therapy (typically based on age, lipid levels, blood pressure, diabetes status, smoking, and family history), HS is not a contraindication to it. The relevant decision is made with your primary care physician using standard cardiovascular risk frameworks.

What about NSAIDs and my cardiovascular risk?

NSAIDs (ibuprofen, naproxen, diclofenac, etc.), used to manage HS pain, carry a documented cardiovascular risk with regular long-term use, particularly at higher doses. In patients with substantial cardiovascular risk, this warrants a discussion with the prescribing provider. Short-term use during flares is generally low-risk; chronic use at maximum doses over years has meaningful cardiovascular implications.

Are GLP-1 agonists relevant for me?

For HS patients with type 2 diabetes, substantial obesity, or both, GLP-1 receptor agonists offer benefits for glycemic control, weight management, and cardiovascular events. They may also provide indirect benefits for HS through weight reduction. Reimbursement in Germany varies and is evolving; specific indications and access should be discussed with your primary care physician or endocrinologist.

My family has heart disease — should I be more worried?

A family history of premature cardiovascular disease (men <55, women <65) is an additional cardiovascular risk factor that compounds with the HS-related increase. This warrants more proactive cardiovascular risk management — earlier and more frequent screening, lower thresholds for intervention, and active modification of all risk factors. Discuss your family history specifically with your primary care physician.
Disclaimer. This article is for general education and does not constitute personal medical advice. Cardiovascular and metabolic management requires individual assessment by qualified providers, usually including your primary care physician and, where relevant, specialists in internal medicine or cardiology.

References

1. Garg A, Malviya N, Strunk A, et al. Comorbidity screening in hidradenitis suppurativa: Evidence-based recommendations from the US and Canadian Hidradenitis Suppurativa Foundations. - Journal of the American Academy of Dermatology, 2022
2. Egeberg A, Gislason GH, Hansen PR. Risk of major adverse cardiovascular events and all-cause mortality in patients with hidradenitis suppurativa. - JAMA Dermatology
3. Sabat R et al. Increased prevalence of metabolic syndrome in patients with acne inversa. - PLOS One
4. Reddy S, Strunk A, Garg A. Incidence of myocardial infarction, stroke, and cardiovascular-associated death among patients with hidradenitis suppurativa: a population-based analysis. - JAMA Dermatology
5. Tzellos T, Zouboulis CC. Review of Comorbidities of Hidradenitis Suppurativa: Implications for Daily Clinical Practice. - Dermatology and Therapy, 2020