Hadar Lev-Tov, MD, who directs the Miami HS Center at the University of Miami School of Medicine, is on a mission to learn all he can about exercise for patients with hidradenitis suppurativa (HS).

“When we talk about holistic interventions that doctors can provide [to lower inflammation and risk of disease in the general population], generally speaking, we talk about nutrition, we talk about exercise, and maybe we talk about sleep,” he told Medscape Medical News. “But exercise has by far the most robust evidence, it’s easier to study, and it’s easily prescribable.”

For patients with HS, however, there are a host of questions. What types of exercise are possible? Given their pain and often limited physical activity, what can patients with HS tolerate in an exercise program? How can exercise be personalized? And can these patients really improve their functional strength, physical activity, and overall wellness through exercise?

Such questions led Lev-Tov, associate professor of dermatology at the University of Miami, to collaborate with David Mandel, PT, PhD, a physical therapist there. With a small team of other researchers, they are documenting that a 12-week personalized home-based strengthening program utilizing resistance bands — and modifications as needed — can lead to significant improvements in functional strength and endurance without the exercises themselves causing increases in flares. 

Physical therapists do a lot of wound care and post-surgical care, “but seeing how HS is such a systemic issue and how it really impacts almost everything was surprising,” said Mandel, assistant professor of clinical PT at the University of Miami, in an interview. “I was surprised by how debilitating it all is.”

Lev-Tov and Mandel, who presented preliminary results from their pilot study in 2025 at both the American Academy of Dermatology annual meeting and the annual Integrative Dermatology Symposium (IDS), hope that their findings will lead to a larger study, more research by other investigators, and ultimately to validated interventions and tools such as guidance for physical therapists, personal trainers, dermatologists, and patients — and even exercise apps that patients can use at home. 

Patients with HS are often guided toward “low-intensity, low-friction types of exercise” such as yoga, swimming, and walking, “but we really don’t have much data to support it,” Steven Daveluy, MD, who attended the IDS presentation by Lev-Tov and Mandel, told Medscape Medical News. “And we don’t have time to personalize exercise routines to each patient.”

Regarding physical therapy for exercise training, “the hard part is, I don’t think the physical therapist would really know what to do. There’s no data out there about helping patients with HS,” Daveluy, professor and dermatology program director at Wayne State University School of Medicine, Detroit, said. “I like the idea that it’s being researched.”

Positive Outcomes With Muscle Strengthening 

Moderate exercise can help disrupt the cycles of systemic inflammation characteristic of HS and its common comorbidities (such as obesity, metabolic syndrome, and cardiovascular disease) through multiple pathways. Decreasing adipose tissue, for one, decreases the release of pro-inflammatory adipokines. But just as importantly, according to Lev-Tov and Mandel, activating muscle leads to the release of myokines, some of which induce anti-inflammatory responses. 

“As you strengthen muscle, you’re breaking muscle fibers, and the muscle releases myokines first to repair that. But the initial inflammatory response then switches to an anti-inflammatory response that is much larger,” Mandel told Medscape. “Especially if we’re focusing on larger muscle groups, we can impact a larger amount of anti-inflammatory myokine release…Aerobic exercise alone won’t affect the muscle fibers enough.” 

For the study, which is ongoing, Mandel assessed the strength and function of almost 80 patients with HS. For those with moderate and severe HS per the International Hidradenitis Suppurativa Severity Score system, he developed individualized programs utilizing resistance bands and simple body weight exercises. He reassessed these patients at 6 and 12 weeks and checked in with them by phone occasionally to inquire about their comfort and determine when modifications were needed.

When axillary flexibility and pain was problematic, for instance, he worked with the patient to shift upper body exercises to the other side, if possible, or to focus temporarily on the lower body. When pain in the buttock was limiting, “exercises that require you to sit and do knee extensions would be modified to be done standing or laying down [while] targeting the same muscle groups,” he explained. 

To measure strength, function and endurance, Mandel used validated outcome measures that are relatively easy to perform in a clinic and for which there are published normative data for age and gender: the 6-minute walk test, grip strength, and the 30-second chair stand test. (The chair stand test assesses functional leg strength and endurance by counting how many full stands one can complete in 30 seconds with arms crossed over chest.)

At baseline, patients with moderate (n = 33) or severe (n = 26) HS had mean chair stand and walk scores that were near or less than 75% of expected scores in healthy age-and-sex-matched individuals. 

And surprisingly, even those patients with mild severity (n = 20) disease had impairment: 80% and 82% of the normative values on the chair stand and walk tests, respectively. Lev-Tov expected these patients would have similar ability to perform exercises as healthy adults, but this wasn’t the case. “Even though they weren’t as significantly impaired, they still were functionally lower,” Mandel said. 

A preliminary analysis of 22 patients who completed the 12-week intervention shows mean chair stand results rising from 76% to 96% of normative values and mean walk test results rising from 73% to 83%. (Both increases were statistically significant.) Mandel and Lev-Tov plan to run a second round of analyses once 30 patients have completed the intervention. 

Surprisingly, at baseline, patients in all severity categories had grip strength that was above normative values. Mandel and his team are reassessing whether grip strength is an optimal measure for HS and what other measures could be used to assess upper extremity strength in these patients. 

And unsurprisingly, the attrition rate was high — about 55%. In studies of exercise in healthy adults, the attrition rate tends to be 40%-50%, Mandel said. (Additionally, some patients with moderate and severe disease participated in the one-time baseline assessments but were not willing to participate in the intervention.) Flares that patients experienced during the intervention were not attributed to the exercises, he said. 

Encouraging Signs, Research Questions Moving Forward 

Takeaways from the research thus far have included the finding that patients with even mild HS develop limited mobility and muscle weakness — and that “we need to prescribe range of motion and resistance exercises early and not wait until they become limited,” Mandel said. 

In future research, Lev-Tov told Medscape, there are a host of questions to explore, including the impact of such an exercise program — and of “building the myokine factory” — on disease activity, pain levels, and amounts of medication required. “We’d love to see the effects internally, perhaps using blood markers, urine markers, and even measuring any transcriptomic changes in the skin,” he said, “and changes in the gut microbiome.” 

Researchers have studied the anti-inflammatory effects of exercise on various organs of the body — but “not so much the skin,” he said, referring to a 2011 review in Nature Reviews Immunology on the anti-inflammatory effects of exercise. “It’s understudied, to say the least.”

Significant reductions in inflammation likely take time, Mandel said. “Twelve weeks will only do a little bit” for inflammation control, he said. “There would have to be systemic change over multiple months to years to really get them to a point where [patients are] really controlling their inflammation.” 

Anecdotally, Lev-Tov and Mandel feel encouraged. During the study, Mandel observed how study participants learned to make modifications themselves, and how a relatively simple exercise program could spur on broader lifestyle changes. Moreover, some patients told Mandel at the end of the intervention they were feeling better and planned to continue the exercises long-term.

“Patients who weren’t doing any exercise, who weren’t even going to work, were starting to walk more and become more active. And several patients told us that since they’d been doing the exercise, they were also eating better,” he said. One patient with lower body involvement “went to a bike shop and bought a wider seat for her bicycle so she should start biking again.”

After completion of the intervention, Mandel said that when he caught up with a few of the patients at their regular appointments with Lev Tov, “they said they were continuing.”

Lev-Tov, Mandel, and Daveluy report having no relevant financial disclosures.