Table 1.

Vitamin and mineral recommendations for patients with HS

Vitamins/minerals	Levels in HS patients	Supplementation and other recommendations	Study type	Clinical considerations
Vitamin A	Low*	Acitretin, isotretinoin, and alitretinoin can be used as adjunct therapies for HS40: grade B recommendation**, level II evidencea Mild or moderate disease, combination therapy with isotretinoin and spironolactone or adalimumab [17]	Systematic review [18] Retrospective chart review	Vitamin A toxicity can occur with chronic ingestion of large amounts of synthetic vitamin A (approximately 10 times higher than the recommended dietary allowance, or approximately 50,000 international units) Retinoic acid, a vitamin A metabolite, is teratogenic in the first trimester of pregnancy [19]
Vitamin D	Low	Check vitamin D levels at the time of initial diagnosis and document levels over time, noting low levels of 25-hydroxy vitamin D [25(OH)D] below 20 ng/mL Vitamin D supplementation as HS treatment: grade B/C recommendation**b, level II/III evidence a, c Supplementation with cholecalciferol is preferred over ergocalciferol; cholecalciferol more efficaciously raises serum 25(OH)D [20]	Retrospective study [21] Non-randomized controlled trials [20, 22]	To assess vitamin D status: obtain serum 25(OH)D Deficiency: 25(OH)D levels <12 ng/mL (<30 nmol/L), insufficiency: 25(OH)D levels <20 ng/mL (<50 nmol/L) 25(OH)D target range for repletion: 20–40 ng/mL Vitamin D toxicity may occur with excessive doses. Monitor for symptoms of hypervitaminosis D. [22]
Vitamin B12	Low*	Check vitamin B12 levels in HS patients who are elderly, obese, have signs of cardiovascular disease or have alcohol use disorder to optimize management with standard HS therapeutics [5, 23] Biweekly supplementation with 1,000 µg vitamin B12 intramuscular in patients with HS and Chron's disease [24]	Case series Case-control study	There is no high-quality evidence that supplemental vitamin B12 is beneficial in patients with HS eating a balanced diet [25]
Iron	Low	Serial hemoglobin measurements to assess HS disease severity and response to treatment Diagnosis of iron deficiency anemia [26] ↓Red blood cell (RBC) count ↓ Hemoglobin and hematocrit ↓ Absolute reticulocyte count ↓ Mean corpuscular volume (MCV)	Case report	Numerous oral iron formulations are available and are equally effective. Liquid iron (allows for dose titration) or tablets containing ferrous salts are the most effective for treating iron deficiency anemia Gastrointestinal side effects are common with oral iron administration. Changing the frequency of supplementation to every other day and with meals may improve symptoms [26]
Zinc	Low	No recommendations to measure or monitor serum zinc levels Zinc pharmacological forms: zinc gluconate [8], zinc glutamate [12], pyrithione zinc (grade C recommendation, b level III evidencec) [13, 27], oral zinc with niacinamide [6], zinc-sulfate-based regimens [5, 27], and in combination with antibiotics [7] Daily oral zinc gluconate supplementation of 90 mg (grade C recommendation,b level II evidencea) [12] Cleanser for hair-bearing areas: pyrithione zinc-containing (1%) shampoos [27]	Systematic literature review CME article 13	Gastrointestinal side effects are more common with zinc sulfate administration. Consuming zinc with meals or switching to zinc gluconate may improve symptoms [27]

^*Accompanied by other micronutrient deficiencies.

^**Grade B recommendation: recommendation based on inconsistent or limited quality patient-oriented evidence (morbidity, mortality, symptom improvement, cost reduction, quality of life) [28].

^aLevel II evidence: evidence provided from limited quality patient-oriented evidence [29].

^bGrade C recommendation: recommendation based on consensus, usual practice, opinion, disease-oriented evidence (intermediate, physiologic, or surrogate endpoints that may or may not reflect improvements in patient outcomes), and case series for studies of diagnosis, treatment, prevention, or screening [28].

^cLevel III evidence: evidence provided from consensus guidelines, extrapolations from bench research, usual practice, opinion, disease-oriented evidence (intermediate or physiologic outcomes only), and case series for studies of diagnosis, treatment, prevention, or screening [28].