Real-world Efficacy of Sodium Hypochlorite Body Wash in Managing Hidradenitis Suppurativa

Abstract

Hidradenitis suppurativa (HS) is a chronic skin condition characterized by nodules, abscesses, and tunnels that may develop in various parts of the body, particularly in the axillary, gluteal, and inguinal regions.¹ Treatment for HS varies based on clinical presentation and disease progression and encompasses antibiotics, hormonal therapy, biologics, topical treatments, and surgical procedures. Despite the array of available treatment options, patients typically require multiple treatment modalities to alleviate symptoms, which can include antimicrobial cleansers and washes, though there is limited evidence regarding their effectiveness in managing HS. Here, we evaluated real-world patient-assessed efficacy of sodium hypochlorite body wash in the management of hidradenitis suppurativa. Of the 165 participants enrolled, 145 completed a four-week study evaluating daily use of sodium hypochlorite body wash for hidradenitis suppurativa (HS), representing all Hurley stages and a wide range of disease durations. Significant improvements were observed across key symptoms, with the greatest reduction in pain (3.52 to 1.62, p<0.001), and over 60 percent of participants reported fewer and shorter flares. Most participants found the wash beneficial, with 88.8 percent recommending it, and there was strong support for the dab method among those who used it. These data support clinical utility of hypochlorite washes in the chronic management of HS.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by nodules, abscesses, and tunnels that can develop on any areas of hair-bearing skin, with a predilection for the axillae, gluteal region, and inguinal areas.¹ Presently, there are multiple treatment modalities and approaches aimed at alleviating symptoms and preventing disease progression. These include systemic antibiotic therapy, hormonal treatments, biologics, topical therapies, and surgical interventions, often utilized in combination to manage this debilitating disease.¹

Despite limited evidence to support their effectiveness in HS, antimicrobial cleansers and washes are commonly employed for HS in routine clinical practice and recommended as a component of the treatment regimen across all stages of disease in treatment guidelines.^1–11 Antimicrobial washes, such as chlorhexidine, zinc pyrithione, bleach baths, and benzoyl peroxide aim to reduce inflammation, restore normal skin and hair follicle flora, and prevent resistance to concomitant topical antibiotics.¹ While sodium hypochlorite containing solutions (commonly in the form of "bleach baths") have shown efficacy in treating other dermatological conditions like atopic dermatitis and acne, their utility in managing HS remains unexplored.² We sought to evaluate the efficacy of a commercially available body wash containing sodium hypochlorite in alleviating symptoms experienced by individuals with HS.

METHODS

We conducted a prospective study spanning four weeks in participants diagnosed with HS recruited online from the patient group HS Connect (www.hsconnect.org). Consent was obtained from all participants. Participants were instructed to use the sodium hypochlorite body wash (0.006% NaOCl; CLn Bodywash®) daily for four weeks. Patient-reported evaluations were performed at baseline, two weeks, and four weeks via survey. The treatment regimen consisted of 0.006% NaOCl body wash during bathing as part of the regular skincare routine, with the option to additionally utilize the "dab" method. The dab method entails applying the solution directly to a flared lesion and leaving it on the skin for up to 24 hours. Participants were asked to assess disease activity based on parameters such as redness, swelling, drainage, skin pain, itching, and odor, using a scale of 0 to 5, where 5 indicated the most severe symptoms. Additionally, participants who opted for the dab method were given an extra survey with the same set of questions specifically addressing their experience with this technique.

Descriptive statistics were utilized in this study to summarize patient demographics, disease characteristics, and treatment responses. The use of paired t-tests was used to compare mean symptom severity scores (on a scale of 0–5) at baseline and at Week 4 for both the overall body wash regimen and the dab method subgroup. Statistical significance was set to p-value less than 0.05, with attention paid to severity of changes in swelling, skin pain, drainage, itching, and odor across the treatment period.

RESULTS

One hundred and sixty-five participants were enrolled, with 145 completing all surveys across the four-week period. Within this cohort, 18 (11%) participants reported Hurley Stage 1, 77 (47%) Hurley Stage 2, and 70 (42%) Hurley Stage 3. Participants represented a range of HS duration, consisting of 1 to 5 years (10.4%), 5 to 10 years (18.9%), 11 to 15 years (25.0%), 16 to 20 years (16.5%), 21 to 30 years (20.7%), and over 31 years (8.5%).

With daily use of sodium hypochlorite body wash, participants experienced significant improvement across all assessed signs and symptoms (redness, swelling, drainage, pain, itching, odor) when comparing baseline and Week 4 scores (Table 1). The greatest decrease was observed in pain, with an average score of 3.52 at baseline and 1.62 at Week 4 (p<0.001), representing a 1.90-point reduction. A decrease in the number of flares was reported by 63.5 percent of participants and a decrease in duration of flares by 62.7 percent. When utilizing the dab method, participants experienced significant improvements in redness, swelling, drainage, pain, and itching comparing Week 4 to baseline (Table 2). The scores for odor showed a trend toward improvement with the dab method, but did not reach statistical significance (baseline: 1.54, Week 4: 1.12; p=0.05). The majority (88.8%) of participants stated that they would recommend the body wash to patients with HS. Seventy-five percent of participants tried the dab method. Of those, 85.0 percent indicated they will continue using it and 90.0 percent would recommend it to others.

TABLE 1.

Average symptom rating on a scale of 0 (no symptoms) to 5 (worst symptoms) with daily use of 0.006% NaOCl body wash

SYMPTOM	BASELINE	WEEK 2	WEEK 4	P-VALUE (WEEK 4 VS. BASELINE)
Redness	3.27	2.18	1.77	<0.001
Pain	3.52	2.16	1.62	<0.001
Itching	3.03	1.81	1.71	<0.001
Odor	2.53	1.47	1.26	<0.001
Swelling	3.60	2.19	1.85	<0.001
Drainage	3.13	1.98	1.76	<0.001

TABLE 2.

Average symptom rating on a scale of 0 (no symptoms) to 5 (worst symptoms) with dab method use of 0.006% NaOCl body wash

SYMPTOM	BASELINE	WEEK 2	WEEK 4	P-VALUE (WEEK 4 VS. BASELINE)
Redness	3.27	2.16	1.52	0.0002
Pain	3.52	2.18	1.33	<0.001
Itching	3.03	1.77	1.44	<0.001
Odor	2.53	1.54	1.12	0.05
Swelling	3.60	2.26	1.59	<0.001
Drainage	3.13	2.06	1.59	0.02

DISCUSSION

HS remains a challenging disease to treat and is associated with an enormous impact on quality of life, including depression and low self-esteem.⁴ Most patients require a combination treatment regimen to achieve disease control. Antimicrobial washes, including benzoyl peroxide, chlorhexidine, zinc pyrithione, and bleach baths, are commonly used across all stages and severity of disease, but their use is only supported by anecdotal evidence.¹ Choice of antimicrobial wash is guided by expert opinion, patient preference, accessibility, and affordability. Adherence to daily use of antimicrobial washes can be low (with 30 percent reported in one study), with difficulty finding the wash in the store and affordability reported as the most significant barriers.¹⁰ With the frequent use of antibiotics in HS, bacterial resistance is a common concern. In a cross-sectional analysis, concomitant use of antimicrobial washes, including chlorhexidine, bleach baths, benzoyl peroxide, or a combination, showed decreased bacterial resistance to several classes of antibiotics, including penicillins and cephalosporins.⁸ While clinical experience supports a role for antimicrobial washes in HS, rigorous study of their potential benefits may provide better evidence-guided treatment decisions.

Sodium hypochlorite containing washes, which includes bleach baths, have demonstrated benefit in multiple skin conditions such as atopic dermatitis (AD), acne, and herpes simplex.^5-7,12 They have been utilized and studied most extensively in AD, potentially conferring benefits through anti-inflammatory properties as well as decreasing Staphylococcus aureus colonization.⁵ A recent meta-analysis of bleach baths in AD that included 10 randomized, controlled trials with 307 participants revealed overall improvement in clinician-reported severity by approximately 22.0 percent, with 10.0 percent of patients achieving a 50.0 percent or greater improvement measured by the Eczema Area and Severity Index (EASI).³ The risk of S. aureus colonization was slightly decreased (RR: 0.89, 95% CI: 0.73–1.09) across seven studies that performed culture.³ This specific formulation of sodium hypochlorite body wash has been studied in two open-label trials in 68 total pediatric participants with AD, demonstrating a significant reduction in EASI (46.0%) after six weeks of daily use with bathing.^3,9

We investigated the efficacy of 0.006% NaOCl body wash in the treatment of HS in a real-world setting. Participants experienced significant improvement across all measured signs and symptoms (redness, swelling, drainage, pain, itching, odor) with four weeks of daily use with bathing. The greatest improvement was seen for pain, the most significant symptom in HS, with a reduction of 1.9 points on the 0–5 scale. A decrease in both the number and duration of self-reported flares was also reported by most participants. When utilizing the dab method, wherein the wash is applied to a flared lesion and left in place for up to 24 hours, participants also experienced significant improvements in redness, swelling, drainage, pain, and itch. Most importantly, most participants agreed that they would recommend the body wash daily (88.8%) and the dab method (90.0%) to other patients with HS. Limitations of the current study include the small sample size, lack of control arm, and self-reporting of outcomes. The absence of a lack of control arm prevents direct comparison with standard care or placebo, making it harder to isolate the true effects of the hypochlorite wash. In addition, relying on self-reported results may introduce the possibility of recall bias, though the goal of this study was to assess symptoms purely from the patient perspective. An additional limitation is the use of a non-validated questionnaire to assess symptom changes. While this tool allowed for the collection of relevant patient-reported outcomes, the lack of validation may impact the reliability and reproducibility of the findings. However, it is important to note that no validated questionnaires currently exist specifically for evaluating short-term patient-assessed treatment response in HS, highlighting the need for the development of standardized, validated instruments tailored to this population.

This study demonstrates the real-world efficacy of a sodium hypochlorite wash in improving the symptoms of hidradenitis suppurativa, with improvements across all studied symptoms: redness, swelling, drainage, itching, odor, and even pain. An over-the-counter wash that is available to patients of all HS severities, well-tolerated, and may counter antibiotic resistance is an important addition to the current treatment armamentarium. Furthermore, a significant issue faced by HS patients is delayed diagnosis, often due to difficulties in accessing healthcare or a lack of awareness among providers, which can lead to progression of HS and irreversible tissue destruction.¹¹ A readily available sodium hypochlorite body wash presents an option for patients to initiate a treatment when they suspect HS but have not yet received a diagnosis or have been unable to seek specialized clinical care.