Hidradenitis suppurativa (HS) is a debilitating chronic inflammatory skin disorder characterized by recurrent, painful nodules and abscesses, significantly impairing patients’ quality of life due to chronic pain. Current pain management approaches in HS primarily target inflammation and lesions through pharmacological therapies, surgery, and supportive treatments; however, pain frequently remains inadequately controlled. Osteopathic manipulative medicine (OMM), a hands-on therapeutic approach that treats somatic dysfunction through biomechanical, neurologic, lymphatic, and psychosocial mechanisms, presents a promising, yet underexplored, adjunctive modality for managing chronic HS pain. This comprehensive literature review synthesizes peer-reviewed evidence on the pathophysiology of HS-associated pain, identifies limitations in existing pain management strategies, and critically evaluates current knowledge of OMM’s efficacy in analogous chronic pain conditions. The review highlights significant gaps in current dermatological practice concerning interdisciplinary pain management and proposes potential mechanisms by which OMM may alleviate HS pain, including modulation of inflammation, improvement of lymphatic drainage, normalization of autonomic nervous system function, and reduction of central pain sensitization. Despite strong theoretical and indirect empirical support, direct clinical evidence for OMM in HS remains absent, underscoring the necessity for rigorous interdisciplinary clinical trials to determine the efficacy, optimal techniques, and integration strategies for this promising therapeutic modality. By advocating for research into OMM’s application in HS, this review aims to fill a crucial knowledge gap, enhance patient-centered care, and stimulate innovative cross-specialty collaborations that may substantially improve chronic pain management outcomes in patients suffering from hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease characterized by recurrent painful nodules, abscesses, and draining sinus tracts in intertriginous regions like the axillae, groin, perineal, and inframammary areas [1]. Beyond its hallmark suppurating lesions, HS imposes a severe burden of chronic pain that profoundly diminishes patients’ quality of life​ [1,2]. Pain in HS correlates more strongly with quality-of-life impairment than objective disease severity​. In an international survey of 1,299 HS patients, a majority rated their pain as moderate-to-severe, and 4.5?scribed it as “the worst possible”​ [2]. HS pain severity has been reported as comparable to or worse than pain in conditions like chronic post-traumatic headache, vulvar lichen sclerosus, and leg ulcers​ [3,4,5]. Both nociceptive and neuropathic mechanisms contribute to HS pain: ongoing inflammation drives nociceptive pain, while chronic recurrent disease may induce peripheral nerve alterations and central sensitization of pain pathways​ [5,6]. Central sensitization, a pathologic amplification of pain processing, appears prevalent in HS. A recent case-control study found 36% of HS patients met criteria for central sensitization (versus 12% of controls), meaning HS patients have more than fourfold higher odds of central sensitization, independent of disease stage​ [7]. This neurologic upregulation may help explain why many HS patients experience pain out of proportion to visible inflammation​. Unrelenting pain contributes to depression, anxiety, work disability, and even substance use disorders in this population​ [2,8]. Addressing chronic pain in HS is therefore critical not only for symptom control but also to improve mental health and prevent analgesic misuse. 

Despite the clear need, effective pain management in HS remains a challenge. Standard dermatologic treatments such as antibiotics, retinoids, biologics, and surgery primarily target disease activity and often provide incomplete analgesia​. There are currently no dedicated analgesic therapies approved for HS pain, and evidence-based guidelines offer only general recommendations [9]. Many dermatologists have limited training in chronic pain management and may undertreat HS pain in practice​ [8]. Consequently, patients frequently resort to self-management. Surveys indicate that up to 80% of patients with severe HS regularly use over-the-counter analgesics, and 70% report using complementary and alternative medicine (CAM) therapies to cope with their pain​ [10]. These CAM approaches include herbal supplements, relaxation techniques, and physical modalities, suggesting patients are urgently seeking pain relief beyond what standard medical care provides​. The reliance on CAM highlights an important gap in current practice and an opportunity to integrate novel pain management strategies into HS care.

One such emerging strategy is osteopathic manipulative medicine (OMM), also known as osteopathic manipulative treatment (OMT). OMM is a hands-on, holistic form of therapy practiced by Doctors of Osteopathic Medicine (DOs) that aims to improve physiological function and alleviate pain by addressing somatic dysfunctions like impairments in the musculoskeletal, myofascial, lymphatic, or neural structures​ [11]. Osteopathic medicine is founded on the principles that the body is a unit of body-mind-spirit, it has self-healing capabilities, structure and function are interrelated, and treatment should be based on these tenets​ [12]. In practice, OMM encompasses a variety of manual techniques selected to target specific physiologic dysfunctions​. The osteopathic approach can be conceptualized in five interacting models—biomechanical, respiratory-circulatory, neurologic, metabolic-energy, and behavioral—to address different aspects of a patient’s condition​. Through these models, OMM seeks to restore normal structure and circulation, modulate neural reflexes, reduce stress, and support the body’s homeostatic and immune responses​ [13]. Given this multimodal, whole-person approach, OMM has been proposed as a beneficial adjunct in various difficult-to-treat disorders, including some dermatologic diseases with complex etiologies​ [11]. Notably, OMM has demonstrated efficacy in managing chronic musculoskeletal pain conditions, and evidence suggests it can modulate inflammation and autonomic function​ [14,15]. These properties raise the question: Could osteopathic manipulative medicine play a role in alleviating chronic pain in HS. 

This review examines the intersection of OMM and HS-associated chronic pain. We provide a thematic synthesis of relevant literature from dermatology, pain management, and osteopathic medicine. We summarize the current understanding of chronic pain in HS and its management limitations, outline OMM principles and review evidence for its effectiveness in chronic pain and inflammatory conditions. Emerging research supports a multidisciplinary approach to chronic pain management, emphasizing the importance of collaborative care. By integrating dermatologic and osteopathic perspectives, osteopathic manipulative treatment (OMT) emerges as a promising interdisciplinary strategy for managing chronic pain in patients with HS. Incorporating OMT into HS management addresses an unmet clinical need and represents a meaningful step toward holistic, patient-centered care in dermatology.

2.1 Overview and Characteristics of HS Pain

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disorder notable for recurrent, painful nodules, abscesses, and sinus tracts, predominantly in apocrine gland-bearing regions such as the axillae, groin, and inframammary areas. Pain is widely recognized as the most distressing and debilitating symptom experienced by patients with HS, often reported as severe, persistent, and difficult to control. Unlike other dermatologic diseases, pain in HS is present during both acute flares and between episodes, reflecting the ongoing inflammatory activity and tissue destruction. HS pain is frequently described as deep, throbbing, and stabbing, sometimes radiating beyond the lesions themselves [16,17]. The recurrent and unpredictable nature of HS flares further compounds pain experiences, with many patients reporting a constant baseline discomfort punctuated by episodes of acute, severe pain. This persistent pain contributes substantially to the overall disease burden and is a primary driver of physical disability, psychological distress, and impaired quality of life [18,19]. The social stigma associated with HS—arising from malodorous drainage and visible lesions—can intensify the subjective pain experience, further limiting patients’ social, occupational, and physical activities [20]. Ultimately, pain in HS is a multifaceted and dynamic symptom that significantly impacts the trajectory and management of the disease.

Types of Pain: Nociceptive, Inflammatory, Neuropathic

HS pain is complex and multifactorial, encompassing nociceptive, inflammatory, and neuropathic mechanisms. Nociceptive pain arises from tissue injury and direct mechanical damage due to nodules, abscesses, and sinus tracts. This type of pain is commonly acute and localized, correlating with periods of lesion rupture or infection. Inflammatory pain is perpetuated by chronic cytokine release (e.g., TNF-α, IL-1β) and infiltration of immune cells such as neutrophils and macrophages, leading to persistent activation and sensitization of peripheral nociceptors [18,21]. In advanced disease, repeated inflammation, scarring, and fibrosis can result in nerve injury, contributing to neuropathic pain. Patients may describe neuropathic symptoms as burning, tingling, or electric shock-like sensations, sometimes extending to areas without active lesions [22]. Moreover, the chronicity and intensity of HS pain can induce changes in pain pathways, resulting in pain that is disproportionate to clinical findings. Studies have also noted overlapping features between HS pain and other chronic pain syndromes, such as fibromyalgia, suggesting shared mechanisms of peripheral and central sensitization [16,23]. The interplay between these different types of pain underscores the need for a nuanced and individualized approach to pain assessment and management in HS patients.

Central Sensitization and Chronic Pain Syndromes

Central sensitization refers to an amplification of neural signaling within the central nervous system (CNS) that elicits pain hypersensitivity. In HS, repeated and prolonged nociceptive and inflammatory stimuli are thought to trigger maladaptive changes in the spinal cord and brain, lowering the threshold for pain perception [12,23]. This process manifests clinically as hyperalgesia (increased pain response to normally painful stimuli) and allodynia (pain from non-painful stimuli), and may help explain why many HS patients experience widespread, chronic pain even when lesions are quiescent. Central sensitization is associated with other chronic pain syndromes, such as complex regional pain syndrome and fibromyalgia, both of which have been reported with increased frequency in the HS population [18,24,25]. The resulting chronic pain not only increases physical morbidity but also amplifies psychological comorbidities, such as depression, anxiety, and sleep disturbances [22]. Importantly, central sensitization can diminish the effectiveness of traditional analgesics, necessitating multimodal and multidisciplinary approaches to pain management. The recognition of central sensitization as a major component of HS pain is shifting clinical paradigms, encouraging both clinicians and researchers to address underlying neuroplastic changes in addition to peripheral inflammation.

Patient-Reported Impact on Quality of Life

Pain is the most significant predictor of poor health-related quality of life (HRQoL) in HS and often surpasses that reported by patients with other chronic dermatologic or systemic diseases. Studies using the Dermatology Life Quality Index (DLQI) and pain-specific assessment tools have shown that HS patients consistently score among the lowest for HRQoL, particularly in domains related to physical discomfort, social functioning, and emotional well-being [17,22]. Pain leads to sleep disturbances, chronic fatigue, difficulty with mobility, and impairment in daily activities, including work and self-care. The unpredictable nature of HS pain and flares fosters chronic anxiety, social isolation, and increased risk of depressive disorders [18]. Many patients report withdrawing from relationships, employment, and public activities due to fear of pain, embarrassment, and stigmatization related to visible lesions and malodor. These psychosocial effects can be as disabling as the physical pain itself and may lead to a vicious cycle of distress, disease flares, and worsening overall function.

2.2 Current Pain Management Approaches

Pharmacological Interventions

Pharmacologic management of HS pain is challenging and often unsatisfactory. Nonsteroidal anti-inflammatory drugs (NSAIDs) are typically first-line agents, providing moderate relief for acute inflammatory pain but rarely adequate for severe or chronic cases [17]. Opioids may be used for intractable pain; however, they carry significant risks of dependence, tolerance, and adverse events, and their long-term efficacy is limited. Antibiotics with anti-inflammatory properties (e.g., tetracyclines, clindamycin-rifampin) can be helpful during acute flares but do not address chronic pain [21]. Biologics, particularly TNF-α inhibitors like adalimumab, have shown promise in reducing both lesion count and associated pain, though not all patients respond, and the cost can be prohibitive [26]. Other agents, such as corticosteroids, anti-androgens, and intralesional injections, may provide temporary relief but are rarely sufficient as monotherapy. Neuropathic pain agents, including gabapentinoids and tricyclic antidepressants, may benefit some patients with documented neuropathic symptoms [22]. Given the heterogeneity of HS pain, pharmacological therapy is most effective when tailored to the individual patient’s pain profile and used as part of a broader multimodal plan. 

Surgical and Procedural Interventions

Surgical intervention remains a mainstay for patients with advanced or refractory HS, particularly when sinus tracts and scarring predominate. Procedures range from minor interventions (e.g., incision and drainage, deroofing) to wide excision of affected areas [17,21]. While surgery can reduce the burden of lesions and provide periods of pain relief, it is not curative, and recurrence rates remain high, especially without ongoing medical management. Postoperative pain, wound complications, and scarring are important considerations, and some patients may experience worsened or neuropathic pain following surgery [27]. Laser therapies, such as Nd-YAG and CO2 lasers, offer noninvasive options for select cases and can help control mild to moderate disease, sometimes resulting in decreased pain and improved quality of life. Successful surgical management typically requires a multidisciplinary approach, including pain specialists and wound care, and should be tailored to disease severity, patient preference, and overall health status.

Complementary and Alternative Medicine (CAM) Use

A growing proportion of HS patients seek complementary and alternative medicine (CAM) for pain relief, motivated by dissatisfaction with conventional therapies and the desire for holistic care. CAM approaches reported include dietary modifications (e.g., dairy- or gluten-free diets), supplements (e.g., turmeric, zinc), acupuncture, herbal remedies, and mind-body therapies such as yoga, meditation, and cognitive-behavioral therapy [27]. While some patients anecdotally report pain improvement with CAM, robust clinical evidence is lacking, and randomized controlled trials are scarce. Nonetheless, these modalities may serve as useful adjuncts to medical and surgical care, especially in managing stress, sleep disturbances, and the psychological burden of chronic pain. It is important for clinicians to discuss CAM openly with patients to ensure safety and avoid interactions with prescribed medications. Integrating evidence-based CAM therapies into multidisciplinary care models may offer additional avenues for addressing the multifaceted pain of HS.

Limitations and Inadequacies of Existing Treatments

Despite an expanding armamentarium of therapies, pain control in HS remains suboptimal for many patients. The multifactorial and chronic nature of HS pain—encompassing nociceptive, inflammatory, neuropathic, and centrally mediated mechanisms—renders monotherapy largely ineffective. Many current interventions, including pharmacologic, surgical, and CAM modalities, offer only partial or temporary relief and are often associated with adverse effects or high rates of recurrence [16,23]. There is a notable lack of high-quality clinical trials specifically targeting pain endpoints in HS, and most treatment guidelines focus on lesion clearance rather than pain reduction as a primary goal. Fragmented care, delayed diagnosis, and limited access to multidisciplinary pain management further compound treatment inadequacies [17,20]. There remains a critical need for research into novel analgesic targets, more rigorous evaluation of multimodal strategies, and development of comprehensive care pathways that prioritize both physical and psychosocial aspects of pain. Improving patient-centered outcomes will require a paradigm shift toward integrating pain as a central focus in HS management and research.

3. Osteopathic Manipulative Medicine (OMM): Principles and Mechanisms

3.1 Foundational Principles of OMM

Founded by Andrew Taylor Still, DO in 1874, osteopathic medicine is based on a holistic philosophy defined by four key tenets: 1. the body is a unit, and the person is a unified being of body, mind, and spirit; 2. the body has inherent capacities for self-regulation, self-healing, and health maintenance; 3. structure and function are closely interconnected; and 4. rational treatment is based on these core principles [28]. These tenets form the basis of five osteopathic treatment models commonly used in clinical care: biomechanical, respiratory circulatory, neurologic, metabolic energy, and behavioral. First, the biomechanical model identifies structural dysfunctions and uses osteopathic manipulative treatment (OMT) to improve range of motion, posture, somatic strain, and tissue texture, particularly important in addressing chronic musculoskeletal pain. In the respiratory circulatory model, enhancing respiratory mechanics and circulation helps facilitate tissue oxygenation and waste removal and contributes to decreased pain intensity and improved systemic function [29]. By promoting slower and deeper breathing, this model supports autonomic regulation and contributes to physical relaxation. The neurologic model targets imbalances in the autonomic nervous system through segmental facilitation and reflex activity [30]. Structural issues such as radiculopathy also highlight the importance of the neurologic model, as they can trigger broader neurological effects. Additionally, the metabolic energy model emphasizes maintaining homeostasis and supporting immune and endocrine function to optimize the body's energy utilization during healing processes [31]. Lastly, the behavioral model integrates the psychological, emotional, and social aspects of health, recognizing the dynamic interplay between somatosensory input, cognitive processing, and behavioral responses. This model reinforces the first tenet of osteopathic medicine to treat the body as a whole unit. Together, understanding the four tenets and five models of osteopathic medicine reinforces its emphasis on patient-centered, integrative care and highlights OMM's broad applicability to diverse health conditions.

3.2 Common OMM Techniques Relevant to Chronic Pain

Chronic pain is a biopsychosocial condition that requires multimodal and interdisciplinary treatment; therefore the use of osteopathic manipulative medicine (OMM) techniques is valuable especially in relation to the biomechanical model [28]. Five commonly used OMM techniques for chronic pain include myofascial release, muscle energy techniques, high-velocity low-amplitude (HVLA), lymphatic pump techniques and counterstrain and osteopathy in the cranial field. Myofascial release which can be applied directly or indirectly helps release restricted tissues within the musculoskeletal system and improves blood flow [32]. This technique enhances circulation and tissue mobility potentially reducing chronic muscular tension. Muscle energy techniques (MET) reduce chronic pain by activating patients’ muscles and engaging the stretch reflex to relax and lengthen shortened muscle groups [28,32]. They allow the patient to engage in the treatment actively and reinforce functional improvement. Another technique is HVLA which relieves joint restrictions in chronic conditions by engaging a restrictive barrier thereby decreasing joint pain and improving range of motion [32]. It provides a rapid mechanical release which can relieve chronic joint stiffness and localized pain. Lymphatic pump techniques promote smoother lymphatic flow and enhance immune function through rhythmic pumping motions [32]. This method supports fluid homeostasis and enhances immune surveillance by facilitating lymphatic drainage. Counterstrain involves specific positioning to relieve tender points and induce spontaneous muscle relaxation while osteopathy in the cranial field addresses primary respiratory mechanisms to treat chronic dysfunctions such as headaches [28,33]. These five OMM techniques are widely used in osteopathic medicine and represent valuable approaches in the management of chronic pain.

3.3. Evidence for OMM Effectiveness in Chronic Pain Conditions

Comprehensive Benefits of OMM: Musculoskeletal, Psychosocial, and Quality-of-Life Outcomes Osteopathic manipulative medicine (OMM) has emerged as an effective treatment approach for chronic pain, which affects multiple aspects of health, including psychological well-being, functional capacity, and physical mobility. Rotter et al. reported that OMM significantly reduced pain intensity and improved condition-specific outcomes in patients with four common chronic musculoskeletal pain conditions: chronic neck pain, chronic low back pain, chronic shoulder pain, and chronic knee pain [34]. These findings underscore the broad clinical relevance of OMM beyond these specific conditions. Similarly, OMM led to substantial improvements in quality of life for patients with chronic low back pain, with long-lasting therapeutic effects [35]. These results suggest that OMM not only improves physical function but also directly enhances psychosocial outcomes. Additional research supports the therapeutic value of OMM beyond musculoskeletal disorders; Hope-Bell et al. show that patients treated with OMM reported feeling more relaxed after treatment, a meaningful indicator of reduced psychological distress, including symptoms of depression and anxiety [36]. This suggests that OMM may play a role in improving chronic mental health through relaxation-based mechanisms. Furthermore, OMM reduced levels of cortisol, a key physiological marker of stress, supporting its potential application in managing anxiety, depression, and symptoms of attention-deficit/hyperactivity disorder (ADHD) [37]. Although further studies with larger participant groups are necessary to confirm these findings, current evidence indicates that OMM may significantly benefit both psychosocial health and overall quality of life. Continued research into its broader therapeutic applications is needed.

Effects on inflammatory markers and autonomic nervous system

Inflammation is a critical factor in chronic myofascial pain (MFP), a common inflammatory condition characterized by elevated levels of inflammatory mediators such as interleukin-1β (IL-1β), IL-6, and tumor necrosis factor-α (TNF-α) [38]. The quantitative analysis of these inflammatory markers should be evaluated to investigate the efficacy of osteopathic manipulative medicine (OMM) in treating chronic inflammatory conditions. Shah et al. reported that neuropeptides, cytokines, and catecholamines are significantly elevated near active myofascial trigger points [39]. Therefore, if OMM treatment demonstrates reduced levels of these mediators near trigger points, it would support its effectiveness in managing chronic myofascial pain. Some indirect OMT techniques such as counterstrain have already demonstrated their effectiveness by reducing IL-6 levels, while broader non-pharmacologic interventions including OMM and spinal manipulative therapy have shown decreased pro-inflammatory markers such as TNF-α and IL-6 and increased levels of anti-inflammatory cytokines like IL-4 [38,40]. Although more specific studies that directly measure inflammatory marker levels before and after OMM treatment are necessary, its potential as a non-toxic, drug-free therapeutic option for chronic inflammation is promising. In addition to its anti-inflammatory effects, OMT may influence the autonomic nervous system (ANS), which plays an important role in physiological stress regulation. Rechberger et al. demonstrated that high-velocity low-amplitude (HVLA) and cranial OMT techniques applied to the cervical spine increased parasympathetic activity, while thoracic techniques elevated sympathetic output [41]. These findings suggest that OMT may help restore autonomic balance and reduce sympathetic overactivity, providing clinical benefits for both stress-related and inflammatory conditions.

Safety profile and patient acceptability

Osteopathic manipulative medicine (OMM) is generally considered a safe intervention when performed by well-trained physicians. In a study of 925 patients with chronic conditions, the incidence of adverse events was only 2.5%, with the most common symptoms being mild pain or discomfort [28]. When applied with careful attention to vulnerable areas such as the cervical spine, OMM can be safely performed and is effective for managing chronic pain. Lam et al. present a study of 16 patients with chronic coccydynia treated with OMT and report significant clinical improvement, along with a high satisfaction rate, as 50% of patients completed follow-up, and none of them reported negative feedback [42]. These findings indicate a high level of patient acceptability and trust in OMM as a reliable form of care for chronic conditions although the small sample size limits the findings. Unlike drug-induced therapies, OMM avoids systemic side effects, making it preferable for patients sensitive to medications or with contraindications to drug-based treatments. Consorti et al. explored patient experiences through qualitative interviews and found that participants described OMM as “a path of awareness,” emphasizing not only physical benefits but also a deeper understanding of their body and overall well-being [43]. These insights emphasize the value of continued research on OMM in patient care, which could enhance future OMM strategies for chronic pain management by valuing patient expectations and satisfaction.

4. Application of OMM to Hidradenitis Suppurativa Pain

4.1 Potential Mechanisms for OMM Benefit in HS

Osteopathic Manipulative Medicine (OMM) is a multifactorial treatment for pain modulation and this may be important in regards to hidradenitis suppurativa (HS), where traditional therapies often fall short in chronic pain management. OMM targets numerous physiological pathways contributing to the chronic pain in HS through its effect on lymphatic drainage, neural signaling and the autonomic system. Lymphatic drainage is a manipulative therapy intended to increase lymphatic flow [13]. Lymphatic drainage has been proven to reduce edema and infections by removing excess fluid, inflammatory mediators, and cellular waste from the interstitial space [44,45]. Therefore, chronic inflammation associated with HS can be helped with lymphatic drainage techniques targeting lymphatic system flow to decrease edema, and to limit the development of painful nodules and abscesses. In addition, individuals who suffer from HS acknowledge that they have high-stress levels that are likely contributing to inflammation and pain perception as a result of autonomic dysregulation [46]. This is substantial since HS has both nociceptive and neuropathic pain contributions [47,48]. osteopathy in the cranial field (OCF), a second type of osteopathic manipulative therapy, is based upon noninvasive techniques of fascial palpation from cranium to sacrum [49]. OCF is designed to down-regulate elevated sympathetic nervous system responses typically seen in patients with chronic pain by modifying craniosacral body rhythms. In increasing parasympathetic activity, a patient may experience relaxation of tissue and enhanced physiological regulation. This shift may also reduce central sensitization and persistent pain [49]. These mechanisms suggest that OMM may be able to alter some mechanisms that drive HS pain such as inflammation or autonomic dysregulation, although it will be necessary to conduct further clinical investigations to substantiate its therapeutic role in HS. 

4.2 Existing Evidence and Preliminary Observations

Although clinical trials on OMM in the treatment of HS have not been carried out to date, indirect evidence from other related disorders supports its potential relevance. Randomized controlled trials have validated that OMM can reduce pain and improve function in most illnesses such as headaches and chronic low back pain [50,51]. These findings show OMM’s influence on both inflammatory and neuromuscular pathways involved in chronic pain. A study done by Walkowski et al. indicated that lymph drainage methods caused significant changes in levels of cytokines, including IL-8, MCP-1, MIP-1α and G-CSF [13]. These findings indicate that OMM can modulate immune response and systemic inflammation. In dermatology, the use of OMM, particularly lymphatic drainage, has been shown to be successful in the treatment of such conditions as stasis dermatitis, Elephantiasis nostras verrucosa and trigeminal neuralgia where there is also autonomic and lymphatic dysfunction [44]. Although these findings are not HS-specific, they are relevant information that makes it worthwhile to further investigate the use of OMM in treating chronic pain in HS. There is a critical literature deficiency of clinical trials that evaluate specifically the efficacy, safety and long-term effects of OMM in HS. Lack of previous studies in this area present a clear window of opportunity for interdisciplinary studies to assess OMM’s contribution to HS chronic pain treatment. Lastly, recent case reports offer evidence, and literature suggests that OMGG may benefit patients with chronic inflammatory conditions — an applicable consideration, considering HS is likewise a chronic inflammatory condition. The overlap of pathophysiology and mechanisms presents it as reasonable and imperative, therefore, to explore the possible role of OMM in HS.

4.3 Practical Considerations and Treatment Adaptations

Safety Precautions in Active HS Lesions

Application of Osteopathic Manipulative Medicine (OMM) in hidradenitis suppurativa (HS) requires careful clinical judgment, particularly during active flare-ups. Many OMM techniques involve direct manipulation. If these techniques are done over draining, ulcerated, or inflamed lesions, especially to areas such as the axillae or groin, they may exacerbate pain or risk secondary infection. In these cases, practitioners can use indirect maneuvers that support systemic function without aggravating active lesions.

Contraindications of Lymphatic Techniques

Lymphatic drainage has been proved to reduce edema and enhance immune clearance in chronic inflammatory diseases. However, in the context of HS, its use must be cautious and condition-dependent. Lymphatic techniques are contraindicated over acute infection sites, open abscesses, active drainage, or systemic bacteremia due to the risk of pathogen dissemination [52]. These complications are particularly relevant in the setting of HS flares, in which lesions may possibly be under risk of rupture or secondary infection. Other contraindications include deep vein thrombosis, acute heart failure, recent fractures, organomegaly, and hematologic disease.  Indirect maneuvers, such as the pedal and thoracic pump, may offer a safer alternative to support lymphatic flow without direct contact with active lesions. The pedal pump technique involves gentle rhythmic dorsiflexion applied at the feet, creating a fluid wave that enhances whole-body circulation. The thoracic pump also follows the same philosophy of regulating thoracic pressure to allow lymphatic return and respiratory effectiveness [53]. With proper application, such indirect techniques are able to provide systemic lymphatic drainage without aggravating the lesions seen in HS.

Contraindications for Osteopathy in the Cranial Field

Osteopathy in the cranial field (OCF), an OMM modality employed to reduce central sensitization and sympathetic tone, is generally well tolerated in stable patients. However, it has important contraindications. Cranial manipulation is contraindicated in patients with acute trauma, absence of biomechanical dysfunction, or treatment-resistant patients [44]. Before initiating OCF in HS patients, especially with a history of neurological disease, a thorough neurologic history and screening are warranted. Lastly, the safe and effective application of OMM in HS relies upon individualized patient assessment, clear knowledge of contraindications, and close collaboration with dermatology and other specialist services. If used judiciously, OMM can be of great value in pain mitigation and regulation of physiology without compromise to patient safety. 

Proposed Strategies for Integration with Standard Dermatologic Care

Integration of Osteopathic Manipulative Medicine (OMM) and manual therapies into fundamental dermatologic treatment of hidradenitis suppurativa (HS) must be a coordinated and multidisciplinary process. Successful integration is initiated with clear communication among dermatologists, osteopathic physicians, and other medical professionals to make certain that manual intervention is optimally suited to the dermatologic disease and overall state of general health of individual patients. OMM techniques are safest when performed on stable or quiescent phases of HS in order to minimize the risk of eliciting inflammation or secondary infection [52]. When paired with pharmacologic therapies—such as antibiotics and biologics—OMM may have synergistic effects through the augmentation of lymphatic drainage and systemic inflammation regulation. While dermatology clinics are often fast-paced and don't always permit regular OMM, many dermatologic conditions, such as HS, would be enhanced by its use [44]. Standardized treatment protocols and investment in educational training of clinicians can enhance care's safety, accessibility, and dependability further. Even though training in OMM has not been provided to all clinicians, information about its value as an adjunct therapy and early referral to trained professionals can open up more treatment options to more complex dermatologic illnesses [44]. Further research is needed to confirm the efficacy of OMM and to more clearly establish its role in the treatment of HS.

Patient Selection and Individualized Treatment Approaches

Safe and effective use of OMM in HS patients demands careful patient selection and personalized treatment planning. Manual therapy may not be suitable for all patients with HS at all stages of their condition. Treatment methods are to be taken into consideration by keeping in mind the frequency and severity of active lesions, patient preference, pain tolerance, and co-morbidities. During severe flares, particularly on draining, open, or with systemic symptoms, manual therapy as a whole should be avoided, especially those with direct contact near the affected areas [52]. Pedal or thoracic pumping may be utilized to aid systemic lymphatic function without exacerbating local tissue integrity further [53]. A personalized approach requires careful consideration of relative and absolute contraindications to certain OMM maneuvers. A medical history and physical exam should always precede any use of OMM, with particular consideration of cardiovascular, neurologic, and lymphatic systems. For instance, osteopathy in the cranial field may be indicated in certain patients with HS who have characteristics of chronic pain or central sensitization but not for those with recent head injury or other neurologic contraindications [44]. Equally important is aligning manual therapy with the goals of care and tolerance of the patient. Most take most benefit from integrative care during phases of quiescence in HS, in which manual therapies can relieve pain, assist lymphatics, and modulate the stress response. Shared decision-making, informed consent, and patient education regarding OMM objectives and limitations are key to delivering safe, individualized care. Combination of osteopathic and dermatologic teams enhances clinical outcomes by optimizing benefit and reducing risk by having therapeutic decisions dependent on both dermatologic and systemic factors.

5. Critical Analysis: Identified Research Gaps and Future Directions

5.1 Current Limitations and Knowledge Gaps

Despite the increased interest and need for pain management strategies in those with hidradenitis suppurativa (HS), there is a lack of research regarding the clinical application of osteopathic manipulative medicine (OMM). There is a notable absence of dedicated clinical trials assessing the efficacy, safety, and long-term sequelae of OMM in populations with HS. Theoretical rationale and indirect evidence from other chronic pain conditions support OMM's potential for pain management in HS. However, the lack of empirical data limits the validation of these implications. The therapeutic value must be confirmed by randomized control trials before OMM can be incorporated [44]. For those physicians who do practice OMM, there is a lack of evidence-based treatment protocols for the use of OMM in HS patients. Since patients with HS often have inflammatory nodules, sinus tracts, and/or chronic neuropathic pain, a standardized technique for OMM that would be applicable to HS is needed [54]. Dermatologic care typically focuses on immunologic and surgical management of the active lesion, with pain management often falling short [55]. There is a lack of knowledge about which patients with HS would be most likely to benefit from OMM since predictors of treatment response are not yet established. With heterogeneity of HS, and central sensitization occurring in over one-third of patients, clinical or neurophysiological indicators that are pertinent to treatment stratification must be established [56]. Otherwise, clinicians are unable to tailor OMM to those who would be most likely to benefit.

5.2 Recommendations for Future Research

Initially, pilot clinical trials should be initiated to determine the feasibility, safety, and therapeutic impact of OMM on HS-associated pain. These studies must utilize validated pain assessment tools, stratify based on central sensitization status, and assess the functional and quality-of-life outcomes. Because the pain of HS is frequently refractory to conventional treatments and neuropathic in nature, early-phase trials can provide insight into patient selection, treatment durations, and appropriate OMM modalities. Mechanistic studies are also needed, specifically to elucidate how OMM would be capable of exerting anti-inflammatory, immunomodulatory, or neuromodulatory effects in HS [57]. Understanding the effects is important for the application of OMM in HS patients. Earlier studies have suggested that OMM techniques may influence lymphatic drainage, autonomic tone, and neural reflex arcs, but underlying molecular and neurophysiological processes are poorly characterized [57]. Laboratory-based and translational research must focus on quantifying changes in cytokine profiles, autonomic balance, and neural sensitization following OMM interventions. Finally, research must be directed toward developing and implementing models of interdisciplinary care that integrate dermatology, osteopathic medicine, and pain management. These models would enable coordination between the lesion-directed treatments used now and new holistic therapies such as OMM. This creates a more patient-centered strategy for addressing the pain caused by HS.

Chronic pain associated with hidradenitis suppurativa (HS) significantly diminishes patient quality of life and remains inadequately addressed by conventional management strategies. This comprehensive review underscores osteopathic manipulative medicine (OMM) as an innovative yet underexplored therapeutic modality uniquely capable of addressing multiple dimensions of HS pain, including inflammation, lymphatic congestion, musculoskeletal dysfunction, autonomic imbalance, and central sensitization. Although current evidence specifically applying OMM to HS is limited, strong theoretical rationale and demonstrated efficacy of OMM in similar chronic inflammatory and pain conditions justify rigorous clinical investigation. Future interdisciplinary studies, incorporating dermatologists, osteopathic physicians, pain specialists, and immunologists, are essential to establish OMM’s clinical utility, optimal techniques, and integration strategies within HS management. Ultimately, validating and adopting OMM could substantially enhance patient-centered, holistic care for those suffering from this challenging dermatologic condition, marking a significant advancement toward comprehensive interdisciplinary treatment in dermatology.