Chronic inflammatory conditions characterized by both dermatologic manifestations and metabolic dysfunction, such as hidradenitis suppurativa (HS), psoriasis, and polyendocrine metabolic ovarian syndrome (PMOS), significantly impact physical and psychological well-being. HS and psoriasis are considered primary dermatologic conditions, whereas PMOS is primarily a reproductive endocrine disorder with hallmark dermatologic manifestations including acne, acanthosis nigricans, androgenetic alopecia, and hirsutism.1 Of note, as of May 2026, PMOS is the updated nomenclature for the condition previously known as polycystic ovarian syndrome (PCOS) to reflect its nature as a complex multisystem disorder; the diagnostic criteria remain the same.2,3 Although the pathogenesis and clinical manifestations of these three conditions are distinct, each of these disorders involves immune dysregulation, metabolic abnormalities, and hormonal imbalances. Therefore, these conditions can be similarly considered under the conceptual framework of metabolic inflammatory, also known as “metabo-inflammatory,” conditions, a term referring to conditions related to a chronic state of systemic inflammation as a result of metabolic dysfunction, oftentimes linked to obesity, insulin resistance, and/or adipose tissue dysfunction.4 Patients often experience psychological distress, including anxiety, depression, and suicidality, creating a cycle of worsening cutaneous and systemic inflammation and, in turn, a decline in mental health.5,6
Emerging evidence suggests that lifestyle interventions, particularly exercise and mind-body practices aimed at stress reduction, may modulate systemic inflammation and improve metabolic and psychological outcomes, with a less certain effect on cutaneous disease directly. This review examines the effects of physical activity on stress reduction for HS, psoriasis, and the dermatologic components of PMOS (cystic acne, acanthosis nigricans, and hirsutism), and considers its potential as an adjunctive therapeutic strategy in these skin conditions.
A literature review was conducted using PubMed and Google Scholar from database inception through October 2025. Search terms included combinations of the following: “hidradenitis suppurativa,” “psoriasis,” “PCOS,” “dermatology,” “hirsutism,” “acanthosis nigricans,” “exercise,” “physical activity,” “stress,” and “inflammation,” and “quality of life.” Eligible publications included original research articles, systematic reviews, meta-analyses, clinical trials, and expert consensus guidelines published in English. Studies were selected that provided meaningful clinical or mechanistic insights into exercise-related changes in metabolic, inflammatory, and/or dermatologic aspects of these three conditions, and those with trials of physical activity-based intervention. Screening and selection were performed by four authors, who independently reviewed titles and abstracts against the eligibility criteria; potentially relevant articles were then assessed in full text. Exclusion criteria were: non-English-language publications; articles without accessible full text; studies not addressing exercise or physical activity in relation to HS, psoriasis, or PMOS; and conference abstracts, editorials, and opinion pieces lacking primary data or a structured evidence synthesis.
For the purposes of study selection, a publication was judged to provide “meaningful clinical or mechanistic insight” if it reported (1) a patient-level clinical outcome relevant to these conditions (eg, a validated dermatologic severity measure, a metabolic or inflammatory biomarker, or a psychological/quality-of-life measure) in response to a defined physical-activity exposure or intervention, or (2) a mechanistic pathway plausibly linking exercise to the inflammatory, metabolic, or neuroendocrine processes underlying these conditions. All four authors applied these criteria, and borderline cases were resolved by consensus.
Where a well-conducted systematic review or meta-analysis addressed a given question, it was prioritized as a source for pooled or summary-level conclusions; primary studies were prioritized when they provided condition- or endpoint-specific detail not captured by existing syntheses (particularly dermatologic outcomes), when directly relevant interventional data were sparse, or when the evidence base was too limited or heterogeneous to have been synthesized. When relevant, the reference lists of key articles were manually reviewed to identify supplementary sources.
Prolonged psychosocial stress can exacerbate chronic inflammatory diseases through activation of the autonomic nervous system, hypothalamic-pituitary-adrenal (HPA) axis, and immune pathways.7–11 Excess cortisol has deleterious effects on the skin, disrupting barrier function, impairing keratinocyte differentiation and migration, impeding wound healing, and increasing the risk and severity of skin infections by downregulating epidermal antimicrobial peptide expression.6,12–18 Stress also heightens neural activity related to pain and itch perception, potentially exacerbating cutaneous discomfort.6,19,20
Stress is recognized as a potential exacerbating factor for HS, psoriasis, and PMOS, all of which are associated with elevated IL-6, TNF-ɑ, and C-reactive protein levels.5,6,21,22 These cytokines are potent activators of the HPA axis, perpetuating the inflammatory loop.23 Chronic inflammation and its visible cutaneous manifestations contribute to psychosocial burden and psychiatric comorbidities.6,24–29 This bidirectional relationship between psychological stress, systemic inflammation, and cutaneous disease provides a rationale for interventions that may address both physical and psychological health (Figure 1).
During exercise, the cardiovascular, immune, endocrine, and musculoskeletal systems achieve allostasis, or the re-equilibration of homeostasis, through short and long-term adaptations.10 The effects of aerobic exercise on the HPA axis are conditional on the intensity and duration of activity, a phenomenon accounted for by an intensity threshold effect.30 While moderate- to high-intensity exercise provokes increases in circulating cortisol levels at least in the short-term, low-intensity exercise promotes greater metabolic clearance of cortisol through increased cellular uptake, reducing the systemic impact of stress exposure.10,31 Long-term, regular exercise induces lasting adaptations that enhance the body’s homeostatic capacity and shifts immune function toward an anti-inflammatory state.10,30,32 Although these findings have been strongly supported by exercise physiology literature, these mechanisms have not been proven to provide direct dermatologic benefit. Changes in cortisol or inflammatory markers do not necessarily translate to improved skin disease. Therefore, these mechanisms should be considered hypothetical rather than therapeutic in regards to cutaneous outcomes in metabo-inflammatory dermatologic conditions. Aerobic exercise, resistance training, and yoga-based exercise programs have each been investigated for psoriasis, PMOS, and HS (Table 1).
Abbreviations: BASDAI = Bath Ankylosing Spondylitis Disease Activity Index; BASFI = Bath Ankylosing Spondylitis Functional Index; BMI = body mass index; BP = blood pressure; CI = confidence interval; DAS-28 = Disease Activity Score 28; DHEA = dehydroepiandrosterone; DLQI = Dermatology Life Quality Index; GI = gastrointestinal; HAQ-S = Health Assessment Questionnaire for the Spondyloarthropathies; HRQoL = health-related quality of life; HS = hidradenitis suppurativa; MD = mean difference; PASI = Psoriasis Area and Severity Index; PCOS = polycystic ovarian syndrome; PCOSQ = Polycystic Ovary Syndrome Questionnaire; PMOS = polyendocrine metabolic ovarian syndrome; PSQI = Pittsburgh Sleep Quality Index; RCT = randomized controlled trial; VAS = visual analogue scale.
Author (Year)
Exercise Type
Design/Sample Size
Intervention Duration
Control
Dermatologic Endpoint
Metabolic/ Psychological Endpoint
Principal Findings (Classified by Evidence Tier)
Major Limitations
Sheppard et al (2024)33
Aerobic exercise (walking group)
Prospective cohort / 16
20 weeks (supervised wks 1–10; independent wks 11–20)
None (within-subject vs. baseline)
PASI, DLQI
Blood pressure, pulse wave velocity, functional capacity, well-being, psychological health
Direct: ↓PASI wk 10 (p = 0.01) and wk 20 (p = 0.001); ↓DLQI wk 20 (p = 0.04). Indirect: ↓BP (wk 20 systolic −8.8 mmHg, p = 0.001) and ↓pulse wave velocity (p = 0.02); improved functional/psychological measures
No control group; small n = 16; no blinding; effect not separable from general activity/attention
Silva et al (2023)34
Functional training vs. resistance training
RCT / 41 (aged 18–65)
12 weeks
Functional (elastic bands) vs. resistance (weight machines)
None (cutaneous outcomes not evaluated)
BASFI, BASDAI, HAQ-S, DAS-28, muscle strength, QoL domains
Skin disease not measured; no non-exercise control
Tewani et al (2023)35
Yoga + naturopathy lifestyle program
Case report / 1
Two 10-day sessions 6 months apart + home protocol
None
PASI (lesion clearance), pruritus
Blood glucose, HbA1c, vitamin D/B12, BP, BMI, sleep (PSQI), pain, fatigue, GI symptoms
n = 1; multimodal (yoga + naturopathy + diet) → not attributable to exercise; not generalizable
Tiwari et al (2019)36
Aerobic (walking in place) ± metformin
RCT / 66
6 months (3 supervised + 3 home-based)
Exercise + placebo vs. exercise + metformin
Acne, acanthosis nigricans, hirsutism
Menstrual cyclicity, waist circumference, waist-hip ratio, BMI, glucose tolerance, serum testosterone
Direct: Significant improvements in hirsutism. No significant change in acne or acanthosis nigricans in either arm. Indirect: ↑menstrual cyclicity, ↓anthropometrics both arms; ↑glucose tolerance, ↓testosterone in metformin arm only
No true sedentary/no-metformin control; hirsutism benefit confounded by metformin; exercise-alone effect indeterminable
De Frène et al (2015)37
Aerobic (steps/sport) within multimodal lifestyle program
Prospective within-patient / 33 (overweight)
24 weeks
None (within-subject)
Acne (VAS), body-hair/hirsutism domain (PCOSQ)
BMI, total PCOSQ (HRQoL)
Direct: ↑acne VAS F(2,29.3) = 4.2; ↑body-hair domain F(2,35.6) = 3.3 (mostly by wk 12). Indirect: ↑total PCOSQ F(2,37.5) = 23.7; no significant ↓BMI (MD 1.71; 95% CI −1.38 to 4.81)
Diet + exercise + psychological components combined → exercise effect not isolable; no control group; within-patient design
Patel et al (2020)38
Mindful yoga
RCT / 31 (aged 23–42)
3 months (1-h classes ×3/week)
Usual-care control
Hirsutism; acne (self-reported only, not formally measured)
Free testosterone, DHEA, adiponectin, glucose, insulin, BMI, waist-hip ratio, anxiety, depression
Direct: no significant change in hirsutism; acne not formally evaluated (some self-reported improvement). Indirect: ↓free testosterone (p = 0.0413), ↓DHEA (p = 0.0574), ↓adiponectin (p = 0.0045); ↓anxiety (p = 0.0365), ↓depression (p < 0.001)
Primary dermatologic endpoint (acne) not measured; small n; no active comparator
The benefits of exercises on general health cannot be assumed to equal benefits in skin disease, thus the evidence below is categorized into three tiers: (1) direct evidence measuring change in cutaneous disease outcomes; (2) indirect evidence measuring metabolic and inflammatory outcomes; (3) evidence for psychological or quality of life outcomes.
Patients with psoriasis who followed a graduated intensity program consisting of two weekly one-hour group walks over 10 weeks followed by independent physical activity for another 10 weeks demonstrated significantly reduced Psoriatic Area and Severity Index (PASI) scores at 10 and 20 weeks, and reduced Dermatology Life Quality Index (DLQI) scores and therefore increased quality of life at 20 weeks in the absence of other lifestyle changes (Tier 1).33 Intervention subjects also demonstrated significantly lower blood pressure at 10 and 20 weeks compared to baseline (Tier 2), and significant beneficial changes in mental health (p = 0.01) and energy (p = 0.04) components of the 36-item Short Form Health Survey, the anxiety component of the Hospital Anxiety and Depression Scale (p = 0.04), and all measures of functional capacity by week 20 (Tier 3). Depression scores also decreased, but not to a statistically significant level.
Naldi et al conducted a randomized controlled lifestyle intervention trial including overweight or obese adults with chronic plaque psoriasis with PASI score ≥ 10 who had failed systemic treatment. These patients were randomized to a 20-week dietary plan combined with an exercise routine of continuous aerobic physical exercise sessions for at least 40 minutes three times a week, versus informative counseling about weight loss. The intervention group had significantly higher reduction in PASI score (p = 0.02), with a significantly higher proportion achieving 50% PASI score reduction (Tier 1).39 Although these results are promising, results cannot be completely attributed to aerobic exercise alone given the combination with dietary changes, which limits the isolated direct evidence for exercise.
Several studies have shown that aerobic exercise programs are beneficial for patients with PMOS in terms of inflammatory markers, health-related QoL, mental health, and cardiorespiratory fitness, as well as for prevention of PMOS. However, few studies have examined the direct effect of aerobic exercise on the cutaneous manifestations of PMOS.40–42 Existing studies demonstrate mixed results. Metabolic and endocrine outcomes should be treated primarily as mechanistic context rather than dermatologic evidence. Tiwari et al compared outcomes between 66 women with PMOS randomized to an exercise regimen consisting of marching in place for 30 minutes three days a week combined with metformin 850 mg BID over six months, versus the exercise regimen alone. Both groups exhibited significant improvements in hirsutism at 3 and 6 months, with no changes noted in acanthosis nigricans or acne in either group at either time point. While addition of metformin resulted in significantly higher benefits in menstrual cycle, hirsutism, weight, body mass index, waist circumference, waist hip ratio, serum testosterone, and oral glucose tolerance test, no difference was noted between the two groups in acanthosis nigricans or acne.36 This suggests exercise may potentiate the effects of metformin for multiple metabolic parameters and hirsutism, but not acne or acanthosis nigricans. However, with no true control group, it is impossible to know what the benefits of the exercise alone might have been over a sedentary control not taking metformin. In a multimodal 24-week lifestyle modification program including diet, physiotherapist-led exercise subprogram (“increasing number of steps per day” and “practicing sports”), and psychological support, significant improvements were reported in acne, hirsutism, and emotional health.37 Due to the multimodal lifestyle interventions evaluated within the study, the direct correlation between exercise and improvements in dermatologic symptoms and emotional health cannot be determined.
No interventional studies have directly assessed aerobic exercise effects on HS lesions. Studies suggest that regular aerobic exercise may be beneficial in preventing or modulating HS, but these studies do not establish a direct disease-modifying effect and are thus currently hypothetical.43,44
Silva et al demonstrated that functional and resistance training using resistance bands and weight training can both improve physical functionality, muscular strength, and QoL in psoriatic arthritis patients (Tier 2 and 3); however, cutaneous symptoms were not evaluated.34
Yoga combines physical movement, breathwork, and mindfulness, and has shown benefits in immune function, endocrine and metabolic balance, and mental health.45 While studies examining effects of yoga for dermatologic conditions are relatively few, implementing yoga as an adjunct therapy for managing autoimmune and inflammatory disorders such as multiple sclerosis, rheumatoid arthritis, ankylosing spondylitis, inflammatory bowel disease, and autoimmune periodontitis has been widely explored in the literature, suggesting applicability in dermatology.46
Patel et al compared outcomes in patients with PMOS who attended one-hour mindful yoga classes three times weekly for three months to a control group with PMOS, and demonstrated that yoga classes significantly decreased testosterone and DHEA levels (Tier 2), anxiety as measured by the Beck Anxiety Inventory, and depression as measured by the Beck Depression Inventory-II (Tier 3). While some subjects self-reported improvement in their acne, this endpoint was not evaluated in the study, and no significant changes in hirsutism were found.38 Therefore, direct dermatologic evidence is absent in this study.
A case report on the incorporation of yoga and integrative lifestyle interventions as part of a treatment plan for one patient with palmoplantar psoriasis demonstrated significant remission of psoriatic lesions (Tier 1), as well as improvement in pruritus, fatigue, pain, and sleep, and patient-reported overall wellbeing (Tier 3).35 However, this study incorporated multiple nonpharmacologic interventions, so attribution of impact to yoga alone is difficult.
Patients with psoriasis are up to 50% more likely to develop cardiovascular disease, with risk increasing with disease severity.47 This association is largely attributed to the systemic inflammatory milieu characteristic of psoriasis, which contributes to endothelial dysfunction and atherosclerotic plaque formation.47 This elevated cardiovascular risk may be compounded by reduced physical activity in psoriasis patients compared to controls, as evidenced by multiple cross-sectional and cohort studies.48–51
In an analysis of 9174 patients, including 232 with psoriasis, those with psoriasis were significantly less likely to engage in vigorous exercise compared to other patients (16.1% vs. 28%, p = 0.042).49 Similarly, a study of 9940 German patients with psoriasis found that 25.6% of participants with mild psoriasis and 46.6% with moderate-to-severe psoriasis reported that psoriasis had prevented them from exercising at least once.52 Patients with moderate-to-severe disease report lower activity levels than those with mild psoriasis.53
Similar reductions in physical activity are observed in PMOS and HS populations, in whom clinician-assessed and self-reported disease severity are inversely associated with intensity of physical activity.43,44,54
Disease-specific barriers to activity across all three conditions include anxiety about negative social reactions to visible lesions, physical discomfort, and fear of triggering disease flares. A study found that in psoriasis, while BSA involvement does not correlate with physical activity levels, there is an inverse correlation between patients’ subjective perception of disease severity and participation in moderate-to-vigorous exercise.55 Reported barriers to physical activity in patients with psoriasis include skin sensitivity, increased pruritus with exercise, and fear of judgment; patients with severe psoriasis (PASI ≥10) have described avoiding public fitness centers and pools due to concerns about negative reactions from others.56,57 Among patients with PMOS, perceived ineffectiveness of lifestyle interventions and embarrassment about exercising in public settings are frequent deterrents to physical activity.58 In HS, heat, sweat, and friction are recognized triggers of disease flares, prompting patients to avoid exercise.59 Further, the pain and functional impairment associated with HS can significantly limit mobility and daily functioning.60
Physical activity plays a multifaceted role in mitigating inflammation, metabolic dysfunction, and psychological distress across the chronic metabo-inflammatory dermatologic conditions of HS, psoriasis, and PMOS. However, it is important to distinguish the well-established general health benefits of exercise from the limited evidence demonstrating direct improvement in cutaneous disease. Evidence from clinical and experimental studies suggests that regular low-intensity exercise can attenuate systemic inflammation by reducing pro-inflammatory cytokines, enhancing immune regulation, and improving metabolic parameters. Furthermore, by decreasing stress and depressive symptoms, physical activity may hypothetically disrupt the cycle linking psychological distress to cutaneous inflammation.61 Aerobic exercise shows promising findings in psoriasis and in PMOS, however, research directly assessing exercise-induced improvements in cutaneous disease in all three conditions, and particularly in HS, remains limited.
Direct dermatologic evidence of exercise benefits in PMOS varies by each dermatologic endpoint: hirsutism, acne, and acanthosis nigricans. Hirsutism improved with multimodal aerobic exercise regimens, but since both studies combined exercise with metformin or lifestyle interventions, an independent effect cannot be proven.36,37 One study found that yoga improved androgen levels, indicating indirect endocrine evidence, as well as psychological outcomes, but did not significantly improve hirsutism.38 Improvements in acne demonstrated inconsistent results. The Tiwari et al study did not demonstrate improvement while improvement was seen in the De Frene et al study.36,37 Improvements in acne were self-reported but not formally evaluated in the yoga trial by Patel et al.38 Acanthosis nigricans was assessed only by Tiwari et al, where it did not improve in either study group.36 Overall, the direct dermatologic evidence for exercise in PMOS is limited and inconsistent, and metabolic/endocrine or psychological improvements should not be equated with cutaneous benefit.
While obesity is not a clearly causal factor in HS, the condition is significantly associated with obesity, and existing reports suggest that obesity may contribute to the development of HS via mechanical friction in larger skin folds, humid microenvironments promoting bacterial proliferation, and increased systemic inflammation.62,63 Current literature supports that weight loss in certain populations and dietary modification can improve HS severity. Aerobic and combination aerobic-resistance training mitigates inflammatory markers, promotes weight loss, and reduces metabolic syndrome scores, concurrent type 2 diabetes, and metabolic syndrome, which are all recognized comorbidities of HS.62,64–66 However, these represent indirect, hypothetical mechanisms, and no studies to date have evaluated direct improvement in HS lesions with exercise.
There are no reports examining the effects of structured exercise interventions on HS cutaneous outcomes; data from an ongoing study to assess the outcomes of an exercise intervention for HS patients may help fill this knowledge gap.67 Accordingly, any suggestion that exercise acts as a disease-modifying adjunct in HS remains hypothetical and should not be presented as established therapy. While patients with HS face several barriers to regular physical activity, including fear of triggering flares, pain, and limited mobility, few receive lifestyle counseling in ambulatory settings; only 2.4% physicians report counseling about exercise in HS patients, and 2% perform depression screening.68
Several studies have evaluated the effects of weight loss on disease severity in psoriasis, and most have demonstrated beneficial outcomes. A meta-analysis found greater reduction in PASI scores among patients undergoing weight loss interventions compared to controls, with participants significantly more likely to achieve a 75% reduction in baseline PASI score (direct dermatologic outcome).69 However, only one RCT in this analysis included exercise. This study evaluated both dietary changes and an aerobic exercise program, limiting the ability to attribute improvements solely to physical activity.40 Thus, while exercise appears to be a promising adjunctive therapy for both systemic inflammation and mental well-being, further controlled studies are needed to determine its direct dermatologic benefits independent of weight loss and other lifestyle interventions.
Integrating exercise into the care of patients with chronic metabo-inflammatory skin conditions requires thoughtful planning, patient education, and active involvement from healthcare providers. Dermatologists are uniquely positioned to initiate conversations about exercise and stress management, yet current data indicate that such counseling remains underutilized in routine care. Dermatologists should routinely discuss physical activity with metabo-inflammatory patients due to their increased cardiometabolic risk in a nonjudgmental manner, and encourage exercise incorporation into treatment plans based on a patient’s capabilities, needs, and interests.
As our understanding of the relationship between inflammation, stress, and skin health deepens, standardized exercise intervention trials with dermatologic endpoints are needed to inform clinical guidelines and establish evidence-based recommendations for incorporating exercise into comprehensive treatment strategies for HS, psoriasis, and PMOS. Although evidence for direct improvement of cutaneous disease with exercise remains limited, improvements in cardiometabolic and psychological health are well supported by current literature. With further studies, proper guidance, and personalized, inclusive interventions, exercise can become a significant tool in the comprehensive care of metabo-inflammatory dermatologic conditions, empowering patients to take an active role in managing their health and improving long-term outcomes.
HS, psoriasis, and the dermatologic manifestations of PMOS share pathophysiologic commonalities in inflammatory, metabolic, and immune dysregulation. These conditions all carry a heavy psychosocial and QoL burden that contribute to a cycle of physical and mental stress and worsening cutaneous disease activity. Increasing evidence demonstrates the potential of physical activity, specifically aerobic exercise, functional and resistance training, and yoga, as low-cost, accessible adjunct therapies to improve psychosocial and metabolic cutaneous disease by decreasing systemic inflammation and improving metabolic parameters. The strength of evidence for dermatologic effect differs by condition; psoriasis has the strongest direct evidence, evidence in PMOS is limited and inconsistent for cutaneous manifestations despite evident metabolic and psychological benefits, and direct evidence in HS is absent. More targeted clinical trials with cutaneous endpoints are needed to define optimal exercise modalities, intensity, and duration across these conditions and to evaluate their independent effects on skin pathology.
Savannah G. Moore; P.O. Box 70580, Johnson City, TN 37614; 8287684505; sprinklesg@etsu.edu
The authors declare that they have no conflicts of interest. No funding was received for this literature review.
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