Obesity and the Skin

A look at Bariatric associated skin disorders

Objectives:

Participants will be able to summarize obesity-associated changes in skin

Describe at least 3 skin manifestations of obesity

Describe dermatologic diseases aggravated by obesity

Obesity was considered a symbol of wealth and social status

The more money you had, the more food you could eat

Epidemiology

Major public health problem in the US

Obesity in the US has increased significantly in the last 30 years

In the US, obesity and morbid obesity is serious and costly

Greater than 2/3 of US American adults are obese

1/4 to 1/3 of American Adults are obese.

1 in 6 children and adolescents are overweight The southern states have the

highest prevalence (35%)

Obesity Trends* Among U.S. AdultsBRFSS, 2010

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2010

By 2000, no state had a prevalence of obesity less than

10%, 23 states had a prevalence between 20–24%, and

no state had prevalence equal to or greater than 25%.

In 2010, no state had a prevalence of obesity less than

20%. Thirty-six states had a prevalence equal to or

greater than 25%; 12 of these states (Alabama,

Arkansas, Kentucky, Louisiana, Michigan, Mississippi,

Missouri, Oklahoma, South Carolina, Tennessee, Texas,

and West Virginia) had a prevalence equal to or greater

than 30%.

Economic Cost

The economic costs of obesity are staggering

Treating obesity and morbid obesity adults and their complications costs 100 billion yearly approximately

More than 50 million were directly related to medical cost Obesity increases the risk for coronary heart disease,

hypertension, hyperlipidemia, arthritis and diabetes

Cause increase risk of sleep apnea: breast, endometrial, and colon caner: gallbladder disease, infertility, diverticulitis etc.

However, minimal attention is paid to the effects of obesity on the skin

Obesity Defined

Obesity is defined by Body Mass Index (BMI)

A measure of weight for height used to define or classify obesity and overweight in adults

BMI Charts are used commonly

Normal weight BMI under 25

> 25 to 29 is over weight

> 30 is obesity

> 40 morbid obesity

> 35 severe obesity if comorbidities exist

WARMER WEATHER!

Skin folds can lead to problems associated with warmer weather regardless of one’s body weight

Obese individuals have more skin and thus perspire more

Immobility, hygiene and presence of excessive moisture can lead to multiple skin issues

Overweight Patient Skin Considerations

Higher rate of candidiasis

Intertrigo and rash formation

Lower blood perfusion affect healing

Ability to fight infection

Personal hygiene may become difficult

Can not inspect skin visually

Skin: largest organ

20 sq. ft. (average size body)

15% of body weight

Skin problems documented as high as 75% of obese persons reporting some type of skin issue related to moisture or friction

Given its complex structure and barrier function the loss of skin integrity can lead to serious life-threatening situations

Pannus (Abdominal Apron)

Excessive fat, tissue, and skin at the bottom of the abdomen

More commonly related to obesity or people who have lost a large amount of weight, but still has excess skin

Classified by Grades: Grade 1-Covers pubic hairline

Grade 2-Pannus extends to cover the entire mons pubis

Grade 3-Pannus extends to cover upper thigh

Grade 4-Pannus extends to mid-thigh

Grade 5-Extends to the knee and below

Fat redistribution in obesity

Women typically have higher percentage of body fat than men, and adipose tissue is distributed differently in men and women

Men tend to accumulate fat in their upper body(abdomen) and women tend to accumulate fat in their lower body (hips and thighs)

Functions of the skin

Communication medium

Sensory organ

Thermoregulatory system

Environmental barrier

Elimination agent

Loss of skin integrity

Infection

Pain

Body odor

Damaged self-esteem

Altered mobility

Risk Factors that can lead to loss of skin integrity

Factors leading to loss of skin integrity

Adipose tissue has less blood supply, leading to inadequate oxygenation

Excessive sweating increases skin moisture which could lead to bacterial/fungal infections within the folds

Friction, shear, and immobility

Poor nutrition can lead to inadequate protein vitamins and nutrients essential to wound repair

Iatrogenic damage due to catheters, tubes, and other interventions can cause injury to the skin

Risk factors/complications associated with Skin Disorders

Sedentary lifestyle

Energy dense, high-fat foods

History of diabetes/type 2 diabetes

Family history of obesity

Polycystic ovarian disease

Metabolic syndrome

Prolonged immobility

Excess caloric intake=increase body weight

Comorbidities associated with obesity

Hypertension

Ischemic heart disease

Type 2 diabetes

Stroke

Osteoarthritis

Chronic Renal Failure

Sleep apnea

Back pain

Gall bladder disorders

Venous Insufficiency

Immobility

Lymphedema

Breast/ovarian cancer

GERD

Non-alcoholic Fatty Liver Disease

Colon/breast/ovarian cancer

Esophageal cancer

Risk for pressure ulcers in the bariatric patient

Adipose tissue is not well vascularized More susceptible to Ischemic effects of pressure

Pressure Ulcer Mapping in bariatric patients Indicate pressure is redistributed differently in obese

patients

Normal weight patients-sacrum, head, and heels

Obese patients- high pressure remains over boney prominence and indicated over soft tissue areas: buttocks, back, lower legs

Ulcer locations and characteristics

Buttocks

Back folds

Bilateral hips-patient placed in chairs that are too narrow

Higher risk for device related pressure damage; oxygen tubing, tubing, endotracheal tubes, tracheostomy tubes

Most can be prevented with proper bariatric equipment, placement of equipment, and frequent skin inspection under high pressure areas

Intertrigo

Infectious or non-infections inflammatory condition of two opposed skin surfaces

Moisture trapped between two skin folds causing maceration

Pressure of large underlying skin, creating areas of pressure injury

Friction-one skin surface moves across another

Shear with movement resulting in fissures at the base of the skin folds

Preventing Intertrigo

Keep the skin clean, dry, and supported

Minimizing the of effects of moisture, pressure, friction, and shearing

Treatment:

Textile with antimicrobial silver complex

Chronic Venous Insufficiency

Obesity is a recognized risk factor for the development of chronic venous insufficiency

Failed valves in the veins of the legs cause increased venous pressure, edema, and subsequent eczematous changes in the distal leg skin.

The intra-abdominal pressure found in obese patients causes an oppositional force to venous return from the lower extremities

Hemosiderin staining

Venous blood pools in the extremities with the formation of edema

This eventually lead to hemosiderin staining (leaking out of the hemoglobin component of red blood cells to permanently discolor the tissue)

Venous Insufficiency

Years-decades of obesity can damage the venous system and circulatory changes occur.

Which can lead to a more serious venous ulceration

Occur commonly over the medial malleolus and can drain a substantial amount of fluid due to the associated edema

Skin related problems aggravated by obesity

Lymphedema

Results up to 75% in obese population

In the morbidly obese edema can occur in the face, hands, extremities, and abdomen(pannus).

Creates functional Impairment, pain, and chronic cellulitis

Skin is dry, hyperkeratotic, and chronically affected by fibromas, lymphangiomas, and papillomas

Lymphedema

Obesity impedes lymphatic flow, which lead to collection of protein-rich lymphatic fluid in the subcutaneous tissue

Initially patients present with soft, pitting edema beginning in the feet and progress proximally

Over time further accumulation of fluid, decreased oxygen tension, and macrophage function lead to fibrosis and a chronic inflammatory state

Lymphedema

Provides a culture medium for bacterial growth

The patient is subject to repeated infections which can lead them in a downward spiral

Chronic Lymphedema

Chronic lymphedema can lead to elephantitis nostras verrucosa

Define by hyperkeratosis, and papillomatosis of the epidermis overlying an indurated dermis and subcutaneous tissue

Obese surgical patient Obese patients who undergo major surgery have a

higher risk of postoperative complications:

Sepsis

Skin ulcers

Wound infections

Wound dehiscence

Venous thromboembolic disorders

Respiratory complications

Renal Failure

Death

Incision complications

Following incision, healing is expected to involve the formation of a watertight seal within 24 hours.

Wound healing may be slower in patients with obesity.

Surgical wounds are more prone to dehiscence and evisceration in the obese patient due to increased tension on the edges of the fascia at the time of wound closure. This increases the pressure on the tissues, reducing perfusion and oxygen delivery.

Wound healing also may be slower in the patient with obesity due to poor nutrition, tension on wound edges, reduced microperfusion, and emotional stress.

Obese Critically Ill

At risk for systemic inflammatory response syndrome

Multi-organ dysfunction syndrome

The risk for skin breakdown and wound deterioration

is related to hypotension,

hypoxia, and

hypoperfusion of multi-organ dysfunction syndrome

Obesity-associated changes in skin

Obesity and skin physiology:

1. Skin barrier function

2. Sebaceous glands/Sebum production

3. Sweat glands

4. Lymphatics

5. Collagen structure/function

6. Wound healing

7. Micro/macrocirculation

8. Subcutaneous fat

Changes in skin physiology

Skin Barrier Function-

Increased transepidermal water loss, which leads to dry skin and impaired skin barrier repair

Sebaceous glands/sebum production-

Increased sebum production plays a major role in acne.

Acne is exacerbated by obesity associated disorders such as hyperandrogenism and Hirsutism.

Sweat glands-obese patients sweat more profusely because of thick layers of subcutaneous fat, which increase both friction and moisture

Lymphatics-obesity Impedes lymphatic flow, which leads to the collection of protein-rich lymphatic fluid in the subcutaneous tissue.

The accumulation of fluid often leads to lymphedema

Collagen structure/wound healing-In obese individuals the skin mechanically weaker than in a leaner individual.

Micro/macrocirculation

Subcutaneous Fat

Skin manifestations of obesity

Skin manifestations of obesity

Insulin resistance

Insulin resistance syndrome

Acanthosis nigricans

Acrochordons

Keratosis pilaris

Hyperandrogenism

Hirsutism

Skin manifestations of obesity

Mechanical

Plantar hyperkeratosis

Striae Distensae

Cellulite

Adiposis dolorosa

Lymphedema

Chronic venous insufficiency

Skin manifestations of obesity

Infectious

Intertrigo

Candida

Folliculitis

Necrotizing cellulitis/fasciitis

Skin manifestations of obesity

Inflammatory

Hidradenitis Suppurativa

Psoriasis

Metabolic

Tophaceous gout

Acanthosis Nigricans

Acanthosis nigricans (ak-an-THOE-sis NIE-grih-kuns) is a benign condition characterized by symmetric, velvety hyperpigmented Plaques on the skin and intertriginous areas such as the

Back

Axillae

Acanthosis Nigricans

Most common dermatological skin manifestation

Often affects: axilla, groin, posterior neck (Can occur in almost any location)

Acrochordons (Skin Tags)

Described as soft brown papules most commonly seen on the neck and in the axilla and groin.

High friction areas

Frequently seen in association with acanthosis nigricans

Keratosis Pilaris

Small perifolicular, spiny papules on extensor aspects of extremities

Manifest in those with greater BMI

Hirsutism

In obese women hirsutism may result from an increase production of testosterone associated with visceral obesity

Striae Distensae (stretch marks)

Striae distensae (stretch marks) are smooth, linear bands of skin.

When they first appear: red, purple white- flatten

These lesions occur most commonly on the abdomen, thighs, buttocks, and arms

Theory: rapid stretching of the skin-tension on the skin from expanding subcutaneous deposits

Stretch marks causes significant cosmetic concern for many people

Striae Distensae (stretch marks)

Close up view >

Plantar Hyperkeratosis

Defined as “diffuse thickening” of the stratum corneum

Abnormal transference of weight during walking that alters the alignment of the foot causing an increase stress over boney prominences

Plantar hyperkeratosis

The most common dermatological manifestation in patients who weigh 76% to 100% more than their IBW.

The excess weight of the patient with obesity disrupts the normal foot anatomy.

Cellulite

Occurs mainly in women on the thighs, buttocks, pelvic region, and abdomen.

Its characterized by skin dimpling

Cellulite results from changes in the epidermis and dermis rather than changes in adipose tissue

It often presents in healthy nonobese individuals, it is exacerbated by obesity

Skin Infections

Skin infections of the morbidly obese are benign to life threatening

Obesity increases the incidence of cutaneous infections, including candidiasis, intertrigo, folliculitis, cellulitis, necrotizing fasciitis, gas gangrene.

Obese patients hospitalized for skin infections has increased over time

Diabetes and obesity are risk factors for necrotizing soft tissue infections

Mechanisms of skin infections

Skin folds trap moisture causing maceration and related microbial growth

Lymphatic flow hindered, decreasing oxygenation of surrounding tissues

Venous insufficiency

Increased tension on wound edges predispose patient to poor wound healing and wound dehiscence of a closed wound

Skin PH higher in obese individuals

Leads to increase risk of candida- which thrive in alkaline environments

Conditions

Physical Challenges maintaining hygiene

warm, dark, and moist conditions favor growth of yeast and fungal infections

Secondary bacterial infections may develop

lead to cellulitis if not treated

Cellulitis

Conditions left untreated can lead to secondary bacterial skin infections may also develop and progress to cellulitis

Cellulitis defined: bacterial skin infection that

involves swelling, tenderness, blistering, and redness of the skin

Bacterial infections

Folliculitis-infection of the hair follicles

Furunculosis-boil, abscess, deep folliculitis infection

Erysipelas- commonly cause by streptococcus

can complicate lymph edematous limbs

Necrotizing Fasciitis- infection of the subcutaneous tissue that leads to progressive destruction of fascia and fat

Hidradenitis Suppurativa

Definition: a chronic recurrent disease manifested by abscesses, fistulas, and scarring tracts along predominantly the apocrine gland-bearing skin

Obesity has not been consistently found to be associated with this disease, but likely exacerbates underlying disease by increasing shearing force

Psoriasis( red dry patches of thickened skin)

Inverse psoriasis appears to be particularly related to obesity

Inverse psoriasis often appears in the axilla, in the skin folds around genitals, between buttocks, under breasts and in the groin

Psoriasis can be indistinguishable from intertrigo in obese patients

Psoriasis

Diabetic foot ulceration

Obesity and type 2 diabetes are closely related

almost 24 million adults in the US have diabetes

one of the main risk factors for type 2 diabetes

Obesity is a major risk factor for chronic hyperglycemia

15% of patients with diabetes are affect by DFU

In obesity, a diabetic foot ulcer can become life threatening due to lack of self-care and self-awareness and be hindered by excess weight

Diabetic foot ulcers

Most commonly occur on the plantar surface of the foot at the base of the metatarsals.

Care usually consists of :

debridement of the callous

management of bio burden

protection against osteomyelitis

Surgical Debridement

Offloading- larger size offloading equipment or wheelchair and bed rest

DFU

Areas of repetitive trauma are at high risk for ulcer formation-

metatarsal heads

heels

are at risk for callous, followed by ulcer formation

Once a DFU occurs, it often deteriorates to a complex, infected wound.

often can lead to amputations

More than 80,000 amputations annually in the United States

Treatment strategies

Weight loss

Improve Insulin Resistance

Antibiotics

Topical Steroids

Steroids

Compression therapy

Antifungals

Surgical intervention

Treatment strategies

Drug-induced weight gain is a side effect of many medications commonly prescribed by dermatologist.

For example: Oral Corticosteroids

Weight gain can lead to

non-compliance as well as

exacerbation of comorbid conditions related to obesity

Conclusion

Obesity is recognized as a major public health problem

Prevalence of obesity has increased

Little attention given to obesity related skin problems

Due to the growing number of obese patients, dermatologists, nurses, primary care teams and patients must work together to reduce the detrimental effects of obesity on the skin

References

 

1. Beitz, J. Providing quality skin and wound care for the bariatric patient. J Ostomy

Wound Management. 2014; 60(1): 12-21.

2. Yosipovitch. Gil MD, Devore, A MD, and Dawn, A. MD . Obesity and the skin: Skin

Physiology and Skin manifestations of obesity. J American Academy of Dermatology.

2007; 56:901-16

3. Pokorny, M. RN, PHD. Skin physiology and diseases in the obese patient. J Bariatric

nursing and surgical patient care. 2008; 3(2):125-128.

4. Baranoski, S, Ayello, E., Cuddigan, J. Wound care essentials, bariatric population. 2011;

3: 542-552.

5. Bryant, Ruth A. Nix. Denise P. Acute and chronic wounds, current management options.

2007: 249-333

6. Redlin, J. Crit Care Nurs Clin North AM. Skin Integrity in Critically Ill Obese Patients .

2009;21(3):311-v

Questions