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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
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