1. Obesity and the Skin A look at Bariatric associated skin disorders

2. 2 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

3. 3  Obesity was considered a symbol of wealth and social status  The more money you had, the more food you could eat

4. 4 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%)

5. 5 Obesity Trends* Among U.S. Adults BRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

6. 6 Obesity Trends* Among U.S. Adults BRFSS, 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%.

7. 7 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

8. 8 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

9. 9 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

10. 10 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

11. 11 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

12. 12 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

13. 13 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)

14. 14 Functions of the skin  Communication medium  Sensory organ  Thermoregulatory system  Environmental barrier  Elimination agent

15. 15 Loss of skin integrity  Infection  Pain  Body odor  Damaged self-esteem  Altered mobility

16. Risk Factors that can lead to loss of skin integrity

17. 17 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

18. 18 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

19. 19 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

20. 20 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

21. 21 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

22. 22 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

23. 23 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

24. 24 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

25. 25 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)

26. 26 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

27. Skin related problems aggravated by obesity

28. 28 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

29. 29 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

30. 30 Lymphedema  Provides a culture medium for bacterial growth  The patient is subject to repeated infections which can lead them in a downward spiral

31. 31 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

32. 32 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

33. 33 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.

34. 34 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

35. 35 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

36. 36 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

37. Skin manifestations of obesity

38. 38 Skin manifestations of obesity Insulin resistance  Insulin resistance syndrome  Acanthosis nigricans  Acrochordons  Keratosis pilaris  Hyperandrogenism  Hirsutism

39. 39 Skin manifestations of obesity Mechanical  Plantar hyperkeratosis  Striae Distensae  Cellulite  Adiposis dolorosa  Lymphedema  Chronic venous insufficiency

40. 40 Skin manifestations of obesity Infectious  Intertrigo  Candida  Folliculitis  Necrotizing cellulitis/fasciitis

41. 41 Skin manifestations of obesity Inflammatory  Hidradenitis Suppurativa  Psoriasis Metabolic  Tophaceous gout

42. 42 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

43. 43 Acanthosis Nigricans  Most common dermatological skin manifestation  Often affects: axilla, groin, posterior neck (Can occur in almost any location)

44. 44 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

45. 45 Keratosis Pilaris  Small perifolicular, spiny papules on extensor aspects of extremities  Manifest in those with greater BMI

46. 46 Hirsutism  In obese women hirsutism may result from an increase production of testosterone associated with visceral obesity

47. 47 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

48. 48 Striae Distensae (stretch marks)  Close up view >

49. 49 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

50. 50 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.

51. 51 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

52. 52 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

53. 53 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

54. 54 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

55. 55 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

56. 56 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

57. 57 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

58. 58 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

59. 59 Psoriasis

60. 60 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

61. 61 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

62. 62 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

63. 63 Treatment strategies  Weight loss  Improve Insulin Resistance  Antibiotics  Topical Steroids  Steroids  Compression therapy  Antifungals  Surgical intervention

64. 64 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

65. 65 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

66. 66 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

67. Questions