SKIN PROBLEMS IN OBESITY
What is Obesity?
Obesity is a chronic disease defined as having an excessive accumulation of adipose tissue or body fat. An objective measurement usually involves the calculation of one’s body mass index (BMI) by dividing a person’s weight in kilograms by the square of a person’s height in meters. A BMI value over 30kg/m2 is considered as obesity.
Obesity affects multiple organs in the body and is a major risk factor for various cardiovascular, respiratory, endocrine, and psychiatric disorders (e.g. depression). It is also part of the metabolic syndrome, which is a group of conditions that increase the risk for heart disease, stroke, diabetes, high blood pressure, and other diseases.
Skin changes are present in around 60-70% of obese patients. Some skin diseases, such as atopic dermatitis and psoriasis, are also influenced by obesity. It is important for clinicians to recognize these skin changes so that patients can be advised and can receive multidisciplinary care.
What are the Skin Changes in Obesity?
The skin’s physiology can be altered by obesity. Some of the skin changes include:
- Altered transepidermal water loss that can lead to xerosis (dry skin)
- Altered collagen structure and decreased mechanical strength of the skin
- Impaired wound healing
- Increased sebum production
- More profuse sweating
- Increase in bacterial overgrowth, which can cause unpleasant body odor
- Vascular dysfunction leading to ulcerations, varicose veins, and decreased sensitivity to pain
- Reduced tissue oxygenation
- Increased friction and moisture between skin folds
Common Skin Manifestations in Obesity
Plantar Hyperkeratosis
Plantar hyperkeratosis refers to the thickening of the skin over the heel, foot arch, and great toe of obese individuals. This is due to the increase in pressure and mechanical stress over the weight-bearing areas of the feet that causes mechanical trauma and injury. Aside from weight loss, the treatment and management of plantar hyperkeratosis include the use of topical keratolytic agents like urea or salicylic acid. For other cases, surgical debridement of the lesions is also possible.
Acanthosis Nigricans
Acanthosis nigricans usually presents as dark, velvety, raised lesions (plaques) commonly seen on the neck, axillae, and the area below the breasts. These lesions are due to insulin resistance in obesity. Treatment includes weight reduction, medications for insulin resistance, topical retinoids, and keratolytic agents.
Acrochordons (Skin Tags)
Skin tags are benign lesions that hang off the skin and are usually found on sites of friction, such as the neck, armpits, and groin area. These flesh-colored soft lesions are usually attached to the skin by a stalk. Obese individuals tend to have more skin tags due to constant rubbing together of the skin and insulin resistance. Treatment options include electrosurgery, surgical excision, cryotherapy, ligation, and shave excision.
Striae Distensae
Striae distensae, also known as stretch marks, appear on obese individuals due to the mechanical stretching of the skin, as well as the tearing of elastic fibers in the dermis. Weight gain, overuse of steroids, and other hormonal changes can also be associated with stretch marks. These benign lesions appear as longitudinal, atrophic marks; and are often seen on the breasts, abdomen, thighs, and buttocks. Treatment and management of striae distensae is often a combination of two or more treatment modalities. Options include topical agents such as tretinoin and glycolic acid, as well as procedures such as dermabrasion, laser therapy, and microneedling.
Intertrigo
Intertrigo presents as red, macerated plaques, sometimes accompanied by a burning sensation that usually appears on skin folds such as the axillae, abdominal skin folds, groin area, and inframammary area. Obese patients sweat more profusely, which increases friction and moisture in the skin fold areas. Intertrigo can co-exist with a secondary fungal or bacterial infection. Treatment options include mild topical steroids, antifungals, or antibacterial agents. Cool compress and barrier creams such as zinc oxide are adjunct treatment options.
Psoriasis, Atopic Dermatitis
Psoriasis is a chronic inflammatory skin disease presenting as thick, red, scaly lesions on the scalp and body. Obesity can negatively affect the disease course of psoriasis, and can lessen the efficacy of systemic treatment in psoriasis lesions. Obesity also increases the prevalence of atopic dermatitis. Weight loss can improve the disease course and treatment outcomes for both psoriasis and atopic dermatitis patients who are obese.
Hirsutism
Hirsutism refers to the excessive, male-like pattern of hair growth in a female. Fatty tissues in obese, female patients can increase the androgen levels (male hormones) in the body, causing hirsutism. Many obese females also have polycystic ovary syndrome (PCOS), which causes hormonal imbalance, resulting in excess hair growth. Treatment options include plucking, waxing, shaving, oral contraceptives, especially for those with PCOS, electrolysis, and laser therapy.
Varicose Veins
Obese patients can have chronic venous insufficiency (CVI). This occurs when the leg veins do not allow blood to properly flow back to the heart. In obese patients, the excess fat can put extra pressure on the leg veins, causing the swollen, tortuous, bluish-colored appearance of the blood vessels (i.e., varicose veins). Treatment options include the use of compression stockings, elevation of the legs, mild to moderate physical activity, and certain surgical interventions for severe cases. Laser treatment and sclerotherapy are other options.
Stasis Dermatitis
Patients with CVI can go on to develop stasis dermatitis, which presents as red, scaly patches commonly located on the medial malleoli. Lesions can be itchy and can be accompanied by swelling, warmth, hyperpigmentation, and sometimes even ulcers. Management of the disease involves lifestyle changes such as avoiding prolonged standing, mild to moderate physical activity, elevation of the feet, and use of compression stockings. Treatment options include topical corticosteroids, topical and oral antibiotics (for secondary bacterial infections and ulcers), gauze compresses, and moisturizing creams to protect the skin barrier.
Take-Home Messages
The management of skin diseases in obese patients can be challenging. It requires a lot of motivation and patience to be able to commit to the lifestyle changes needed for weight loss. It is better to visit your physician or dermatologist for any concerns regarding skin changes in obesity. A holistic, multidisciplinary approach to management is best, as it addresses the skin concerns as well as the root of the problem.
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