Transcript skin changes in the obese population

Obesity and the Skin
A look at Bariatric associated skin disorders
Objectives:
 Participants will be able to summarize obesityassociated changes in skin
 Describe at least 3 skin manifestations of obesity
 Describe dermatologic diseases aggravated by
obesity
2
 Obesity was considered
a symbol of wealth and
social status
 The more money you
had, the more food you
could eat
3
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%)
4
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%
5
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%.
6
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
7
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
8
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
9
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
10
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
11
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
12
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)
13
Functions of the skin
 Communication medium
 Sensory organ
 Thermoregulatory system
 Environmental barrier
 Elimination agent
14
Loss of skin integrity
 Infection
 Pain
 Body odor
 Damaged self-esteem
 Altered mobility
15
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
17
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
18
Comorbidities associated with obesity
 Hypertension
 Venous Insufficiency
 Ischemic heart disease
 Immobility
 Type 2 diabetes
 Lymphedema
 Stroke
 Breast/ovarian cancer
 Osteoarthritis
 GERD
 Chronic Renal Failure
 Non-alcoholic Fatty
Liver Disease
 Sleep apnea
 Back pain
 Gall bladder disorders
 Colon/breast/ovarian
cancer
 Esophageal cancer
19
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
20
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
21
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
22
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
23
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
24
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)
25
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
26
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
28
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
29
Lymphedema
 Provides a culture
medium for bacterial
growth
 The patient is subject
to repeated infections
which can lead them
in a downward spiral
30
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
31
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
32
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.
33
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
34
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
35
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
36
Skin manifestations of obesity
Skin manifestations of obesity
Insulin resistance
 Insulin resistance syndrome
 Acanthosis nigricans
 Acrochordons
 Keratosis pilaris
 Hyperandrogenism
 Hirsutism
38
Skin manifestations of obesity
Mechanical
 Plantar hyperkeratosis
 Striae Distensae
 Cellulite
 Adiposis dolorosa
 Lymphedema
 Chronic venous insufficiency
39
Skin manifestations of obesity
Infectious
 Intertrigo
 Candida
 Folliculitis
 Necrotizing cellulitis/fasciitis
40
Skin manifestations of obesity
Inflammatory
 Hidradenitis Suppurativa
 Psoriasis
Metabolic
 Tophaceous gout
41
Acanthosis Nigricans
 Acanthosis nigricans (ak-anTHOE-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
42
Acanthosis Nigricans
 Most common
dermatological skin
manifestation
 Often affects: axilla, groin,
posterior neck (Can occur in almost
any location)
43
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
44
Keratosis Pilaris
 Small perifolicular, spiny
papules on extensor aspects
of extremities
 Manifest in those with greater
BMI
45
Hirsutism
 In obese women hirsutism may
result from an increase
production of testosterone
associated with visceral obesity
46
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
47
Striae Distensae (stretch marks)
 Close up view >
48
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
49
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.
50
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
51
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
52
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
53
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
54
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
55
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
56
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
57
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
58
Psoriasis
59
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
60
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
61
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
62
Treatment strategies
 Weight loss
 Improve Insulin Resistance
 Antibiotics
 Topical Steroids
 Steroids
 Compression therapy
 Antifungals
 Surgical intervention
63
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
64
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
65
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
66
Questions