The effect of obesity on skin disease and epidermal permeability barrier status in children

Abstract: Obese adult patients have many dermatoses, such as skin tags, candida infection, cellulite, and intertrigo, but only limited data have been published on obese children and the barrier function of their skin. Sixty‐five overweight and obese children (n = 40, BMI 85th–95th percentile; n = 25, BMI > 95th percentile) (aged 8–15; mean age 11.6) and 30 normal‐weight controls (aged 7–15; mean age 11.1) underwent a clinical evaluation and calculation of transepidermal water loss (TEWL). Higher weight percentile was associated with a higher incidence of some dermatoses. Skin tags were found in 40% of subjects in the 95th percentile and 2.5% of those in the 85th percentile. Striae distensae were observed in 32% of patients in the 95th percentile and 22.5% of those in the 85th percentile. Plantar hyperkeratosis was observed only in 20% of the 95th percentile subjects and was not observed in the other groups. TEWL values at the forearm site were significantly higher (p < 0.05) in obese children than in the control group, but no significant differences in TEWL values according to BMI level were found between the two groups of obese children. Degree of obesity influences the incidence of some associated dermatoses; skin tags, striae distensae, and plantar hyperkeratosis were more frequent in children in the 95th percentile of BMI. Obesity increases the TEWL rate, suggesting that obese children might become more easily overheated as weight increases, with more profuse sweating because of the thick layers of subcutaneous fat.     

The impact of obesity on skin disease and epidermal permeability barrier status

Background Obese subjects frequently show skin diseases. However, less attention has been paid to the impact of obesity on skin disorders until now. Objective The purposes of this study are: to highlight the incidence of some dermatoses in obese subjects and to study the water barrier function of the obese skin using transepidermal water loss (TEWL). Methods Sixty obese subjects and 20 normal weight volunteers were recruited. Obese group was further divided into three body mass index (BMI) classes: class I (BMI 30–34.9 kg/m²), class II (BMI 35–39.9 kg/m²) and class III (BMI 40 g/m²). All subjects attended dermatological examination for skin diseases. To assess barrier function, TEWL measurements were performed on the volar surface of the forearm using a tewameter. Results The results of this study showed that: (i) obese subjects show a higher incidence of some dermatoses compared with normal‐weight controls; in addition the dermatoses are more, frequent as BMI increases; (ii) the rate of TEWL is lower in obese subjects, than in the normal‐weight subjects, particularly in patients with intra‐abdominal obesity. Conclusion Specific dermatoses as skin tags, striae distensae and plantar hyperkeratosis, could be considered as a cutaneous stigma of severe obesity. The low permeability of the skin to evaporative water loss is observed in obese subjects compared with normal weight control. Although the physiological mechanisms are still unknown, this finding has not been previously described and we believe that this may constitute a new field in the research on obesity.     

Obesity and the skin: skin physiology and skin manifestations of obesity

Obesity is widely recognized as an epidemic in the Western world; however, the impact of obesity on the skin has received minimal attention. The purpose of this article is to highlight the association between obesity and dermatologic conditions. We review the impact of obesity on the skin, including skin physiology, skin manifestations of obesity, and dermatologic diseases aggravated by obesity. Obesity is responsible for changes in skin barrier function, sebaceous glands and sebum production, sweat glands, lymphatics, collagen structure and function, wound healing, microcirculation and macrocirculation, and subcutaneous fat. Moreover, obesity is implicated in a wide spectrum of dermatologic diseases, including acanthosis nigricans, acrochordons, keratosis pilaris, hyperandrogenism and hirsutism, striae distensae, adiposis dolorosa, and fat redistribution, lymphedema, chronic venous insufficiency, plantar hyperkeratosis, cellulitis, skin infections, hidradenitis suppurativa, psoriasis, insulin resistance syndrome, and tophaceous gout. We review the clinical features, evidence for association with obesity, and management of these various dermatoses and highlight the profound impact of obesity in clinical dermatology. LEARNING OBJECTIVE: After completing this learning activity, participants should be aware of obesity-associated changes in skin physiology, skin manifestations of obesity, and dermatologic diseases aggravated by obesity, and be able to formulate a pathophysiology-based treatment strategy for obesity-associated dermatoses.     

Skin manifestations of obesity: a comparative study

Background Obesity is one of the world’s biggest health problems nowadays. Little research has been done on the skin diseases that affect obese patients. Objective To study the prevalence of skin manifestations in obese patients compared with a control group of normal‐weight patients. Methods A total of 76 obese patients [body mass index (BMI) ≥30 kg/m²] and 73 with normal‐weight volunteers (BMI 18.5–24.9 kg/m²) were included in the study and had their complete medical history and skin examination evaluated by the same examiner. All patients were investigated for the presence of metabolic syndrome. Results The dermatoses that showed a statistically significant relationship with obesity, compared with the control group were: striae (P < 0.001), plantar hyperkeratosis (P < 0.001), acrochordons (P = 0.007), intertrigo (P < 0.001), pseudoacanthosis nigricans (P < 0.001), keratosis pilaris (P = 0.006), lymphedema (P = 0.002) and bacterial infections (P = 0.05). The presence of striae, pseudoacanthosis nigricans and bacterial infections were also found to be correlated with the degree of obesity. Conclusions Obesity is strongly related to several skin alterations that could be considered as markers of excessive weight. Skin care of obese patients deserves particular attention, not only because of the high prevalence of cutaneous alteration but mainly because many of these disorders are preventable and could be treated, improving patient’s quality of life.     

Dermatosis en pacientes con sobrepeso y obesidad y su relación con la insulina

IntroductionThe prevalence of obesity has increased worldwide in recent years. Some authors have described skin conditions associated with obesity, but there is little evidence on the association between insulin levels and such disorders.ObjectiveTo describe the skin disorders present in overweight and obese patients and analyze their association with insulin levels.Material and methodsThe study included nondiabetic male and female patients over 6 years of age who were seen at our hospital between January and April 2011. All the patients were evaluated by a dermatologist, who performed a physical examination, including anthropometry, and reviewed their medical history and medication record; fasting blood glucose and insulin were also measured. The patients were grouped according to degree of overweight or obesity and the data were compared using analysis of variance or the χ² test depending on the type of variable. The independence of the associations was assessed using regression analysis.ResultsIn total, 109 patients (95 adults and 13 children, 83.5% female) were studied. The mean (SD) age was 38 (14) years and the mean body mass index was 39.6 ± 8 kg/m². The skin conditions observed were acanthosis nigricans (AN) (in 97% of patients), skin tags (77%), keratosis pilaris (42%), and plantar hyperkeratosis (38%). Statistically significant associations were found between degree of obesity and AN (P = .003), skin tags (P = .001), and plantar hyperkeratosis. Number of skin tags, AN neck severity score, and AN distribution were significantly and independently associated with insulin levels.ConclusionsAN and skin tags should be considered clinical markers of hyperinsulinemia in nondiabetic, obese patients.     

Treatment of Striae Distensae with Nonablative Fractional Laser versus Ablative CO2 Fractional Laser: A Randomized Controlled Trial

Background

Striae distensae are atrophic dermal scars with overlying epidermal atrophy causing significant cosmetic concern. Although a variety of laser and light sources have been used for the treatment of striae distensae, to date no definite ''gold standard'' treatment modality has been determined.

Objective

To assess and compare the efficacy and safety of nonablative fractional photothermolysis and ablative CO₂ fractional laser resurfacing in the treatment of striae distensae.

Methods

Twenty-four ethnic South Korean patients with varying degrees of atrophic striae alba in the abdomen were enrolled in a randomized blind split study. The patients were treated with 1,550 nm fractional Er:Glass laser and ablative fractional CO₂ laser resurfacing. Each half of the abdominal lesion was randomly selected and treated three times at intervals of 4-weeks using the same parameters. Digital photography was conducted and skin elasticity and the width of the widest striae in each subject were measured at the baseline and 4 weeks after the final treatment. Clinical improvement was assessed by comparing pre- and post-treatment clinical photographs by two blinded physicians and participant satisfaction rates were evaluated. Skin biopsies were taken from three participants. All adverse effects were reported during the study.

Results

Although they do not statistically differ, both treatments with nonablative fractional laser and ablative CO₂ fractional laser showed a significant clinical and histopathologic improvement of striae distensae over pretreatment sites.

Conclusion

These results support the use of nonablative fractional laser and ablative CO₂ fractional laser as effective and safe treatment modalities for striae distensae of Asian skin. However, neither treatment showed any greater clinical improvement than the other treatment.     

Striae distensae of pregnancy. An in vivo biomechanical evaluation

Background and objective Striae distensae of pregnancy is a common finding. There is currently a lack of information about the rheological characteristics of such lesions. The purpose of this study was to compare the mechanical properties of striae distensae before and after delivery. Patients and methods A total of 79 primigravid entered the study. Rheological properties of skin were evaluated in vivo using a Cutometer® equipped with a 2-mm probe. Results Mechanical properties of striae distensae developing during pregnancy resembled those of the surrounding skin. By contrast, significant differences were yielded during post-partum. Extensibility of striae distensae was increased although parameters of elasticity remained normal. Conclusions Rheological properties of striae distensae of pregnancy vary in time. This might reflect the changes in hormones and in the mechanical stresses normally setting the skin under tension.     

Treatment of striae distensae combined enhanced penetration platelet-rich plasma and ultrasound after plasma fractional radiofrequency

Abstract

Background: Striae distensae (striae alba) is a challenging cosmetic problem for which various treatment modalities have been applied. However, the treatment of striae distensae has not been satisfactory. Objectives: This study was done to evaluate the effectiveness and the safety of enhanced penetration of platelet rich plasma with ultrasound after plasma fractional radiofrequency for the treatment of striae distensae. Subjects and method: Eighteen participants with striae distensae were treated with a Legato system (Alma Lasers, Israel) every two weeks for a total of four sessions. Thereafter, in order to enhance platelet-rich plasma penetration, ultrasound is applied. Clinical photographs were taken before first treatment and two months after the final treatment. Objective and subjective improvement scores were evaluated to demonstrate the efficacy. Abdominal skin biopsies were obtained from three individuals and histological changes were analyzed by light microscopy. Results: During the two months after the last treatment, the average width of the widest striae had decreased from 0.75 to 0.27 mm. In the objective assessment, 71.9% of the participants reported ‘‘good” or “very good’’ overall improvement. In the subjective assessment, and 72.2% of the participants reported ‘‘very satisfied” or “extremely satisfied’’ with overall improvement. The only reported side effect was post-inflammatory hyperpigmentation (11.1%). Conclusions: The plasma fractional radiofrequency and transepidermal delivery of platelet-rich plasma using ultrasound is useful in the treatment of striae distensae.     

Galvano-puncture and dermabrasion for striae distensae: a randomized controlled trial

Objective: To assess the effects of galvano-puncture (GG) and dermabrasion (DG) in reducing striae distensae in the gluteal region of women. Methods: This randomized, controlled, single-blind clinical trial was conducted at the UNIFAL-MG. Participants were 48 female who had striae distensae alba in the gluteal region. They were randomly divided in GG; DG; and Control Group (CG). The length and width of the largest striae were measured (in millimeters) using a caliper. The same striae were assessed before and after treatment. Infrared thermography was performed in the gluteal region to assess local microcirculation. Results: Intragroup analysis showed a significant reduction in the dimension of the striae between baseline and treatment session 10 in the GG and DG groups. Between-group analysis revealed a reduction in the width and length of the striae for both the GG and DG groups, but there were no significant differences between the two groups. When compared to the CG and the DG group, the GG group had significant improvements, as shown by thermography. Conclusion: Both GG and DG are effective in reducing striae length and width. However, only the thermography results showed significant differences between GG and control, and between GG and DG.     

Striae distensae after tension-requiring skin sutures

Three cases of striae distensae which developed along suture scars after skin surgery were described. The production of striae should be taken into consideration in surgery of the skin, especially in young woman.     

Changes in inflammatory markers correlated with increased testosterone after laparoscopic sleeve gastrectomy in obese Chinese men with acanthosis nigricans

Bariatric surgery is an effective method for severe obesity and its related comorbidities. This study was performed to explore the alterations of sex hormones and inflammatory markers following laparoscopic sleeve gastrectomy (LSG) among obese Chinese men with acanthosis nigricans (AN). Sixty‐five obese men who underwent LSG were enrolled, comprising simple obesity without AN (OB group, n = 20) and obesity with AN (AN group, n = 45). There were 31 healthy male controls with normal body mass index (BMI) included. Anthropometry data, inflammatory markers, sex hormones and metabolic parameters were compared preoperatively and 12 months post‐operatively. At baseline, patients in the AN group were associated with more severe metabolic abnormalities than the OB and control groups. Twelve months after surgery, AN patients obtained significant improvement in skin condition and reduction in AN score. BMI, fasting insulin (FINS), and Homeostatic Model Assessment of Insulin Resistance (HOMA‐IR), tumor necrosis factor‐α (TNF‐α) and total testosterone (TT) were significantly changed in both groups, while interleukin (IL)‐6, IL‐8 and C‐reactive protein were changed significantly only in the AN group. Moreover, FINS, HOMA‐IR, TT and IL‐6 levels were changed more in the AN group than those in the OB group. Multivariate regression analysis revealed that TT increase correlated significantly with reduction in FINS and HOMA‐IR in both groups, but correlated with changes in IL‐6 only in the AN group. In conclusion, LSG is effective in improving the skin condition of obese men with AN. The increased TT in AN patients correlated with amelioration of inflammatory state in addition to insulin resistance after LSG.     

Pattern of pediatric dermatoses in a tertiary care centre of South West Rajasthan

Background:

The evaluation for skin disorders forms an important component of primary health care practice for all including children. The prevalence of certain skin diseases in children can reflect status of health, hygiene, and personal cleanliness of a community.

Aims:

This study was planned to evaluate the magnitude of skin diseases, pattern of various dermatoses, factors contributing to these dermatoses and concurrent systemic disease among children up to five years of age.

Materials and Methods:

Consecutive 1000 children, aged up to five years, attending the Dermatology OPD of RNT Medical College and MB Government Hospital, Udaipur were the subjects of this study. A detailed general, systemic and cutaneous examination followed by relevant investigations were carried out. The findings were recorded in a proforma for analysis and interpretation of data.

Results:

One thousand twenty seven (1027) diagnoses were made in 1000 children. Etiological analysis revealed that majority (417; 40.60%) of dermatoses belonged to infection and infestation group followed by eczematous (358; 34.86%) and hypersensitivity (105; 10.22%) groups. Of the infection and infestation group, bacterial infection (141; 13.72%) was the most common entity followed by scabies (107; 10.42%), fungal (67; 6.52%), and viral infection (35; 3.40%).

Conclusion:

This study provides a preliminary baseline data for future clinical research. It might also help to assess the changing trends of pediatric dermatoses.     

Contractile forces generated by striae distensae fibroblasts embedded in collagen lattices

Striae distensae are characterized by linear, smooth bands of atrophic-appearing skin that are reddish at first and finally white. They are due to stretching of the skin, as in rapid weight gain, or mechanical stress, as in weight lifting. The pathogenesis of striae distensae is unknown but probably relates to changes in the fibroblast phenotype. In order to characterize striae distensae fibroblasts, alpha-smooth muscle actin expression and contractile forces were studied. Five healthy women with early erythematous striae and five healthy women with older striae were selected. Paired biopsies were taken from the center of lesional striae and adjacent normal skin. Fibroblasts were obtained by an explant technique and expanded in vitro in Dulbecco’s modified Eagle‘s medium. Contractile forces generated by fibroblasts in collagen lattices were measured with the Glasbox device developed in our laboratory. Alpha-smooth muscle actin expression was studied by immunofluorescence labeling of cells and by flow cytometry. Fibroblasts from early striae distensae were the richest cells in alpha-smooth muscle actin filaments and generated the highest contractile forces. Their peak contractile force was 26% greater than normal fibroblasts. There was a 150% higher level of alpha-smooth muscle actin content in fibroblasts from early striae distensae compared with fibroblasts from normal skin. In contrast, there was no significant difference in force generation between old striae fibroblasts and normal fibroblasts with cells expressing no alpha-smooth muscle actin. The contractile properties of fibroblasts from striae distensae varies depending on the stage of the disease. In early striae distensae, fibroblasts acquire a more contractile phenotype, corresponding to that of myofibroblasts.     

Skin tags and acanthosis nigricans in patients with hepatitis C infection in relation to insulin resistance and insulin like growth factor-1 levels

Background:

Skin tags (ST) are papillomas commonly found in the neck, axillae of middle-aged and elderly people

Aim:

Insulin and insulin-like growth factor (IGF-1) levels are affected by hepatitis C virus (HCV) infection and both of them may be implicated in the etiopathogenesis of ST and acanthosis nigricans (AN) through their proliferative and differentiating properties. So, the aim of this work was to evaluate the impact of HCV infection on ST and AN through the estimation of insulin resistance and IGF-1.

Materials and Methods:

Participants were arranged into four groups: (ST +ve / HCV +ve) 23 subjects, (ST+ / HCV -ve) 19 subjects, (HCV -ve / ST-ve) 20 subjects and (ST-ve /HCV +ve) 22 subjects. Age, ST size, color, number, AN, fasting glucose, fasting insulin, insulin resistance, IGF-1, HCV-antibodies (Ab) were recorded.

Results:

The mean number of ST in Group 1 was half the number of ST in Group 2 (11.0±9.3 / 22.3±14.0) (P=0.005). The difference in insulin resistance between the same groups was non-significant (13.1±10.6 / 9.0±5.5) (P=0.441) while the difference in IGF-1 was statistically significant (218.6±46.2 /285.4±32.8) (P=0.002). The multivariate logistic regression for the variables revealed that insulin resistance is the only factor affecting the occurrence of ST (OR=1.096, P=0.023). Multivariate regression analysis for the variables showed that HCV was borderline but not a significant factor affecting the number of ST (Beta=-0.409, P=0.053). The number of patients with AN was doubled in Group 2 in comparison to Group 1 but this was non significant 3(13%) / 6(32%) (P=0.2800).

Conclusion:

HCV is associated with a significant decrease in the ST number and in the serum level of IGF-1 together with an obvious decrease in the occurrence of AN. Our results may point to the entrant effect of insulin resistance and IGF-1 in ST and AN development. The current study suggests the evaluation of IGF-1-lowering agents in the control of ST and AN especially in the females with polycystic ovary and in the prevention of the recurrence of ST after surgical removal.     

Treatment of striae distensae using fractional ablative CO2 laser in skin types II-IV: a retrospective case series study

Striae distensae (SD) are atrophic dermal scars often found on abdomen, breasts, thighs, and hips of pregnant women. The strias’ self-healing without any intervention is a poor possibility. Till now, several lasers and light sources have been used for treatment of SD. However, there are no integrated therapeutic approaches determined for treatment of SD yet. So, in this study, the therapeutic effect of fractional ablative CO₂ laser in women with pregnancy was assessed. Twenty-four ethic Iranian women aged between 20 and 42 years with various severity of pregnancy SD enrolled in retrospective case series study. Participants with skin types II-IV were treated in four sessions with a one-month interval by fractional ablative CO₂ laser. The severity of striae was determined by Daveys scoring. Clinical improvement was assessed by comparing pretreatment and posttreatment clinical photographs based on global improvement scoring. The evaluation of clinical results showed that fractional ablative CO₂ laser was an effective treatment. Twenty of 24 (83.3%) patients showed improvement. Clinical improvement was affected by striae severity (P = 0.03). Also, there were no statistical differences between clinical improvements with skin types, striae scar severity, number of pregnancy, and striae location.     

Decreased expression of collagen and fibronectin genes in striae distensae tissue

Striae distensae are characterized by a thinning of connective tissue stroma to produce linear, atrophic-appearing skin. Excessive adrenocortical activity, genetic factors and inherited defects of connective tissues, etc. are important causative factors in the formation of striae distensae, but the basic aetiology is not known. Total RNA was extracted from skin biopsies of five patients with striae distensae. The expression of genes coding for types I and III procollagen, elastin, fibronectin and β-actin were studied and compared with those of four sex- and age-matched healthy individuals. The percentages of types I and III procollagen mRNA were 9.9 ± 2.9% (mean ± s.d.) and 10.6 ± 1.6%, respectively, of the corresponding controls. The value for fibronectin mRNA in striae distensae was 7.3 ± 1.8% of the control. The steady-state ratio fibronectin/type I procollagen mRNAs was 0.12 ± 0.01 in striae distensae and (MS ± 0.01 in the control. These observations suggest that expression of collagens, elastin and fibronectin genes are apparently decreased, and that there is a marked alteration of fibroblast metabolism, in striae distensae.     

An investigation of striae distensae using reflectance confocal microscopy

Background: Striae distensae, otherwise known as stretch marks, are white or red scar‐like streaks on the skin. Although they are not associated with adverse health outcomes, striae are associated with significant cosmetic morbidity. While they have been well characterised histopathologically, a non‐invasive method of microscopic lesion assessment of striae would be welcome. Methods: To gain insight into the small‐scale morphological features associated with striae we undertook an in vivo investigation of nine patients with striae alba and one with striae rubra utilising reflectance confocal microscopy (RCM). Results: Here we demonstrate that features known to be present using light microscopy, such as parallel collagen bundles in the dermis, and some features that are not well recognised by light microscopy, including distortion of dermal papillae, are demonstrable using RCM. Conclusions: Characterising the features of early and established striae distensae with confocal microscopy is an important foundation for future work. The potential ability to reliably identify the earliest pathological changes in skin in early lesions or before clinically manifest striae develop – a task facilitated by our findings – will increase the understanding of their pathogenesis and will have significant practical utility in monitoring the impact of future preventative interventions.     

A cross-sectional study of dermatological problems among differently-abled children

Background:

Differently-abled children may be particularly susceptible to skin disorders either as a direct consequence of their disability or due of lack awareness regarding personal and environmental hygiene.

Aim:

To study the prevalence of skin problems in differently-abled children.

Materials and Methods:

A total of 122 differently-abled children in two special schools were examined for this study. Details regarding the disabilities were obtained from the school records.

Results:

More than half (53.2%) of the children had skin problems. Infections and infestations, acne, and dermatitis were the common dermatoses encountered in the present study.

Conclusion:

Periodic skin examination is of vital importance for all people with disabilities to reach a proper diagnosis and to offer treatment. Health education for teachers and parents on maintenance of sound personal hygiene and a clean environment is also recommended.     

Clinical features and risk factors for striae distensae in Korean adolescents

BACKGROUND: Despite the high prevalence of striae distensae, clinical studies are few in number, and their pathophysiology still obscure. OBJECTIVES: To determine the prevalence and clinical characteristics of striae distensae that occur in Korean adolescents, and to correlate their clinical features with family history, other dermatological conditions, and body measurements. METHODS: One hundred and fifty-seven healthy Korean students, aged 15 to 17, were studied. A questionnaire and physical examination were employed to assess the subjects' past and family history, and the distribution, clinical features and severity of striae distensae. RESULTS: Striae distensae were present in 131 subjects (83.4%). Ninety-four (88.2%) of 109 male and 37 (77.1%) of 48 female subjects were affected. The striae were white in colour in 69.5% and asymptomatic in most of the subjects. They developed at an average age of 13.8 years. Family history was present in 18 subjects (11.5%). Seborrhoea of the face was positively correlated (P < 0.035) with striae distensae, and atopic dermatitis negatively correlated (P < 0.001). In both sexes, the buttock was the most prevalent area of striae development, followed by the lower back and knee in boys and by the thigh and calf in girls. Striae were significantly more common on the thigh of girls and on the knee of boys. CONCLUSIONS: Our results indicate that striae distensae are a common skin condition that occurs early in puberty regardless of gender, and that they have a different anatomical distribution and relationship with body measurements in each gender.