Research Article, Clin Dermatol Res J Vol: 2 Issue: 2
Skin Complications of Obesity: Controlled Prospective Study
*Corresponding Author : Esam Elshimi
Hepatology and Gastroenterology department-National Liver Institute Menoufia University, Egypt
E-mail: [email protected]
Received: July 25, 2017 Accepted: September 21, 2017 Published: September 28, 2017
Citation: Mohammad NE, Elshimi E, Galal SA, Mohammad MH, Kotb HG, et al. (2017) Skin Complications of Obesity: Controlled Prospective Study. Clin Dermatol Res J 2:2.
Introduction: Obesity is a worldwide public health burden with an increasing prevalence. It is mainly attributed to interactions between diet, sedentary life and genetic predisposition. A chronic accumulation of adipose tissue found in obesity is associated with long term consequences such as diabetes, cardiovascular diseases, hypercholesterolemia, etc. Many skin changes have been reported in obese patients.
Aim of the work: was to clarify various skin changes and diseases related to obesity.
Patients and methods: It was carried out from May 2015 to August
2016; 100 (50 males, 50 females) adult patient of age (18-60) years old with body mass index (BMI) ≥ 30 kg/m2] and one hundred (50 males, 50 females) adult control of age (18-60) years old (BMI 18.5-24.9 kg/m2) were included in the study. Serum lipid profile, liver and renal functions, fasting and post prandial blood sugar and clinical examination were done to exclude hypertension and other cardiovascular diseases.
Result: significantly more skin diseases were found in obese patient than control; plantar hyperkeratosis, Acanthosis nigricans, Scalp scale (dandruff), Skin tags, Striae cutis, Intertrigo, Callosity, Candida that strongly correlated the degree of obesity. Many patients had more than two conditions. The most frequent combination observed were Acanthosis nigricans with skin tags, Striae and varicosity are significantly more among obese females than obese males.
Conclusion and recommendation: obese patients experienced more skin diseases than non-obese. Obese females have more skin diseases than obese males. Obese patients with skin diseases should reduce their weight to improve their skin lesions.
Keywords: Skin diseases; Obesity; Acanthosis nigricans
Obesity is defined as a state of excess adipose tissue mass. This condition usually translates into excessive body weight. It can develop regardless the body weight; body builder can develop remarkable overweight without excessive body fatness (Table 1) [1,2].
|BMI (kg/m2)||Obesity Class||Disease Risk* (Relative to Normal Weight and Waist Circumference)|
|Men ≤ 40 in (≤ 102 cm)
Women ≤ 35 in (≤ 88 cm)
|>40 in (> 102 cm)
>35 in (>88 cm)
|35.0-39.9||II||Very High||Very High|
|Extreme Obesity||≥ 40||III||Extremely High||Extremely High|
Table 1: Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risk* .
Obesity is defined as a measure of Body Mass Index (BMI) which is a ratio of weight to height that is calculated by the following formula:
BMI=weight (kg) ÷ height (m)
There are 500 million adults worldwide who are obese, only 115 million of them; reside in developing countries. Obese and overweight are more prevalent than underweight, a pattern to which the World Health Organization (WHO) refers as “globesity” .
Significantly many factors are affecting the body weight which includes: genetic, metabolic, behavioral, environmental, cultural, and socioeconomic. However behavioral and environmental factors are the largest contributors .
Obesity has negative impact on various body systems including cardiovascular systems, lung function, joints, fertility, glucose metabolism and skin.
Obesity has many harmful effects on skin including: abnormalities in skin barrier, sebaceous glands and sebum, sweat glands, lymphatic system, collagen function structure and function, wound healing, microcirculation and microcirculation and subcutaneous fat .
Many dermatologic changes and diseases are found to be linked with obesity such as Acanthosis nigricans, skin tages, Keratosis pilaris, signs of hyperandrogenism and hirsutism, striae distensae, lymphedema, chronic venous insufficiency, plantar hyperkeratosis, hidradenitis suppurativa, psoriasis, insulin resistance syndrome, and tophaceous gout, higher rates of wound healing complications and hernia recurrence rates following complex abdominal wall surgeries .
Obesity has been proved to increase the incidence of cutaneous infections; candidiasis, intertrigo, candida, furunculosis, erythrasma, tinea cruris, folliculitis, cellulitis, necrotizing fasciitis and gas gangrene. Skin and soft tissue infections (SSTIs) are prevalent in the obese population with rising trend expected .
On the other hand bariatric surgery with massive weight loss resulting in skin redundancy, which in turn leads to pain, skin problems, cosmetic discomfort and psychosocial troubles .
Patients and Methods
This study was done at Alzahraa and Elfayoum university hospitals from May 2015 to August 2016. One hundred (50 males and 50 females) adult patient of age group between 18-60 years old with [body mass index (BMI) ≥ 30 kg/m2] and one hundred (50 male, 50 female) adult control of age group between 18-60 years old (BMI 18.5- 24.9 kg/m2) were included in the study.
Obesity with chronic disease (DM, liver and kidney disease)
All patients were examined consecutively at dermatology clinic while controls were examined at ophthalmology and dentist clinic.
Demographic and clinical data such as age, sex, occupation, education, special habits (such as smoking, drug addiction, and physical activity), family history of obesity in 1st and 2nd degree relatives and family history of skin diseases related to obesity of obese and non-obese were recorded.
A thorough general physical, systemic and cutaneous examination was performed on each patient. The height of each participant was measured to the last 0.1 cm by having him/her stand straight with his/ her back against the wall and marking the point of the top of his/her head without wearing shoes. Waist circumference was measured by encircle the tape between (the midpoint between the lowest rib and the iliac crest) and the umbilicus. Weight was recorded to the last kg with a mechanical balance device. BMI was calculated as weight in kilograms divided by height in meters squares (kg/m2) was used as the index of adiposity. Patients were categorized into three grades: Grade I (BMI 30.0- 34.9); Grade II (BMI 35.0- 39.9) and Grade III, morbidly/ severely obese (BMI ≥ 40).
Blood investigations such as fasting and postprandial blood sugar levels, liver and kidney function tests and serum lipid profile were done for each patient.
Data collected were reviewed. Coding and statistical analysis of collected data were analyzed using SPSS program (statistical package of social science) version 17.
• Mean and standard deviation (SD) were calculated to measure central tendency and dispersion of quantitative data.
• Frequency of occurrence was calculated to measure qualitative data.
Comparison between groups was done using:
• Chi- square- test(X2): for comparison of qualitative data.
• Student t test: for comparison of quantitative data between two groups.
The level of significance was taken at P- value of<0.05.
The results were represented in Tables 2 and 3.
|Mean ± SD||1.70 ± 0.07||1.69 ± 0.09||t=0.34||0.735|
|Mean ± SD||102.62 ± 18.40||60.37 ± 8.57||t=21.14||0.000*|
|BMI (kg/ m2)|
|Mean ± SD||37.42 ± 6.12||22.07 ± 1.82||t= 25.00||0.000*|
|Mean ± SD||131.24 ± 94.01||80.22 ± 1.08||t= 21.63||0.000*|
Table 2: Parameters of the studied group as mean ± SD.
|Mean ± SD||35.96 ± 11.76||38.79 ± 11.18||t=1.74||0.083|
|Range of age||(18-60)years||(18-60)years|
|Unskilled White Collar||10||10||8||8|
|Skilled White Collars||20||20||10||10|
|Single||28||28||36||36||X2 = 2.19||0.333|
|History of regular physical activity|
|No||21 79||21 79||97||97|
Table 3: Sociodemographic profile of the studied group.
Table 4 demonstrates distribution of skin manifestations among the studied group. It was noticed that the presence of plantar hyperkeratosis was (59%,20%), neck Acanthosis nigricans (48%,0%), flexures Acanthosis nigricans(47%, 0%), striae distensae (45%, 15%), intertrigo (41%, 10%), neck skin tags (30%, 10%), callosity (31%, 7%), web macerations (25%, 5%), scalp scale(dandruff) (38%, 25%), and Varicose veins (18%, 6%) of cases and control group respectively, this difference was statistically significant (P value<0.05). There were (51%, 25%) had scalp hair fall (thinning), (24%, 15%) had acne vulgaris and (4%, 2%) had hirsutism as regards cases and control group respectively, this difference was statistically non-significant (P value>0.05).
|Studied groups Variables||Cases (obese) No.=100||%||Control (non-obese) No=100||%||Significance Test||P-value|
|Scalp hair fall|
|Neck Acanthosis nigricans|
|Neck skin tags|
|Flexures Acanthosis nigricans|
|Flexures skin tags|
Table 4: Distribution of some skin manifestations among the studied groups.
Table 5 illustrates relationship between skin manifestations of obesity to grades of obesity. It was observed that the presence of neck Acanthosis nigricans was (28%, 47%, 80%), flexures Acanthosis nigricans (30.7%, 41.6%, 80%), striae distensae (33%, 41%, 68%), intertrigo (20.5%, 30.5%, 88%), neck skin tags (18%, 25%, 60%), callosity (15.3%, 41.3%, 52%) and varicose veins (15%, 33.3%, 24%) in grades (I, II, III) of obesity respectively, this difference was statistically significant (P value<0.05).
|GradeI No=39||%||Grade II No=36||%||Grade III No=25||%||Significance Test||P-value|
|Scalp hair fall|
|Neck Acanthosis nigricans|
|Neck Skin tags|
|Flexures skin tags|
Table 5: Relationship between skin manifestations of obesity to grades of obesity
Plantar hyperkeratosis constituted (51%, 55%, 76%), scalp scale (dandruff) (33.3%, 38%, 44% ) scalp hair fall (thinning) (56%, 33.3%, 40%), acne vulgaris (23%, 33.3%, 12%), hirsutism (0%, 5.5%, 8%) and web macerations (17%, 22%, 40%) in grades (I, II, III) of obesity respectively, this difference was statistically non-significant (P value>0.05).
Table 6 illustrates comparison between obese males and obese females as regards skin manifestations of obesity. It was found that presence of neck Acanthosis nigricans (36%, 60%), striae distensae (32%, 48%), varicose veins (4%, 32%) and hirsutism (0%, 8%) among obese males and obese females respectively, this difference was statistically significant (P .value<0.05).
|Scalp hair fall|
|Neck Acanthosis nigricans|
|Neck Skin tags|
|Flexures skin tags|
|Web macerations Candida|
Table 6: Comparison between obese males and females as a regards skin manifestations of obesity.
Intertrigo represented (42%, 40%), plantar hyperkeratosis (52%, 66%) flexures Acanthosis nigricans (40%, 34%), neck skin tags (24%, 36%), callosity (32%, 30%), web macerations (20%, 30%), scalp scale (dandruff) (38%, 38%), and scalp hair fall (thinning) (38%, 64%) and acne vulgaris (24%, 24%) among obese males and obese females respectively, this difference was statistically non-significant (P value>0.05).
Table 7 illustrate The most common skin manifestations in order of frequency among our patients were plantar hyperkeratosis, scalp hair fall, Acanthosis nigricans, striae cutis distensae, intertrigo, scalp scale (dandruff), callosity, skin tags, web macerations, acne vulgaris, varicose veins and hirsutism.
|Scalp hair fall||51||51%|
|Scalp Scale (dandruff)||38||38%|
Table 7: The most common skin manifestations in order of frequency among our patients.
Table 8 demonstrates family history of obesity among relatives of the studied groups as regards obesity and skin diseases related to obesity. It was found that (53%, 51%) of cases had family history of obesity in 1st and 2nd degree relatives respectively compared to (38%, 29%) of control had family history of obesity in 1st and 2nd degree relatives respectively, this difference was statistically significant (P value< 0.05).
|Cases No.=100||%||Control No.=100||%||Significance Test||P-value|
|Family history of obesity in 1st degree relatives|
|Family history of obesity in 2nd degree relatives|
|Family history of skin diseases related to obesity|
Table 8: Family history of obesity among relatives of the studied groups.
It was found that (51%) of cases had family history of skin diseases related to obesity while among control group was (7%), this difference was statistically significant (P value< 0.05).
Table 9 demonstrates chronic conditions among studied groups, it was noticed that no one had liver or kidney diseases in both groups. Also only (1%) of cases and control suffered of heart diseases.
|Studied groups Variable||Cases No.=100||%||Control No.=100||%||Significance Test||P-value|
|History of heart disease|
|History of hypercholesterolemia|
Table 9: Chronic conditions among the studied groups.
It was found that (27%) of cases had hypertension compared to (8%) of control group, this difference was statistically significant (P Value< 0.05). History of hypercholesterolemia represented as (23%) of cases and (0%) of control group, this difference was statistically significant (P Value<0.05).
Table 10 demonstrate biochemical parameters as (mean ± SD) of studied groups, Investigations to exclude diabetes mellitus shows that the mean fasting blood Sugar of cases was (95.83 ± 8.02) mg/ dl, mean postprandial blood Sugar of cases (129.21 ± 9.34) mg/ dl and Glycated HB of cases (5.82 ± 0.78)% compared with (94.04 ± 8.93) mg/d, (128.04 ± 8.94) mg/dl and (5.79 ± 0.62)% for control group respectively ,this difference was statistically non-significant (P Value>0.05).
|Cases No.=100||Control No.=100||Significance Test||P-value|
|Fasting Blood Sugar(mg/dl)||95.83 ± 8.02||94.04 ± 8.93||1.49||0.138|
|Postprandial Blood Sugar(mg/dl)||129.21 ± 9.34||128.04 ± 8.94||0.90||0.367|
|Glycated Hb (%)||5.82 ± 0.78||5.79± 0.62||0.29||0.772|
|Urea((mg/dl)||31.65 ± 6.53||31.90± 4.78||0.30||0.762|
|Creatinine(mg/dl)||0.85 ± 0.17||0.84 ± 0.15||0.45||0.649|
|SGPT(units/dl)||30.60 ± 8.64||29.28 ± 4.84||1.33||0.185|
|SGOT(units/dl)||30.38 ± 8.32||28.78 ± 5.76||1.57||0.117|
|Cholesterol(mg/dl)||212.88 ± 37.43||168.81 ± 17.56||10.65||0.000*|
|Triglyceride(mg/dl)||193.67 ± 32.93||169.66 ± 18.54||6.35||0.000*|
|HDL(mg/dl)||35.04 ± 5.04||40.20 ± 2.86||8.89||0.000*|
|LDL(mg/dl)||139.06 ± 37.54||94.92 ± 15.70||10.84||0.000*|
|VLDL(mg/dl)||38.59 ± 5.29||34.33 ± 3.75||6.56||0.000*|
Table 10: Biochemical parameters as (mean ± SD) of the studied groups.
Kidney function tests of studied groups reveals that mean level of blood urea of cases was (31.65 ± 6.53) mg/dl, while in control group was (31.90 ± 4.78) mg/dl. Mean level of Creatinine of cases was (0.85 ± 0.17) mg/dl, compared with (0.84 ± 0.15) mg/dl in control group, this difference was statistically non-significant (P Value>0.05). Liver functions tests of studied groups illustrates that mean level of SGPT of cases was (30.60 ± 8.64) units/dl, while was (29.28 ± 4.84) units /dl in control group. Mean level of SGOT cases was (30.38 ± 8.32) units/dl, compared to (28.78 ± 5.76) units /dl in control group, this difference was statistically non-significant (P Value>0.05).
The mean levels of cholesterol of obese were (212.88 ± 37.43) mg/ dl, triglyceride (193.67 ± 32.93) mg/dl, High density lipoprotein HDL (35.04 ± 5.04) mg/dl, low density lipoprotein LDL (139.06 ± 37.54) mg/dl and very low density lipoprotein VLDL (38.59 ± 5.29) mg/ dl. All of them in comparison with non-obese were mean levels of cholesterol (168.81 ± 17.56) mg/dl, triglyceride (169.66 ± 18.54) mg/ dl, HDL (40.20 ± 2.86) mg/dl, LDL (94.92 ± 15.70) mg/dl and VLDL (34.33 ± 3.75) mg/dl this difference was statistically significant (P Value<0.05) (Table 11).
|Scalp hair fall||0.031||0.669|
|Neck Skin tags||0.232(**)||0.001|
|Flexure skin tags||0.40(**)||0.000|
Table 11: Correlation Coefficient of variables with respect to p-value.
The World Health Organization (WHO) defines obesity as “an abnormal or excessive fat accumulation in adipose tissue, to the extent that health is impaired”. In developed countries; it has been stated that the increase in carbohydrate at the expense of fat has contributed to the obesity epidemic. In China, obesity rates have increased rapidly in parallel with a transition from the traditional low fat, high carbohydrate diet to a diet relatively high in fat and less in carbohydrate. The currently accepted classification of obesity for epidemiological purposes defines overweight at body mass index (BMI) levels greater than 25 kg/m2 and obesity beginning at BMI of 30 kg/m2 .
A number of systemic diseases chronic as well as acute lifethreatening- are related to obesity including: coronary heart disease, hypertension, diabetes, hyperlipidemia, osteoarthritis, sleep apnea, cancer breast, endometrial and colon, gallbladder disease, and severe pancreatitis .
Obesity has been linked to many metabolic diseases which in turn associated with some skin diseases; Acanthosis nigricans and skin tags can be signs of insulin resistance, xanthoma and xanthelasma are signs of dyslipidemia. Diabetic patients display numerous more or less specific dermatoses .
Our study was conducted between May 2015 to August 2016 one hundred (50 males, 50 females) adult obese patient of age (18- 60) years old with body mass index (BMI) ≥ 30 kg/m2 and one 100 (50 males, 50 females) healthy adult control of age (18-60) years old (BMI 18.5-24.9 kg/m2) were included in a case–control study to assess various skin changes and diseases associated with obesity.
In this study we compare 100 (50 males, 50 females) adult obese patients of age (18-60) years old and 100(50 males, 50 females) healthy adult control of age (18-60) years old regarding skin manifestations of obesity.
We found that plantar hyperkeratosis, Acanthosis nigricans, scalp scale (dandruff) skin tags, striae, intertrigo, callosity, candida and extremities varicosity show strong correlation with obesity and its degree.
Plantar hyperkeratosis and callosity are the most common skin condition found in our study because occupational exposure (blue collars e.g. cleaners and farmers). Development of plantar hyperkeratosis may be regarded as a physiologic response to mechanical trauma, as obese patients have increase forefoot width and higher plantar pressures during walking and standing.
The prevalence of Acanthosis nigricans in this study is lower than reported for the USA and Brazil because exclusion criteria of our patient to be free from diabetes, those obese patients exhibited Acanthosis nigricans with elevated plasma insulin levels.
Acanthosis nigricans is now considered as a reliable cutaneous marker of hyperinsulinemia in obese individuals. In obese patient’s Acanthosis nigricans may be the result of inappropriate simultaneous activation of distinct tyrosine kinase growth factor receptors due to excessive levels of circulating insulin Hyperinsulinemia increases the production of ovarian androgens, which may lead to associated hirsutism and acne vulgaris .
Striae were prevalent in obese patients in this study and were correlated with the increase in degree of obesity which may be related to excessive tension on the skin caused by excessive weight.
Skin tags (acrochorda) were present in obese patients that were positively correlated with the severity of obesity. Multiple skin tags are frequently associated with non-insulin dependent diabetes mellitus and obesity in a case-control study suggested that skin tags could be a more valuable marker of carbohydrate in-tolerance and diabetes mellitus than obesity .
Intertrigo and candida were more prevalent in patients of our study than those reported in Kuwait because this study was done in Egypt among a group of patients of low to moderate socio-economic state with lake of air conditions. The greater amount and depth of the areas of skin rubbing leads to the increase of moisture and friction, and it appears to contribute to the development of fungal and bacterial infections in obese.
Scalp scales were prevalent in patients group than in control group. There are no epidemiologic studies examining the relationship between obesity and sebum production. This was in agreeing with many authors [12-15].
This study illustrated that acne, keratosis pilaris, psoriasis and hirsutism were not found to have significant correlation with obesity (p. value>0.05) but they are more prevalent in obese than control.
The prevalence of acne is high (24%) but it was not statistically significant in our study because acne was found to be high also in control (15%)This was in agree with .
In our study we found that family history of obesity in 1st and 2nd degree relatives, family history of skin disease related to obesity is statistically significant among obese in comparison with control as obesity is inherited in families that their members share the same life style so susceptibility for developing skin manifestations related to obesity in same families are also increased.
Our study showed that history of hypertension and history of hypercholesterolemia are statistically significant among obese in comparison with control because hypertension and hypercholesterolemia are complications of obesity. In our study we found that face hirsutism, striae and varicosity are significantly more in obese females than obese males because excessive hair face in males is called hypertricoss not hirsutism, striae and varicosity because of weak mesnchyema of females.
Conclusion and Recommendation
Obese patients experienced more skin diseases than non-obese. Obese females have more skin diseases than obese males. Obese patients with skin diseases should reduce their weight to improve their skin lesions.
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