JEADV
DOI: 10.1111/jdv.12820
REVIEW ARTICLE
Bariatric surgery – a dermatologic perspective U. Wollina,1,* M. Dreßler,2,3, T. Lohmann3,4 1
Departments of Dermatology and Allergology, Hospital Dresden Friedrichstadt, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany 2 General and Visceral Surgery, Hospital Dresden-Neustadt, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany 3 Competence Centre for Adipositas and Metabolic Surgery, Hospital Dresden-Neustadt, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany 4 Department of Internal Medicine, Hospital Dresden-Neustadt, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany *Correspondence: U. Wollina. E-mail: [email protected]
Abstract Bariatric surgery has become a standard option in morbid obesity for patients not responding to conventional treatment. A major and stable weight loss can be achieved. Since obesity and weight loss may affect skin diseases, we performed this review to analyse the impact of bariatric surgery on a number of skin diseases. We categorized the skin diseases into three main groups: (i) diseases with a possible benefit from bariatric surgery, (ii) diseases that may develop after bariatric surgery and (iii) diseases that may persist. We hope that dermatologists will achieve an updated knowledge of benefits and possible hazards of this type of surgically induced weight loss. Received: 30 July 2014; Accepted: 1 October 2014
Conflicts of interest None declared.
Funding sources None declared.
Introduction Bariatric surgery (BS) is the arrange of surgical procedures to treat morbid obesity. The most commonly used techniques world-wide are laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (SG). In contrast to LAGB, both RYGB and SG improve insulin sensitivity and gut hormone responses, which can lead to a remission of type 2 diabetes mellitus. The major goal, however, is a stable weight loss to combat excessive obesity. About 15 BMI units can be achieved on average within 2 years after BS. The second important goal of BS is the treatment or prevention of metabolic syndrome.1,2 Since obesity is associated with a number of skin diseases while others show an increased risk of metabolic syndrome and its cardiovascular complications, we performed a literature search to evaluate the impact of BC on various skin diseases. In addition, we searched for dermatologic side-effects caused by BC. A literature research using PUBMEDâ January 2000 to June 2014 choosing the terms “bariatric surgery” AND “skin diseases” revealed 412 references. We will analyse the findings according
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to skin disorders. We will organize this review into skin diseases that may potentially benefit from BS, those who are unresponsive, and skin disorders that may occur after BS.
Skin diseases that may benefit from bariatric surgery Acne inversa/Hidradenitis suppurativa
Acne inversa is a chronic relapsing inflammatory disorder affecting the large body folds, i.e. axillaries, submammary region, groins, outer genitals and anal fold (Fig. 1). The disease affects about 1% of the adult population. Smoking and obesity are well-known risk factors. Treatment for milder types is by medical drugs, whereas advanced cases eventually demand surgery.3 A retrospective questionnaire study in Denmark analysed preand post-BS data of 45 patients with acne inversa. The prevalence of acne inversa among obese patients seems to be increased. In those who underwent BS with a weight loss of at least 15% both the severity and the number of body sites affected was reduced. A remission of the disease was reported by 35% of patients.4
© 2014 European Academy of Dermatology and Venereology
Wollina et al.
2
Intertrigo
Psoriasis
Intertrigo is a superficial inflammatory dermatitis occurring in the large skin fords as a result of moisture, friction and lack of ventilation. It is related to obesity, focal hyperhidrosis and diabetes. The more intense the inflammation is, the higher the risk of breakdown of skin barrier function. This opens the route for bacterial, fungal und viral infections (Fig. 2).5 Since severity of intertrigo is related to the degree of obesity6 body mass reduction by BS may improve intertrigo. Since body mass reduction is accompanied by skin laxity, the positive effect of BS may be seen only after body lift (Fig. 3).
Psoriasis is a chronic relapsing inflammatory Th1/Th17 disease affecting 2–3% of the World population (Fig. 4). Extracutaneous manifestations of the disease include psoriatic arthritis, iridocyclitis and others. There is evidence of an association between severe psoriasis and metabolic syndrome and obesity.9 Obesity is often associated with a resistance to treatment.10 BS-induced weight loss may decrease psoriasis severity.11
Polycystic ovary syndrome
Women suffering from polycystic ovary syndrome are seen frequently in BS (about 30% of female patients). Most of these patients report an improvement of hirsutism and fertility within the first year after BS.7,8
Figure 3 Severe erosive intertrigo.
Figure 1 Inverse acne of the groin, Hurley grade II.
Figure 2 Mild erosive intertrigo with post-inflammatory hyperpigmentation.
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Figure 4 Patient after successful bariatric surgery (loss of >70 kg bodyweight) but skin laxity.
© 2014 European Academy of Dermatology and Venereology
Bariatric surgery
In a retrospective case series of 10 obese psoriasis patients the outcome after BS was analysed with a focus on skin disease. Of these 10 patients eight had RYGB and two LAGB procedures. Six months after BS 70% of patients still had a stable remission of psoriasis and three patient treated previously with systemic drug had discontinued their medication. The quality of life improved markedly from 14.9 6.8 before surgery to 5.0 6.3 after BS.12 Analysing the available literature Sako et al. came to the conclusion, that BS ‘may one be an option for obese patients with refractory psoriasis’.13
3
Bozkurt et al. reported on a 32-year-old woman with diabetes mellitus type 2 and ulcerated necrobiosis lipoidica who, after BS, achieved a complete remission of her skin disease and of diabetes.14
Skin diseases that developed after bariatric surgery The number of patients who developed skin disorders after BS is rather small. However, such cutaneous disorders may be an alarming sign demanding immediate medical actions. We have
Ulcerated necrobiosis lipoidica diabeticorum
Necrobiosis lipoidica is a granulomatous skin disease usually of the lower legs affecting both diabetics and non-diabetics.
Figure 7 Multilocal pyoderma gangrenosum of the abdominal wall.
Figure 5 Extensive plaque-type psoriasis.
Figure 6 Generalized xerosis cutis with features of asteatotic dermatitis.
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Figure 8 Large abdominal fold due to sagging 2 years after bariatric surgery.
© 2014 European Academy of Dermatology and Venereology
Wollina et al.
4
Figure 9 A 43-year-old female patient 2 years after sleeve gastrectomy (loss of bodyweight >60 kg) with pubic lipo-lymphoedema.
Figure 11 Two years after sleeve gastrectomy with an excellent outcome. The remaining abdominal fold, however, demonstrates persistent localized lymphoedema of the elephantiasis nostras type.
to differentiate between short-term adverse effects (within the first 2 years after BC) and long-term adverse effects. Most disorders due to vitamin or trace element deficiencies are seen later. Acquired acrodermatitis enteropathica
Zinc deficiency lead to a characteristic clinical triad: Dermatitis, diarrhoea and alopecia. The dermatitis is preferentially located periorifically. The treatment of choice is zinc substitution. Zinc deficiency may develop after BS in the long-term run in case of inadequate zinc substitution. Cases with acquired acrodermatitis enteropathica after BS have been observed.15–17 Acquired vitamin A deficiency
Figure 10 A 31-year-old male patient with 245 kg bodyweight before bariatric surgery.
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Vitamin A deficiency is a possible complication after BS. Patients develop a severe xeroderma (Fig. 5) and a dry eye syndrome, but more important hearing loss. There is a need of vitamin A substitution in such patients.18 A typical although non-specific cutaneous manifestation if phrynoderma – multiple follicular hyperkeratosis on the
© 2014 European Academy of Dermatology and Venereology
Bariatric surgery
5
Table 1 Obesity and skin disease Diagnosis
Effect(s) of obesity
References
Acne inversa/hidradenitis suppurativa
Increased severity
35, 36
Acanthosis nigricans benigna
Major risk factor
37
Acrochordons (skin tags)
Risk factor for multiple tags
38, 39
Acne
Increased severity
40
Acne keloidalis nuchae
Risk factor
41
Abdominal elephantiasis
Strong risk factor
32
Atopic dermatitis
Higher prevalence
42, 43
Hirsutism and polycystic ovary syndrome
Obesity is a major cause of hormonal imbalance in females
44
Intertrigo and skin infections
Increased risks
Male-pattern alopecia
Increased severity
45
Plantar hyperkeratosis
Risk factor
46
Pressure ulcers
Increased risk
47
Psoriasis
Decreased response to treatment
10
Decreased length of remission
48
Risk factor in case of rapid weight gain
46
Striae distensae
Skin laxity 6
extensor surfaces of legs and arms. When phrynoderma is associated with xerophthalmia and nyctalopia, this is suggestive for vitamin A deficiency.19 Scurvy
Scurvy is a disease caused by vitamin C deficiency. It is a multiorgan disease, when untreated leading to death. The most common symptoms are bruising, mucosal changes including scorbutic siderosis, ecchymotic purpura, haemorrhagic ulcers and pedal oedemas. Inability to walk is a late symptom.20 Scurvy is a rare complication after BR. A 36-year-old woman, who developed bullae, loose skin and haemorrhagias after BS was diagnosed with scurvy.21 Alopecia
Diffuse alopecia especially in women after BS may be an indicator for deficiencies of vitamins and trace elements. A study investigated 87 females after BS (RYGB or SG). Indeed those females with a more severe hair loss after BS had lower values of zinc and iron, demanding for substitution. And there is a second type of temporary alopecia seen shortly after BC caused by protein deficiency.22,23 PASH syndrome and other neutrophilic dermatoses
The triad of pyoderma gangrenosum, acne and suppurative hidradenitis (acne inversa) is known by the acronym PASH syndrome (Fig. 6). PASH syndrome belongs to the heterogeneous
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group of autoinflammatory disorders. A single case has been reported by Marzano et al.24 Bowel bypass syndrome, also known as bowel-associated dermatitis arthritis syndrome, can be a complication after BS, in particular after RYGB. The clinical presentation includes ulcerating lesions and pustules on arms and legs, polyarthralgia, fever and joint effusions. Skin biopsies from the cutaneous lesions reveal a superficial to mid-dermal neutrophilic infiltrate that resembles Sweet syndrome. Antibiotics, glucocorticosteroids and colchicine have been used for treatment.25,26 Bacterial overgrowth in blind intestinal loops seems to be a possible trigger for neutrophilic dermatoses.27
After successful BS an acquired skin laxity (cutis laxa) can often be observed. Cutis laxa is characterized by redundant, sagging and inelastic skin (Fig. 7).28 Histologic investigations demonstrated a poorly organized collagen structure, elastin degradation and focal scar formation within macroscopically normal areas.29 Loss of collagen with insufficient collagen network has also been confirmed by other groups but not the loss of elastin.30,31 Various disorders with a questionable relation to bariatric surgery
In their excellent review on BS and skin disease, Halawi et al. listed a number of case reports. All of these are single cases, sometimes with the eruption of skin diseases several years after surgery. Their list includes various types of vasculitis (HenochSch€ onlein purpura, necrotizing vasculitis with arthritis, nodular non-suppurative panniculitis), cryoglobulinaemia with renal failure and dermatitis herpetiformis. All of these complaints started at least 1.5 to maximum of 5 years after surgery.27
Skin diseases that persist after bariatric surgery There are some disorders which develop during the years of morbid obesity that will not improve after successful BS. Patients who had abdominal lymphoedema may still show disturbances of lymphatic flow (Fig. 8). The subgroup of patients with fibrotic transformation of subcutaneous tissue into abdominal elephantiasis nostras will only partially improve (Fig. 9).32 Such patients might benefit from a debulking surgery.33 Such patients are at risk of developing angiosarcoma later.34
Follow-up investigations in patients after bariatric surgery to prevent nutritional deficiencies All patients have to be investigated clinically for signs of nutritional deficiencies 3, 6, 9, 12, 18 and 24 months after BS and later on once a year. We prescribe all patients a multivitamin drug, high-dose vitamin D (on average 20 000 U/week) and vitamin B12 (1000 lg s.c. every 3 months). Trace elements such
© 2014 European Academy of Dermatology and Venereology
6
as iron, zinc, copper or other vitamins (especially vitamin B1 and B6) are substituted if necessary. Therefore, cutaneous symptoms are important in clinical follow-up (Figs 10 and 11).
Discussion and conclusions Obesity is a risk factor for a number of skin diseases and may increase severity or limit response to treatment in others (Table 1). BS has become a cost-effective surgical option in case of morbid obesity with a potential to eradicate symptoms of the associated metabolic syndrome.1,2 Our literature review demonstrates, that BS has a potential to improve inflammatory skin diseases like acne inversa and psoriasis in obese patients, but available data are too limited for any final conclusion. However, BS seems to be a proof of principle that weight loss may improve course and prognosis of chronic skin disease. On the other hand, prevalence of acne inversa and psoriasis will make it most unlikely, that BS will be a common procedure for such conditions. Furthermore, skin diseases that develop after BS play an important role to identify health risks caused mainly due to malabsorption and dietary deficiencies. Their early recognition and substitution of vitamins and trace elements will improve the outcome after BS.
References 1 Picot J, Jones J, Colquitt JL et al. The clinical effectiveness and costeffectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess 2009; 13: 1–190, 215–357, iii–iv. 2 Pham S, Gancel A, Scotte M et al. Comparison of the effectiveness of four bariatric surgery procedures in obese patients with type 2 diabetes: a retrospective study. J Obes 2014; 2014: 638203. 3 Wollina U, Koch A, Heinig B et al. Acne inversa (Hidradenitis suppurativa): a review with a focus on pathogenesis and treatment. Indian Dermatol Online J 2013; 4: 2–11. 4 Kromann C, Ibler KS, Kristiansen V, Jemec GB. The influence of body weight on the prevalence and severity of hidradenitis suppurativa. Acta Derm Venereol 2014; 94: 553–557. 5 Kalra MG, Higgins KE, Kinney BS. Intertrigo and secondary skin infections. Am Fam Physician 2014; 89: 569–573. 6 Boza JC, Trindade EN, Peruzzo J et al. Skin manifestations of obesity: a comparative study. J Eur Acad Dermatol Venereol 2012; 26: 1220–1223. 7 Escobar-Morreale HF, Botella-Carretero JI, Alvarez-Blasco F et al. The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery. JCEM 2005; 90: 6364–6369. 8 Jamal M, Gunay Y, Capper A et al. Roux-en-Y gastric bypass ameliorates polycystic ovary syndrome and dramatically improves conception rates: a 9 year analysis. Surg Obes Relat Dis 2012; 8: 440–444. 9 Armstrong AW, Harskamp CT, Armstrong EJ. The association between psoriasis and obesity: a systematic review and meta-analysis of observational studies. Nutr Diabetes 2012; 2: e54. 10 Edson-Heredia E, Sterling KL, Alatorre CI et al. Heterogeneity of response to biologic treatment: perspective for psoriasis. J Invest Dermatol 2014; 134: 18–23. 11 Hossler EW, Wood GC, Still CD et al. The effect of weight loss surgery on the severity of psoriasis. Br J Dermatol 2013; 168: 660–661. 12 Farias MM, Achurra P, Boza C et al. Psoriasis following bariatric surgery: clinical evolution and impact on quality of life on 10 patients. Obes Surg 2012; 22: 877–880.
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13 Sako EY, Famenini S, Wu JJ. Bariatric surgery and psoriasis. J Am Acad Dermatol 2014; 70: 774–779. 14 Bozkurt S, Coskun H, Kadioglu H et al. Remission of ulcerated necrobiosis lipoidica diabeticorum after bariatric surgery. Case Rep Dermatol Med 2013; 2013: 352579. 15 Bae-Harboe YS, Solky A, Masterpol KS. A case of acquired zinc deficiency. Dermatol Online J 2012; 18: 1. 16 Cunha SF, Goncßalves GA, Marchini JS, Roselino AM. Acrodermatitis due to zinc deficiency after combined vertical gastroplasty with jejunoileal bypass: case report. Sao Paulo Med J 2012; 130: 330–335. Acrodermatitis enteropathica: report of 17 Valdes R, Mauret M, Castro A. one case [Spanish]. Rev Med Chil 2013; 141: 1480–1483. 18 Ramos-Levı AM, Sanchez-Pernaute A, Rubio Herrera MA. Dermatitis and optic neuropathy due to zinc deficiency after malabsortive bariatric surgery. Nutr Hosp 2013; 28: 1345–1347. 19 Oc on J, Cabrejas C, Altemir J, Moros M. Phrynoderma: a rare dermatologic complication of bariatric surgery. JPEN J Parenter Enteral Nutr 2012; 36: 361–364. 20 Olmedo JM, Yiannias JA, Windgassen EB, Gornet MK. Scurvy: a disease almost forgotten. Int J Dermatol 2006; 45: 909–913. 21 Stolle LB, Heidemann E, Bischoff-Mikkelsen M. Scurvy is not entirely a historical disease [Danish]. Ugeskr Laeger 2012; 174: 499–500. 22 Rojas P, Gosch M, Basfi-fer K et al. Alopecia in women with severe and morbid obesity who undergo bariatric surgery [Spanish]. Nutr Hosp 2011; 26: 856–862. 23 Ruiz-Tovar J, Oller I, Llavero C et al. Hair loss in females after sleeve gastrectomy: predictive value of serum zinc and iron levels. Am Surg 2014; 80: 466–471. 24 Marzano AV, Ishak RS, Colombo A et al. Pyoderma gangrenosum, acne and suppurative hidradenitis syndrome following bowel bypass surgery. Dermatology 2012; 225: 215–219. 25 Patton T, Jukic D, Juhas E. Atypical histopathology in bowel-associated dermatosis-arthritis syndrome: a case report. Dermatol Online J 2009; 15: 3. 26 Tu J, Chan JJ, Yu LL. Bowel bypass syndrome/bowel-associated dermatosis arthritis syndrome post laparoscopic gastric bypass surgery. Australas J Dermatol 2011; 52: e5–e7. 27 Halawi A, Abiad F, Abbas O. Bariatric surgery and its effects on the skin and skin diseases. Obes Surg 2013; 23: 408–413. 28 Mohamed M, Voet M, Gardeitchik T, Morava E. Cutis laxa. Adv Exp Med Biol 2014; 802: 161–184. 29 Light D, Arvanitis GM, Abramson D, Glasberg SB. Effect of weight loss after bariatric surgery on skin and the extracellular matrix. Plast Reconstr Surg 2010; 125: 343–351. 30 Orpheu SC, Coltro PS, Scopel GP et al. Collagen and elastic content of abdominal skin after surgical weight loss. Obes Surg 2010; 20: 480–486. 31 Fearmonti RM, Blanton M, Bond JE et al. Changes in dermal histomorphology following surgical weight loss versus diet-induced weight loss in the morbidly obese patient. Ann Plast Surg 2012; 68: 507–512. 32 Kohli R, Argento V, Amoateng-Adjepong Y. Obesity-associated abdominal elephantiasis. Case Rep Med 2013; 2013: 626739. 33 Wollina U, Heinig B, Sch€ onlebe J, Nowak A. Debulking surgery for elephantiasis nostras with large ectatic podoplanin-negative lymphatic vessels in patients with lipo-lymphedema. Eplasty 2014; 14: e11. 34 Salas S, Stock N, Stoeckle E et al. Chronic lymphedema due to morbid obesity: an exceptional cause of abdominal wall angiosarcoma. Virchows Arch 2008; 453: 217–219. 35 Schrader AM, Deckers IE, van der Zee HH, Boer J, Prens EP. Hidradenitis suppurativa: a retrospective study of 846 Dutch patients to identify factors associated with disease severity. J Am Acad Dermatol 2014; 71: 460–467. 36 Crowley JJ, Mekkes JR, Zouboulis CC et al. Association of hidradenitis suppurativa disease severity with increased risk for systemic comorbidities. Br J Dermatol 2014; doi: 10.1111/bjd.13122. [Epub ahead of print]
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Bariatric surgery
37 Kluczynik CE, Mariz LS, Souza LC et al. Acanthosis nigricans and insulin resistance in overweight children and adolescents. An Bras Dermatol 2012; 87: 531–537. 38 Shaheen MA, Abdel Fattah NS, Sayed YA, Saad AA. Assessment of serum leptin, insulin resistance and metabolic syndrome in patients with skin tags. J Eur Acad Dermatol Venereol 2012; 26: 1552–1557. 39 Akpinar F, Dervis E. Association between acrochordons and the components of metabolic syndrome. Eur J Dermatol 2012; 228: 106–110. 40 Lau K, H€ oger PH. Skin diseases associated with obesity in children [German]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013; 56: 539–542. 41 Verma SB, Wollina U. Acne keloidalis nuchae: another cutaneous symptom of metabolic syndrome, truncal obesity, and impending/overt diabetes mellitus? Am J Clin Dermatol 2010; 11: 433–436. 42 Silverberg JI, Silverberg NB, Lee-Wong M. Association between atopic dermatitis and obesity in adulthood. Br J Dermatol 2012; 166: 498–504.
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43 Luo X, Xiang J, Dong X et al. Association between obesity and atopic disorders in Chinese adults: an individually matched case–control study. BMC Public Health 2013; 13: 12. 44 Pasquali R, Gambineri A. Therapy in endocrine disease: treatment of hirsutism in the polycystic ovary syndrome. Eur J Endocrinol 2013; 170: R75–R90. 45 Yang CC, Hsieh FN, Lin LY et al. Higher body mass index is associated with greater severity of alopecia in men with male-pattern androgenetic alopecia in Taiwan: a cross-sectional study. J Am Acad Dermatol 2014; 70: 297–302. 46 Baselga Torres E, Torres-Pradilla M. Cutaneous manifestations in children with diabetes mellitus and obesity. Actas Dermosifiliogr 2014; 105: 546–547. 47 Cai S, Rahman M, Intrator O. Obesity and pressure ulcers among nursing home residents. Med Care 2013; 51: 478–486. 48 Coimbra S, Oliveira H, Figueiredo A et al. Factors associated with the length of remission of psoriasis vulgaris. Clin Drug Investig 2013; 33: 855–860.
© 2014 European Academy of Dermatology and Venereology
DOI: 10.1111/jdv.12820
REVIEW ARTICLE
Bariatric surgery – a dermatologic perspective U. Wollina,1,* M. Dreßler,2,3, T. Lohmann3,4 1
Departments of Dermatology and Allergology, Hospital Dresden Friedrichstadt, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany 2 General and Visceral Surgery, Hospital Dresden-Neustadt, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany 3 Competence Centre for Adipositas and Metabolic Surgery, Hospital Dresden-Neustadt, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany 4 Department of Internal Medicine, Hospital Dresden-Neustadt, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany *Correspondence: U. Wollina. E-mail: [email protected]
Abstract Bariatric surgery has become a standard option in morbid obesity for patients not responding to conventional treatment. A major and stable weight loss can be achieved. Since obesity and weight loss may affect skin diseases, we performed this review to analyse the impact of bariatric surgery on a number of skin diseases. We categorized the skin diseases into three main groups: (i) diseases with a possible benefit from bariatric surgery, (ii) diseases that may develop after bariatric surgery and (iii) diseases that may persist. We hope that dermatologists will achieve an updated knowledge of benefits and possible hazards of this type of surgically induced weight loss. Received: 30 July 2014; Accepted: 1 October 2014
Conflicts of interest None declared.
Funding sources None declared.
Introduction Bariatric surgery (BS) is the arrange of surgical procedures to treat morbid obesity. The most commonly used techniques world-wide are laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (SG). In contrast to LAGB, both RYGB and SG improve insulin sensitivity and gut hormone responses, which can lead to a remission of type 2 diabetes mellitus. The major goal, however, is a stable weight loss to combat excessive obesity. About 15 BMI units can be achieved on average within 2 years after BS. The second important goal of BS is the treatment or prevention of metabolic syndrome.1,2 Since obesity is associated with a number of skin diseases while others show an increased risk of metabolic syndrome and its cardiovascular complications, we performed a literature search to evaluate the impact of BC on various skin diseases. In addition, we searched for dermatologic side-effects caused by BC. A literature research using PUBMEDâ January 2000 to June 2014 choosing the terms “bariatric surgery” AND “skin diseases” revealed 412 references. We will analyse the findings according
JEADV 2014
to skin disorders. We will organize this review into skin diseases that may potentially benefit from BS, those who are unresponsive, and skin disorders that may occur after BS.
Skin diseases that may benefit from bariatric surgery Acne inversa/Hidradenitis suppurativa
Acne inversa is a chronic relapsing inflammatory disorder affecting the large body folds, i.e. axillaries, submammary region, groins, outer genitals and anal fold (Fig. 1). The disease affects about 1% of the adult population. Smoking and obesity are well-known risk factors. Treatment for milder types is by medical drugs, whereas advanced cases eventually demand surgery.3 A retrospective questionnaire study in Denmark analysed preand post-BS data of 45 patients with acne inversa. The prevalence of acne inversa among obese patients seems to be increased. In those who underwent BS with a weight loss of at least 15% both the severity and the number of body sites affected was reduced. A remission of the disease was reported by 35% of patients.4
© 2014 European Academy of Dermatology and Venereology
Wollina et al.
2
Intertrigo
Psoriasis
Intertrigo is a superficial inflammatory dermatitis occurring in the large skin fords as a result of moisture, friction and lack of ventilation. It is related to obesity, focal hyperhidrosis and diabetes. The more intense the inflammation is, the higher the risk of breakdown of skin barrier function. This opens the route for bacterial, fungal und viral infections (Fig. 2).5 Since severity of intertrigo is related to the degree of obesity6 body mass reduction by BS may improve intertrigo. Since body mass reduction is accompanied by skin laxity, the positive effect of BS may be seen only after body lift (Fig. 3).
Psoriasis is a chronic relapsing inflammatory Th1/Th17 disease affecting 2–3% of the World population (Fig. 4). Extracutaneous manifestations of the disease include psoriatic arthritis, iridocyclitis and others. There is evidence of an association between severe psoriasis and metabolic syndrome and obesity.9 Obesity is often associated with a resistance to treatment.10 BS-induced weight loss may decrease psoriasis severity.11
Polycystic ovary syndrome
Women suffering from polycystic ovary syndrome are seen frequently in BS (about 30% of female patients). Most of these patients report an improvement of hirsutism and fertility within the first year after BS.7,8
Figure 3 Severe erosive intertrigo.
Figure 1 Inverse acne of the groin, Hurley grade II.
Figure 2 Mild erosive intertrigo with post-inflammatory hyperpigmentation.
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Figure 4 Patient after successful bariatric surgery (loss of >70 kg bodyweight) but skin laxity.
© 2014 European Academy of Dermatology and Venereology
Bariatric surgery
In a retrospective case series of 10 obese psoriasis patients the outcome after BS was analysed with a focus on skin disease. Of these 10 patients eight had RYGB and two LAGB procedures. Six months after BS 70% of patients still had a stable remission of psoriasis and three patient treated previously with systemic drug had discontinued their medication. The quality of life improved markedly from 14.9 6.8 before surgery to 5.0 6.3 after BS.12 Analysing the available literature Sako et al. came to the conclusion, that BS ‘may one be an option for obese patients with refractory psoriasis’.13
3
Bozkurt et al. reported on a 32-year-old woman with diabetes mellitus type 2 and ulcerated necrobiosis lipoidica who, after BS, achieved a complete remission of her skin disease and of diabetes.14
Skin diseases that developed after bariatric surgery The number of patients who developed skin disorders after BS is rather small. However, such cutaneous disorders may be an alarming sign demanding immediate medical actions. We have
Ulcerated necrobiosis lipoidica diabeticorum
Necrobiosis lipoidica is a granulomatous skin disease usually of the lower legs affecting both diabetics and non-diabetics.
Figure 7 Multilocal pyoderma gangrenosum of the abdominal wall.
Figure 5 Extensive plaque-type psoriasis.
Figure 6 Generalized xerosis cutis with features of asteatotic dermatitis.
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Figure 8 Large abdominal fold due to sagging 2 years after bariatric surgery.
© 2014 European Academy of Dermatology and Venereology
Wollina et al.
4
Figure 9 A 43-year-old female patient 2 years after sleeve gastrectomy (loss of bodyweight >60 kg) with pubic lipo-lymphoedema.
Figure 11 Two years after sleeve gastrectomy with an excellent outcome. The remaining abdominal fold, however, demonstrates persistent localized lymphoedema of the elephantiasis nostras type.
to differentiate between short-term adverse effects (within the first 2 years after BC) and long-term adverse effects. Most disorders due to vitamin or trace element deficiencies are seen later. Acquired acrodermatitis enteropathica
Zinc deficiency lead to a characteristic clinical triad: Dermatitis, diarrhoea and alopecia. The dermatitis is preferentially located periorifically. The treatment of choice is zinc substitution. Zinc deficiency may develop after BS in the long-term run in case of inadequate zinc substitution. Cases with acquired acrodermatitis enteropathica after BS have been observed.15–17 Acquired vitamin A deficiency
Figure 10 A 31-year-old male patient with 245 kg bodyweight before bariatric surgery.
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Vitamin A deficiency is a possible complication after BS. Patients develop a severe xeroderma (Fig. 5) and a dry eye syndrome, but more important hearing loss. There is a need of vitamin A substitution in such patients.18 A typical although non-specific cutaneous manifestation if phrynoderma – multiple follicular hyperkeratosis on the
© 2014 European Academy of Dermatology and Venereology
Bariatric surgery
5
Table 1 Obesity and skin disease Diagnosis
Effect(s) of obesity
References
Acne inversa/hidradenitis suppurativa
Increased severity
35, 36
Acanthosis nigricans benigna
Major risk factor
37
Acrochordons (skin tags)
Risk factor for multiple tags
38, 39
Acne
Increased severity
40
Acne keloidalis nuchae
Risk factor
41
Abdominal elephantiasis
Strong risk factor
32
Atopic dermatitis
Higher prevalence
42, 43
Hirsutism and polycystic ovary syndrome
Obesity is a major cause of hormonal imbalance in females
44
Intertrigo and skin infections
Increased risks
Male-pattern alopecia
Increased severity
45
Plantar hyperkeratosis
Risk factor
46
Pressure ulcers
Increased risk
47
Psoriasis
Decreased response to treatment
10
Decreased length of remission
48
Risk factor in case of rapid weight gain
46
Striae distensae
Skin laxity 6
extensor surfaces of legs and arms. When phrynoderma is associated with xerophthalmia and nyctalopia, this is suggestive for vitamin A deficiency.19 Scurvy
Scurvy is a disease caused by vitamin C deficiency. It is a multiorgan disease, when untreated leading to death. The most common symptoms are bruising, mucosal changes including scorbutic siderosis, ecchymotic purpura, haemorrhagic ulcers and pedal oedemas. Inability to walk is a late symptom.20 Scurvy is a rare complication after BR. A 36-year-old woman, who developed bullae, loose skin and haemorrhagias after BS was diagnosed with scurvy.21 Alopecia
Diffuse alopecia especially in women after BS may be an indicator for deficiencies of vitamins and trace elements. A study investigated 87 females after BS (RYGB or SG). Indeed those females with a more severe hair loss after BS had lower values of zinc and iron, demanding for substitution. And there is a second type of temporary alopecia seen shortly after BC caused by protein deficiency.22,23 PASH syndrome and other neutrophilic dermatoses
The triad of pyoderma gangrenosum, acne and suppurative hidradenitis (acne inversa) is known by the acronym PASH syndrome (Fig. 6). PASH syndrome belongs to the heterogeneous
JEADV 2014
group of autoinflammatory disorders. A single case has been reported by Marzano et al.24 Bowel bypass syndrome, also known as bowel-associated dermatitis arthritis syndrome, can be a complication after BS, in particular after RYGB. The clinical presentation includes ulcerating lesions and pustules on arms and legs, polyarthralgia, fever and joint effusions. Skin biopsies from the cutaneous lesions reveal a superficial to mid-dermal neutrophilic infiltrate that resembles Sweet syndrome. Antibiotics, glucocorticosteroids and colchicine have been used for treatment.25,26 Bacterial overgrowth in blind intestinal loops seems to be a possible trigger for neutrophilic dermatoses.27
After successful BS an acquired skin laxity (cutis laxa) can often be observed. Cutis laxa is characterized by redundant, sagging and inelastic skin (Fig. 7).28 Histologic investigations demonstrated a poorly organized collagen structure, elastin degradation and focal scar formation within macroscopically normal areas.29 Loss of collagen with insufficient collagen network has also been confirmed by other groups but not the loss of elastin.30,31 Various disorders with a questionable relation to bariatric surgery
In their excellent review on BS and skin disease, Halawi et al. listed a number of case reports. All of these are single cases, sometimes with the eruption of skin diseases several years after surgery. Their list includes various types of vasculitis (HenochSch€ onlein purpura, necrotizing vasculitis with arthritis, nodular non-suppurative panniculitis), cryoglobulinaemia with renal failure and dermatitis herpetiformis. All of these complaints started at least 1.5 to maximum of 5 years after surgery.27
Skin diseases that persist after bariatric surgery There are some disorders which develop during the years of morbid obesity that will not improve after successful BS. Patients who had abdominal lymphoedema may still show disturbances of lymphatic flow (Fig. 8). The subgroup of patients with fibrotic transformation of subcutaneous tissue into abdominal elephantiasis nostras will only partially improve (Fig. 9).32 Such patients might benefit from a debulking surgery.33 Such patients are at risk of developing angiosarcoma later.34
Follow-up investigations in patients after bariatric surgery to prevent nutritional deficiencies All patients have to be investigated clinically for signs of nutritional deficiencies 3, 6, 9, 12, 18 and 24 months after BS and later on once a year. We prescribe all patients a multivitamin drug, high-dose vitamin D (on average 20 000 U/week) and vitamin B12 (1000 lg s.c. every 3 months). Trace elements such
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as iron, zinc, copper or other vitamins (especially vitamin B1 and B6) are substituted if necessary. Therefore, cutaneous symptoms are important in clinical follow-up (Figs 10 and 11).
Discussion and conclusions Obesity is a risk factor for a number of skin diseases and may increase severity or limit response to treatment in others (Table 1). BS has become a cost-effective surgical option in case of morbid obesity with a potential to eradicate symptoms of the associated metabolic syndrome.1,2 Our literature review demonstrates, that BS has a potential to improve inflammatory skin diseases like acne inversa and psoriasis in obese patients, but available data are too limited for any final conclusion. However, BS seems to be a proof of principle that weight loss may improve course and prognosis of chronic skin disease. On the other hand, prevalence of acne inversa and psoriasis will make it most unlikely, that BS will be a common procedure for such conditions. Furthermore, skin diseases that develop after BS play an important role to identify health risks caused mainly due to malabsorption and dietary deficiencies. Their early recognition and substitution of vitamins and trace elements will improve the outcome after BS.
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