Skin disorders associated with obesity in children and adolescents: a population-based study

Hidradenitis suppurativa in children and adolescents

Hidradenitis suppurativa in children and adolescents share similar clinical features and distribution of lesions as in adult patients, causing significant physical and psychologic burdens. The disease is associated with several comorbidities; therefore, a diagnostic work-up should include screening for metabolic, psychiatric, autoimmune, and hyperandrogenic comorbidities. The goal of the treatment is to alleviate pain, minimize inflammation and scarring, and prevent disease progression. Currently, there are no hidradenitis suppurativa treatment guidelines for children and adolescents, and the treatment primarily relies on the management of hidradenitis suppurativa in adults. We summarize the current information about the epidemiology, pathogenesis, clinical features, comorbidities, diagnostic work-up, and treatment options for children and adolescents afflicted with hidradenitis suppurativa.

A Review of the Etiologies and Key Clinical Features of Secondary Hyperhidrosis

Secondary hyperhidrosis is a multifactorial condition that poses unique diagnostic and management challenges. Distinguishing secondary from primary hyperhidrosis remains difficult due to overlapping symptoms. This review consolidates existing evidence on the numerous underlying causes and pathophysiologic mechanisms of secondary hyperhidrosis across various disciplines. Secondary hyperhidrosis typically manifests in the fourth decade of life or later, whereas primary hyperhidrosis usually begins earlier. Generalized hyperhidrosis often suggests a secondary cause, though the distribution can vary, including focal symmetric/asymmetric or regional patterns depending on the underlying condition. Key clinical features such as lack of family history and associated symptoms provide additional clues favoring a secondary etiology. Recognizing these distinct characteristics is crucial for accurate differentiation between secondary and primary hyperhidrosis, thereby guiding appropriate evaluation and management of the underlying cause.

TLR2 regulates hair follicle cycle and regeneration via BMP signaling

The etiology of hair loss remains enigmatic, and current remedies remain inadequate. Transcriptome analysis of aging hair follicles uncovered changes in immune pathways, including Toll-like receptors (TLRs). Our findings demonstrate that the maintenance of hair follicle homeostasis and the regeneration capacity after damage depend on TLR2 in hair follicle stem cells (HFSCs). In healthy hair follicles, TLR2 is expressed in a cycle-dependent manner and governs HFSCs activation by countering inhibitory BMP signaling. Hair follicles in aging and obesity exhibit a decrease in both TLR2 and its endogenous ligand carboxyethylpyrrole (CEP), a metabolite of polyunsaturated fatty acids. Administration of CEP stimulates hair regeneration through a TLR2-dependent mechanism. These results establish a novel connection between TLR2-mediated innate immunity and HFSC activation, which is pivotal to hair follicle health and the prevention of hair loss and provide new avenues for therapeutic intervention.

[Translated article] Glucagon-Like Peptide-1 Agonists for Treating Obesity in Patients With Immune-Mediated Skin Diseases

Psoriasis and hidradenitis suppurativa are often associated with obesity. Because chronic low-grade inflammation underlies these 2 diseases, they can progress to more severe forms in patients with obesity if weight-reduction measures are not taken. This review covers pharmacologic alternatives for treating obesity, with emphasis on the benefits associated with the novel use of glucagon-like peptide-1 (GLP-1) agonists that act on satiety receptors. These drugs have led to greater weight loss in clinical trials and real-world settings than orlistat, which until recently was the only drug approved for treating obesity in the European Union. Although experience with GLP-1 agonists in patients with obesity and inflammatory skin diseases is currently scarce, the promising results reported suggest they may offer a useful tool for managing obesity.

Childhood Obesity: An Updated Review

BACKGROUND

Childhood obesity is an important and serious public health problem worldwide.

OBJECTIVE

This article aims to familiarize physicians with the evaluation, management, and prevention of childhood.

METHODS

A PubMed search was conducted in May, 2021, in Clinical Queries using the key terms "obesity" OR "obese". The search included clinical trials, randomized controlled trials, case-control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to English literature and children. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Most obese children have exogenous obesity characterized by a growth rate for height above the 50th percentile, normal intelligence, normal genitalia, and lack of historical or physical evidence of an endocrine abnormality or a congenital syndrome. Obese children are at risk for dyslipidemia, hypertension, diabetes mellitus, non-alcoholic fatty liver disease, obstructive sleep apnea, psychosocial disturbances, impaired quality of life, and shorter life expectancy. The multitude of serious comorbidities necessitates effective treatment modalities. Dietary modification, therapeutic exercise, and behavioral modification are the fundamentals of treatment. Pharmacotherapy and/or bariatric surgery should be considered for obese individuals who do not respond to the above measures and suffer from a serious comorbid condition.

CONCLUSION

Childhood obesity, once established, is often refractory to treatment. Most treatment programs lead to a brief period of weight loss, followed by rapid re-accumulation of the lost weight after the termination of therapy. As such, preventive activity is the key to solving the problem of childhood obesity. Childhood obesity can be prevented by promoting a healthy diet, regular physical activity, and lifestyle modification. Parents should be encouraged to get involved in school and community programs that improve their children's nutritional status and physical activity.

Glucagon-Like Peptide-1 Agonists for Treating Obesity in Patients With Immune-Mediated Skin Diseases

Psoriasis and hidradenitis suppurativa are often associated with obesity. Because chronic low-grade inflammation underlies these 2 diseases, they can progress to more severe forms in patients with obesity if weight-reduction measures are not taken. This review covers pharmacologic alternatives for treating obesity, with emphasis on the benefits associated with the novel use of glucagon-like peptide-1 (GLP-1) agonists that act on satiety receptors. These drugs have led to greater weight loss in clinical trials and real-world settings than orlistat, which until recently was the only drug approved for treating obesity in the European Union. Although experience with GLP-1 agonists in patients with obesity and inflammatory skin diseases is currently scarce, the promising results reported suggest they may offer a useful tool for managing obesity.

Dermatoses in overweight and obese children and their relationship with insulin and skin color

BACKGROUND/AIM

The aim of the present study was to investigate the prevalence of obesity-related dermatoses in obese children, and the association between these dermatoses and insulin resistance as well as skin color.

METHODS

Obese, overweight, and normal weight children according to body mass index who were followed up and treated in the outpatient clinics were included in the study. Dermatological examinations of the participants were performed, and fasting insulin and glucose levels were checked.

RESULTS

The obese and overweight children were evaluated as the patient group (70 girls, 41 boys, mean age: 12.37 ± 3.14 years). One hundred one healthy children with normal weight were determined as the control group (59 girls, 42 boys, mean age: 12.15 ± 2.43). The first five common dermatoses in the patient group when compared with the control group were keratosis pilaris (KP), striae distensae, hyperhidrosis, acanthosis nigricans (AN), and plantar hyperkeratosis. The first five dermatoses which were positively correlated with formation and insulin resistance were KP, striae distensae, AN, hyperhidrosis, and plantar hyperkeratosis. According to the Fitzpatrick skin scale, we found that the darker the skin color, the higher the probability of AN and KP (OR, 0.298; 95% CI, 0.106-0.834, p = 0.021; OR, 0.306; 95% CI, 0.117-0.796, p = 0.015, respectively).

CONCLUSION

Some dermatoses associated with obesity and insulin resistance were not found in obese children, or there was no significant association. These results indicate that many skin morbidities may be prevented by preventing and treating obesity and insulin resistance in the early period.

TLR2 Regulates Hair Follicle Cycle and Regeneration via BMP Signaling

The etiology of hair loss remains enigmatic, and current remedies remain inadequate. Transcriptome analysis of aging hair follicles uncovered changes in immune pathways, including Toll-like receptors (TLRs). Our findings demonstrate that the maintenance of hair follicle homeostasis and the regeneration capacity after damage depends on TLR2 in hair follicle stem cells (HFSCs). In healthy hair follicles, TLR2 is expressed in a cycle-dependent manner and governs HFSCs activation by countering inhibitory BMP signaling. Hair follicles in aging and obesity exhibit a decrease in both TLR2 and its endogenous ligand carboxyethylpyrrole (CEP), a metabolite of polyunsaturated fatty acids. Administration of CEP stimulates hair regeneration through a TLR2-dependent mechanism. These results establish a novel connection between TLR2-mediated innate immunity and HFSC activation, which is pivotal to hair follicle health and the prevention of hair loss and provide new avenues for therapeutic intervention.

Skin manifestations in pediatric obesity: A prospective cohort study

Data on skin manifestations associated with pediatric obesity are limited. We conducted a prospective study to evaluate the association of pediatric obesity with skin dermatoses and dermatologic quality of life. Our findings suggest that ongoing monitoring of skin problems is recommended for children with obesity.

Unraveling the Role of Sex Hormones on Keratinocyte Functions in Human Inflammatory Skin Diseases

The skin exerts several fundamental functions that are the first physical, chemical and immune barriers to the human body. Keratinocytes, the main cell type of the epidermis, provide mechanical defense, support skin integrity and actively endorse cutaneous immune responses. Not surprisingly, considering these crucial activities, alterations in keratinocyte functions are associated with different inflammatory skin diseases. Recent findings indicate that the skin should not only be regarded as a target for hormones but that it should also be considered as an endocrine peripheral organ that is directly involved in the synthesis and metabolism of these chemical messengers. Sex hormones have multiple effects on the skin, attributed to the binding with intracellular receptors expressed by different skin cell populations, including keratinocytes, that activate downstream signaling routes that modulate specific cellular functions and activities. This review is aimed at reorganizing the current knowledge on the role exerted by sex hormones on keratinocyte function in five different inflammatory skin diseases: Hidradenitis suppurativa; Acne vulgaris; Atopic dermatitis; progesterone hypersensitivity; psoriasis. The results of our work aim to provide a deeper insight into common cellular mechanisms and molecular effectors that might constitute putative targets to address for the development of specific therapeutic interventions.

Caring for Pediatric Hidradenitis Suppurativa Patients in the Emergency Department

ABSTRACT

Hidradenitis suppurativa (HS) is a chronic and recurrent inflammatory skin condition resulting in the formation of nodules, sinus tracts, and abscesses in intertriginous areas. We provide recommendations for the management of children presenting to the emergency department with acute HS flares, based on a review of literature and insights from our own clinical experience. The purpose of the recommendations is to educate clinicians on specific considerations that should be made when caring for children with HS.

Cutaneous sequelae of a national health crisis: Obesity and the skin

Background

The global obesity pandemic has far‐reaching health consequences and has become a major global health challenge. The worldwide prevalence of obesity nearly doubled between 1980 and 2008 and based on the latest estimates in the European Union, obesity affects up to 30% of adults. As a consequence of this rising prevalence of obesity, there has been an increase in the frequency of certain disease of the skin.

Objectives

We review the cutaneous sequelae of obesity, firstly describing the physiological consequences of increased adiposity in the skin and secondly examining the dermatoses associated with obesity.

Skin and obesity in childhood: an update

<abstract> <p>Overweight and obesity have grown in children in the last decades and are now an epidemic, leading to significant public health issues in developed and underdeveloped nations. Obese children have a higher prevalence of skin lesions than normal weight children. The present study is an updated-on state of the art of studies describing the association between childhood obesity and related skin lesions. The most frequent obesity-associated dermatological complications in children are acanthosis nigricans and acrochordons, atopic dermatitis, skin infections, and endocrinological changes including hyperinsulinism and hyperandrogenism. Other common skin manifestations associated with obesity are striae distensae and plantar hyperkeratosis. Although the causes of the majority of the skin lesions associated with obesity are not known, the larger mass of adipose tissue and the secretion of peptides (cytokines, hormones, etc.) from enlarged fat cells due to obesity could lead to skin lesions. Therefore, the prevention of obesity is essential to avoid most skin-associated lesions.</p> </abstract>

Changes in Physical Activity in Relation to Body Composition, Fitness and Quality of Life after Primary Bariatric Surgery: a Two-Year Follow-Up Study

Purpose

The success of bariatric surgery varies largely, which may relate to variance in adopting a physically active lifestyle. This study aimed to determine whether two-year changes in physical activity (PA) were associated with weight loss, fat-free mass, cardiorespiratory fitness and quality of life up to two years after bariatric surgery.

Materials and Methods

In this retrospective study, 3879 post-bariatric patients were divided into three groups: 1) decreased PA (n = 388), 2) maintained PA (n = 2002) or 3) increased PA (n = 1498). Measurements regarding PA (Baecke questionnaire), body composition (bioelectrical impedance analysis), estimated cardiorespiratory fitness (Åstrand test) and health-related quality of life (RAND-36) were performed preoperatively and two years post-surgery.

Results

Bariatric patients with increased PA had greater excess weight loss (76.3% vs. 73.2% vs. 72.9%, P < 0.001), greater increases in %fat-free mass (Δ14.0% vs. 13.0% vs. 12.8%; P < 0.001), larger improvements in VO₂max (Δ11.8 vs. 10.2 vs. 8.0 ml/kg/min, P < 0.001), and larger increases in health related quality of life subscale scores (P < 0.05) compared to patients with maintained- and decreased PA.

Conclusions

Bariatric patients who managed to induce improvements in habitual physical activity had better body composition, fitness and quality of life at 2 years post-surgery, compared to patients who maintained or even reduced their PA levels. These findings underscore the importance of perioperative-bariatric care programs to change lifestyle and achieve sustainable improvements in PA levels.

Electronic supplementary material

The online version of this article (10.1007/s11695-020-05009-x) contains supplementary material, which is available to authorized users.

Treatment Patterns, Depression, and Anxiety Among US Patients Diagnosed with Hyperhidrosis: A Retrospective Cohort Study

Introduction

Hyperhidrosis is associated with social and emotional stress due to limitations on health-related quality of life. This study examined real-world treatment patterns and concomitant depression and/or anxiety in patients with hyperhidrosis.

Methods

Commercial health plan members in the US with ≥ 2 hyperhidrosis diagnosis codes and/or antiperspirant prescription claims were identified from January 2010 through November 2017. A control cohort (CC) of patients without hyperhidrosis was matched to the hyperhidrosis cohort on demographic characteristics. Depression and/or anxiety were identified by ≥ 1 relevant diagnosis code or pharmacy claim. A multivariable logistic regression model estimated odds of treatment in the hyperhidrosis cohort, and depression/anxiety in the hyperhidrosis cohort and CC, adjusting for patient characteristics.

Results

A total of 44,484 patients with hyperhidrosis were identified, of whom 58.5% were female, with a mean (± standard deviation) age of 36.5 ± 16.5 years (83.5% ≥ 18 years). A small majority of patients (51.6%, 0.69/person-year) received treatment with prescription antiperspirants. Post-index oral systemic therapies, medical procedures, and surgical options were uncommon. At 12 months post-index, 48.4% of the sample had not filled a prescription for extra- or prescription-strength antiperspirants. Compared with the CC (n = 137,451), a higher percentage of patients with hyperhidrosis had depression or anxiety reported during follow-up (41.1 vs. 28.2%, p < 0.001); this corresponded to higher adjusted odds of depression/anxiety in patients with hyperhidrosis [odds ratio (OR) 1.76, 95% confidence interval (CI) 1.72–1.80, p < 0.001]. Baseline depression and/or anxiety were associated with lower odds of receiving hyperhidrosis treatment (OR 0.77, 95% CI 0.73–0.80), as was increasing age and male gender. Patients with hyperhidrosis also had more frequent incident depression/anxiety during follow-up (18.2 vs. 10.6%, p < 0.001).

Conclusion

In this real-world analysis, hyperhidrosis was associated with increased odds of depression and/or anxiety. However, relatively low percentages of patients received prescription topical or oral treatments or underwent surgery, suggesting that tolerability, efficacy, and provider awareness may be limiting factors in the effective treatment of hyperhidrosis.

Electronic supplementary material

The online version of this article (10.1007/s13555-020-00439-y) contains supplementary material, which is available to authorized users.

Hidradenitis suppurativa in a cohort of overweight and obese children and adolescents

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory, and recurring disease mainly observed in adults. Obesity is considered an important independent factor in HS development and is associated with a higher prevalence of HS in children. We aimed to characterize the clinical presentation of HS in overweight and obese children and adolescents.

METHODS

We performed a cross-sectional observational study during January 2007-April 2015. Overweight and obese patients (5-17 years of age, BMI> 90th percentile) referred to The Children's Obesity Clinic, Department of Paediatrics, Copenhagen University Hospital Holbaek, Denmark, underwent screening for dermatological conditions. A dermatologist ascertained the diagnosis of HS, and disease severity was assessed using Hurley staging and Sartorius score. Tobacco smoke exposure, body mass index (BMI) standard deviation score (SDS), and psychiatric comorbidities were recorded. Our cohort was compared with a reference cohort recruited in a previous study.

RESULTS

A total of 195 children and adolescents underwent screening for dermatological conditions. Nine patients screened positive, and six of these patients were available for examination of whom five presented with HS. All HS cases were mild (median Sartorius score of 9). Four of the five patients (with varying constellations) reported tobacco exposure, a positive family history of HS, and exhibited psychiatric comorbidities.

CONCLUSION

Our findings support that the presence of pediatric HS is correlated with familial disposition to HS and psychiatric comorbidities.

Associations of body condition score with health conditions related to overweight and obesity in cats

OBJECTIVES

To explore the associations of cat body condition score with various health conditions, such as diabetes mellitus, dermatological conditions and hypertension, that have been shown to relate to overweight and/or obesity in cats, dogs or humans.

MATERIALS AND METHODS

Electronic patient records between January 3, 2005 and June 21, 2015 were obtained from a cat-focused primary accession clinic in metropolitan Sydney where the body condition score of cats was routinely evaluated. Binomial logistic regression modelling was conducted to investigate the associations, after adjusting for age, sex and breed, between 21 health conditions and body condition score recorded on a 9-point scale.

RESULTS

Fourteen of the 21 health conditions examined showed significant associations with an increased body condition score, particularly those of 7 and above. These were dermatological conditions, atopic dermatitis, musculoskeletal conditions, arthritis, hypertension, respiratory conditions, asthma, oral conditions, diarrhoea, general and lower urinary tract conditions, ophthalmic conditions, diabetes mellitus and allergic conditions. Additionally, cats with body condition score of 8 or 9 had significantly higher odds for gastrointestinal conditions and upper urinary tract conditions when compared with cats with body condition score of 5.

CLINICAL SIGNIFICANCE

As far as we know, this is the first study reporting positive associations of high body condition score with atopic dermatitis, hypertension, asthma, diarrhoea, ophthalmic conditions and allergic conditions in cats. A large number of positive associations between health conditions and high body condition score indicates that excess fat mass should be given a greater emphasis in preventive health care for cats.

Voluntary exercise improves murine dermal connective tissue status in high-fat diet-induced obesity

Obesity is a risk factor for several cardiovascular and metabolic diseases. Its influence on the skin is less obvious, yet certain negative effects of adipose tissue inflammation on the dermis have been suggested. Excess weight is closely associated with sedentary behavior, so any increase in physical activity is considered beneficial against obesity. To investigate the effects of obesity and physical exercise on the skin, we established a mouse model in which mice were kept either on a high-fat diet or received standard chow. After the two groups achieved a significant weight difference, physical exercise was introduced to both. Animals were given the opportunity to perform voluntary exercise for 40 min daily in a hamster wheel for a period of 8 weeks. We evaluated the status of the dermis at the beginning and at the end of the exercise period by in vivo nonlinear microscopy. Obese mice kept on high-fat diet lost weight steadily after they started to exercise. In the high-fat diet group, we could detect significantly larger adipocytes and a thicker layer of subcutaneous tissue; both changes started to normalize after exercise. Nonlinear microscopy revealed an impaired collagen structure in obese mice that improved considerably after physical activity was introduced. With the ability to detect damage on collagen structure, we set out to address the question whether this process is reversible. With the use of a novel imaging method, we were able to show the reversibility of connective tissue deterioration as a benefit of physical exercise.

Characterization of obesity rates for dermatologic ambulatory office visits to United States physicians

BACKGROUND

Obesity continues to increase in the United States (US) and elsewhere, with a number of published dermatologic associations. The purpose of this study was to characterize obesity among US office visits for dermatologic diseases.

METHODS

Data from the 2005 to 2011 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) were searched for the most common dermatologic diagnoses for which body mass index (BMI) could be classified.

RESULTS

For all dermatologic patient visits, 10% were underweight, 36.5% were normal weight, 23.8% were overweight and 29.7% were obese. Increasing age predicted the yearly increased likelihood of obesity (OR 1.02; 95% CI 1.01, 1.02; p < 0.0001). Logistic regression controlling for age, sex, race and dataset found that in addition to age, NHAMCS dermatologic diagnosis patients were more likely to be obese than NAMCS patients (OR 1.22; 95% CI 1.03, 1.45; p = 0.02). Specific diseases were found to have the highest obesity rates, including psoriasis, hidradenitis suppurativa and acanthosis nigricans.

CONCLUSION

A large proportion of dermatologic diagnosis patients are obese, and awareness could lead to interventions that may improve their disease and decrease risks of comorbidities.

Influence of age, gender, and race on nitric oxide release over acupuncture points-meridians

This study examined the influence of age, gender and race on nitric oxide (NO) release over acupuncture points, meridian without acupoint, and non-meridian regions of the Pericardium (PC) and Bladder (BL) meridian as well as aging on LU meridian in 61 healthy subjects. Biocapture tubes were attached to the skin surface, and total nitrite and nitrate was biocaptured and quantified using chemiluminescence. In elder ages compared to adults, NO levels over the ventral forearm were significantly decreased over LU on radial regions but not altered over PC on medial regions. Conversely, NO content was elevated over BL regions only in overweight/obesity of elder ages. NO levels over PC regions were marginally elevated in overweight/obese males compared to females but did not alter between races. These results suggest a selective reduction of NO release over LU meridian with aging, which is consistent with a progressive decline in lung function and increase in chronic respiratory disease in elder ages. Increased NO levels along the BL meridian in older obese subjects may reflect a modified NO level along somatic-bladder pathway for counteracting bladder dysfunctions with aging. Both of them support somatic-organ connections in the meridian system associated with potential pathophysiological changes with aging.

[What's new in paediatric dermatology?]

Regular analysis of the major journals in dermatology and paediatrics has been used to select forty articles which are representative of the past year in paediatric dermatology. This selection is not exhaustive but rather reflects the interests of the author and also the dominant topics in paediatric dermatology in 2013-2014.

Epidermal Fatty Acid binding protein promotes skin inflammation induced by high-fat diet

Defining specific cellular and molecular mechanisms in most obesity-related diseases remains an important challenge. Here we report a serendipitous finding that consumption of a high-fat diet (HFD) greatly increased the occurrence of skin lesions in C57BL/6 mice. We demonstrated that HFD induced the accumulation of a specific type of CD11c(+) macrophages in skin preceding detectable lesions. These cells primed skin to induce IL-1β and IL-18 signaling, which further promoted the cytokines IFN-γ- and IL-17-mediated skin inflammation. Mechanistically, epidermal fatty acid binding protein (E-FABP) was significantly upregulated in skin of obese mice, which coupled lipid droplet formation and NLRP3 inflammasome activation. Deficiency of E-FABP in obese mice decreased recruitment of CD11c(+) macrophages in skin tissues, reduced production of IL-1β and IL-18, and consequently dampened activation of effector T cells. Furthermore, E-FABP-deficient mice are completely resistant to HFD-induced skin lesions. Collectively, E-FABP represents a molecular sensor triggering HFD-induced skin inflammation.