[Soft skin fibromas: study of their importance and diagnostic significance for colonic neoplasms]. The aims of this study were (a) to examine the association of skin tags and colonic polyps and (b) to identify factors influencing skin tags. Therefore, a consecutive series of 157 medical ward patients with gastrointestinal symptoms who underwent colonoscopy underwent dermatological examination. Skin tags were found in 52% of these patients regardless of sex. (a) There was a statistically significant association between skin tags and colonic polyps (P = 0.33). This association, however, was based solely on an age effect. (b) Influencing factors were weight and age for the number of skin tags and the interaction between sex and the concentration of triglycerides for their size. At any given triglyceride concentration, men had larger skin tags. Published in Der Hautarzt; Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete (1990)

Obesity as a multi-organ disease that affects the entire human organism. Notably, the skin is no exclusion from this postulate. Skin changes in obese patients have been widely studied with regards to mechanical friction, skin infections, and skin hypertrophic conditions, such as acanthosis nigricans and, most commonly, fibromas (skin tags). Almost 60-70% of obese patients present with a variety of skin changes. Herein, we discuss our own experience and review the complex skin changes in obesity. The role of metabolic syndrome and obesity are responsible for the epidemiological prevalence and are involved in the pathogenesis of chronic inflammatory skin diseases, such as psoriasis, atopic dermatitis, and skin malignancies. Here, we comment on the role of nutritional interventions in these patients as it has been proven that low-calorie diet and weight loss is related to improvement of inflammatory skin diseases. The readership of this paper will receive up-to-date overview on the connection between obesity and the skin that is of a practical importance to any clinician working in the field. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Obesity as a multi-organ disease that affects the entire human organism. Notably, the skin is no exclusion from this postulate. Skin changes in obese patients have been widely studied with regards to mechanical friction, skin infections, and skin hypertrophic conditions, such as acanthosis nigricans and, most commonly, fibromas (skin tags). The readership of this paper will receive up-to-date overview on the connection between obesity and the skin that is of a practical importance to any clinician working in the field. Skin physiology and pathology are influenced by the interplay of hormones, immune signaling molecules, and growth factors. Therefore, skin homeostasis reflects the inner state of the organism ( 1 , 2 ). For centuries, the skin has been accepted as a “mirror,” in which the health status of internal organs is reflected. Classic examples of skin changes in systemic diseases include paraneoplastic skin syndromes, accumulation disorders (e.g., Fabry disease), and genetic inherited conditions with cutaneous involvement ( 3 ). Weight reduction, topical retinoids, keratolytic agents, and agents targeted against insulin resistance have been shown to be effective in the treatment of this condition ( 23 ). FIGURE 3 Acanthosis nigricans presented with velvety, brown plaques, and skin tags (fibroma pendulum) on the neck of the patient. Fibroma pendulum (skin tags, acrochordons) represent pedunculated skin-colored papules, most commonly involving the predilection skin sites for acanthosis nigricans (skin folds) ( Figure 3 ) ( 24 ). The number and the distribution of skin tags has been correlated to the degree of hyperinsulinemia ( 25 ). In Figure 4A , we present a male obese patient with scrotal bacteria cellulitis (erysipelas) who presented with diffuse erythema and edema. In Figure 4B , the residual changes after repeated bacterial folliculitis can be observed. The pattern resembles a “moon crater” due to the excessive tension forces in the process of resolving Staphylococcal folliculitis. FIGURE 4 (A) Skin bacterial cellulitis of the scrotum and inguinal area of an obese male patient. (B) Atrophic round scars, secondary to the resolution of bacterial folliculitis, resembling “moon crater” Skin Changes Due to Chronic Venous Insufficiency The increased intra-abdominal pressure in obese patients results in chronic venous insufficiency (CVI) which manifests as varices, lower limb edema, leg ulcers, and lymphedema ( 33 ). In Figure 5 , we present a rare case of elephantiasis nostras verrucosa, which resulted from CVI and secondary lymphedema of the lower limbs characterized by epidermal papillomatosis, in a 54-year-old patient with a BMI of 48.5. FIGURE 5 Elephantiasis nostras verrucosa with skin papillomatosis, pigmentation, and soft tissue overgrowth. We refer the reader to a former work of our group revealing the adverse skin reactions to metformin, commonly used off-label for the treatment of obesity ( 69 ). Rarely, reactions to anti-obesity food supplements have been documented, as in the case of lichen planus pemphigoides ( 70 ). Bariatric surgery induces specific skin manifestations that could be divided into (1) diseases due to metabolic and nutritional disorders, and (2) those derived from cutaneous structural changes after major weight reduction ( 71 ). The most specific adverse skin reactions to this intervention include bowel-associated dermatosis and arthritis syndrome, erythematous macular eruption with a neutrophilic infiltrate, non-pruritic papular eruption with IgG and C3 deposition, and erythema nodosum ( 71 , 72 ). In addition, a new subset of HS associated with malabsorption and deficiency in micronutrients has been described ( 73 ). Zinc deficiency resulting from malabsorption in bariatric surgery has been linked to the development of the rare condition known as necrotic migratory erythema ( 74 ). The most common specific stigmata of obesity on the skin include the “horseshoe-like” plantar hyperkeratosis, skin tags (fibroma pendulum), and acanthosis nigricans, with the latter specific for the insulin resistance in obesity. Therefore, these signs are considered relevant to be screened in obesity and overweight patients. On the other hand, the link between certain chronic skin conditions is a subject of a growing body of evidence. Therefore, patients with chronic inflammatory skin disorders such as psoriasis, AD, hidradenitis suppurativa, and systemic lupus erythematosus should be monitored for obesity with the primary goal of losing weight.

Metabolic syndrome (MeTS) is a well-known health-related problem with several end-organ damages and the resulted side effects such as rising in the blood glucose and lipid and blood pressure. Although MeTS might show several skin symptoms such as acanthosis nigricans, skin tags, acne, and androgenic alopecia, it could also be implicated in the pathophysiology of numerous dermatologic disorders. Furthermore, some dermatologic drugs might be implicated in the incidence or exacerbation of MeTS. Consequently, MeTS and skin problem could interfere closely with each other and each one could predispose the patient to the other one and vice versa. Remembering these close relationships help us to have better therapeutic choices regarding each inflammatory skin conditions. Moreover, some of the skin symptoms should be followed cautiously to define the underlying MeTS.