Obesity-related Skin Conditions

Description

This webinar focussed on the dermatological conditions associated with obesity, and included patient perspective on living with obesity and a skin condition. Clinical speakers provided an overview of common skin conditions like psoriasis, examining the underlying mechanisms linking skin issues to obesity. Preventive strategies were discussed to support effective clinical management and help mitigate the onset or progression of skin conditions in individuals with obesity. More information here: https://easo.org/managing-obesity-related-skin-conditions-dermatological-insights-and-interdisciplinary-strategies/

Comments & Resources

Dr Ludovica Verde provided answers to the audience questions offline:

Q1) How do you deal with the skin reactions patients may experience related to liraglutide treatment? Stop treatment intermittently and restart at a lower dose and up titrate again?

A1) “For patients experiencing skin reactions with liraglutide, intermittent cessation of the drug and restarting at a lower dose, followed by gradual up titration, can help manage side effects. This approach allows the body to adapt to the medication, potentially reducing adverse reactions over time. A dermatological consult can be helpful if reactions persist.”

Q2) From your perspective, what are some of the key barriers people with obesity face in accessing timely and effective dermatological care?

A2) “Individuals with obesity often face stigma and limited access to specialized dermatological care. Physical limitations can complicate travel to appointments, especially for housebound patients, and insurance coverage may not always support skin care treatments for obesity-related conditions. Additionally, many healthcare facilities lack specialized equipment and seating to accommodate people living in larger bodies, creating physical and psychological barriers to care.”

Q3) Are there any emerging therapeutic approaches or recent clinical findings you’re excited about that could enhance dermatological care for people with obesity?

A3) “Promising research focuses on anti-inflammatory treatments for chronic skin conditions, including biologics for psoriasis and atopic dermatitis, which may indirectly benefit obesity management by reducing systemic inflammation. Additionally, research on the microbiome and its relationship to skin and metabolic health holds potential for new treatments.”

Q4) Is there any skin condition due to nutritional deficiencies after bariatric surgery?

A5) “After bariatric surgery, deficiencies in vitamins A, D, E, K, B vitamins, and zinc can lead to various skin conditions. Vitamin A deficiency, for instance, can cause dry, rough skin, while zinc deficiency can lead to rash-like dermatitis. Close monitoring of nutrient levels and supplementation is crucial to prevent these dermatological issues.”

Q6) There is very little evidence or guidance to support good tissue viability or skin care for people with obesity, especially those who are housebound. Helping people perform personal care of skin folds and manage issues of incontinence are largely unevidenced, affecting confidence and social interactions. There is also very little evidence around pressure area care when people’s skin does break down. The evidence base is largely directed at underweight individuals, leaving healthcare staff guessing about best care practices, leading to inequalities in care provision.

A6) “There’s a significant gap in evidence-based guidelines for skin care in people with obesity, particularly for those who are housebound or have limited mobility. Effective personal care of skin folds, managing incontinence, and addressing pressure area care are all critical but under-researched areas. Providing tailored care, such as guidance for fold hygiene and skin barrier protection, can improve tissue viability and reduce the risk of skin breakdown, enhancing comfort and social confidence.”

Key Takeaways

  • Obesity increases risk for skin conditions, including psoriasis, atopic dermatitis, and acanthosis nigricans: Unique dermatological challenges may arise from structural and metabolic changes associated with obesity development, including thicker skin folds, increased surface roughness, and altered skin physiology.
  • Psoriasis and obesity share pro-inflammatory mechanisms, which elevate systemic inflammation and exacerbate skin conditions: Nutritional interventions for skin conditions, particularly anti-inflammatory foods and supervised low-calorie ketogenic diets, show promise for managing psoriasis in patients with obesity.

Next Steps and Future Research

EASO COMs members may wish to collaborate to develop this research area: Panellists highlighted the need for clinical trials on obesity management medications and GLP-1 receptor agonists to determine their effects on skin disorders in people with obesity. Guidance for clinicians on managing skin reactions to obesity treatments like liraglutide and better education on reducing obesity stigma in dermatological care can support progress in this area.

Transcript

Transcripts are auto generated, if you spot an error, please email enquiries@easo.org

Okay, good morning everybody. And thank you so much for joining this webinar on behalf of IESO. Today I’m really delighted to be chairing the session which is entitled Dermatological Considerations in Obesity Treatment.

And I think, as we know, there are over 200 conditions associated with obesity and commonly we’re now seeing a lot of skin conditions which we think, are also associated with obesity. And to some extent, perhaps we don’t recognize that association. So I’m delighted today to have an excellent panel, which includes a patient advocate, Marie Messe, who’s going to give us a little bit of her insight and she’s available to answer questions.

And also we have Professor Teodora Angeva Danleska from Sofia, Bulgaria, and Ludovica Verde, who the nutritionist from Italy, to help us with the session today. So a warm welcome to the panel. Thank you very much.

Before we start, I just wanted to remind everybody about a couple of things going on with the IESO and specifically to remind you about the COMS Summit, which will take place on the 27th to the 28th of November 2024 in Santiago de Compostela in Spain. And the summit will follow a scientific programme inclusive of presentations from clinicians and researchers and clinical case discussions and network opportunities. And this year, the Spanish CEDAW 2024 meeting will be held alongside the summit.

Just to remind you that all COMS offered two nights of complimentary accommodations and free registration. And the final deadline to apply is this Thursday, 31st of October. So if anyone is thinking of attending, please apply now to join.

And also, if you would like to present research from your COMS in the future, in a future COMS webinar, do get in touch with Lisa. She’d be delighted to sort of hear from you. So without further ado, I’d like to start off the webinar today and introduce to you Mari Metti, who he’s a patient advocate.

And Mari Metti has done a little video for us to kick off the session so that we can hear a little bit about the patient experience. And Mari Metti is actually the patient advocate for the European Coalition for People Living with Obesity. She’s also the deputy chair of the Norwegian Lymphoedema and Lipoedema Association.

And she will be presenting patient perspective on living with a skin condition. Thank you very much. Hello, my name is Mari Metti Graf and I live in a city called Tromsø, which is in the northern part of Norway.

I live with obesity and for many years I lived with intertriago, which affected me every day. It’s not necessarily about the discomfort or small pain or the instant urge for scratching on it. No, it’s about the fear, the fear that they could smell it.

I would be afraid that they would think, isn’t she taking care of her personal hygiene? And of course, that affected me when I was at work, when going to work, sitting on the bus. It affected me when I was going to give my children a hug or being intimate with my partner. It held me back from going to the swimming pool and really enjoy the freedom of swimming in the water, which I really appreciate.

So thank you. It makes me very happy that you have a webinar on this. So thank you very much, Mari Metti.

That was a really powerful couple of minutes of sort of sharing your experience. And we’re very grateful because there’s nothing like the patient’s experience to really make us realize really how these conditions can affect patients. And Mari Metti will be available for questions towards the end of the webinar.

So thank you very much. So without further ado, then, we shall move on to our next presentation. And I’m delighted to introduce to you Professor Tudora Andreeva Danilevska, who is from the Department of Pharmacology and Toxicology at the Medical University of Sofia in Bulgaria.

And she’s also the president of the Bulgarian Association for the Study of Obesity and Related Diseases. And Tudora is a general medical physician and she comes across a lot of skin conditions during her everyday job. And today she’s going to share her experience with us with a lecture entitled Recognizing Dermatological Challenges in Obesity.

Professor Tudora, thank you. Thank you, Barbara. So now I’m sharing my presentation with you.

Can you just confirm that you can see everything? Yes. Perfect. Thank you.

Thank you very much. So the first paper which was related to obesity and psoriasis appeared in the Medical Journal in 1963. And as you can see, there was like a plateau during a long period when the community, the medical community doesn’t have any interest regarding the link between obesity and psoriasis.

And nowadays in 21st century, there is a large body of evidence showing that there is a link between not only psoriasis as a skin disorder, but also about obesity and different skin alterations. So I’d like to thank Yasu for inviting me to give you this lecture about Recognizing Dermatological Challenges in Obesity. And this is me.

I’m, as Barbara said, a professor in medicine in Medical Faculty, Medical University in Sofia, Bulgaria. I’m also president of the Bulgarian Association for the Study of Obesity and Related Diseases. And I’m leading the COM in Sofia, Bulgaria.

So it’s a pleasure for me for being part of this interesting webinar. And I think this is the first one which focuses on the different skin alterations in obesity. So skin is the largest organ in the human body.

And it has different functions. And for centuries, skin was believed to be accepted as a mirror in which the health status of our internal organs is reflected. Obesity is now recognized as a chronic disorder, which leads, as Barbara said, to many comorbidities.

But in fact, the skin changes related to obesity have been underestimated with almost 50% of obese and overweight displaying skin comorbidities. And here is a nice graph showing you the different, the frequencies of different skin pathologies. So the most commonly seen in our daily practice skin pathology is the stria distensae, which could also be characterized by different metabolic and endocrinology conditions, but also the horseshoe-like plantar hyperkeratosis, which is on the second top place.

And then you can see 18 different skin comorbidities related to the obesity status. So analysis of 156 obese patients revealed that plantar horseshoe-like hyperkeratosis is the main typical cutaneous stigma in this population of people living with obesity. This reaction, together with the decrease of the plantar arch, is a defensive mechanism of the skin against the mechanical friction and increased gravity load of the hills.

So during my presentation, I will cover different topics related to the skin alterations in obesity. So first, I’ll start by showing you the skin physiology, which is characteristic in people living with obesity. Then a few characteristics of the monogenic obesity syndromes related to the skin, some mechanistic complications that lead to skin disorders.

And in the middle are very important features of the skin related to two very common features of obesity, hyperinsulinemia and hyperandrogenism. So I’ll go through a little bit about skin infections, the vascular problems, skin diseases that are influenced by obesity, and last but not least, some skin complications which are related to obesity treatment. So let’s start by the skin physiology alterations in obesity.

The skin of an obese person is characterized by increased subcutaneous fat, larger skin folds, and higher surface roughness. So here you can see in this graph, picture, sorry, a comparison between different skin parameters in non-obese and obese patients. So what we can see here that we have increased trans-epidermal water loss that could lead to impaired barrier function in a patient living with obesity.

Also, we can see that there is a decreased hydration, alkaline pH in comparison to the normal pH in non-obese, and also reduced microvascular reactivity. So what are the main characteristics of the monogenic syndromes, which are very rare, but in fact, some of their features are related to skin alterations. So in the most commonly seen rare monogenic syndrome, we can see the propionylmalonucleotide deficiency.

We can see that there is a red hair, the very common feature of this monogenic syndrome, and a type one skin characteristic. And I won’t go into details into different, you can see here, obesity syndromes, but there is a real link between monogenic obesity syndromes with some skin signs. So which are the mechanistic complications? You can see here a very nice picture of the plantar hyperkeratosis or the horse-like shoe, you can see.

And another very common feature is the stria distensae, or also known as stretch marks, and they result from the mechanical stretching and tearing of the elastic dermal fibers. The main characteristics of the stria distensae are shown here, they’re reddish or pur-colored, vertical, most often on abdomen area or tight shoulders or buttocks. And it is important to stress that stria distensae is also a common feature in Cushing syndrome, in pregnancy and elastosis.

So here are some pictures of our patients, and you can see this reddish color of the stria distensae mainly located in the abdomen area. So we can also see in our patients living with obesity changes in the skin due to hyperinsulinemia. And hyperinsulinemia increases the productions of different factors such as the higher blood insulin and insulin growth factor one that per se leads to two main features of obesity, which are acanthosis nigricans and fibroma molle.

So acanthosis nigricans is a hyperpigmentation, brown velvet-like flakes, most often in skin folds. And acanthosis nigricans could be also associated with some endocrine and neoplastic processes. Skin tags, also known as fibroma pendulum, are commonly seen in patients with obesity and hyperinsulinemia, and they are located on the skin folds as well as the acanthosis nigricans.

And here on this graph, you can see that increasing the total body fat in percentage increase the number of skin tags in our body. And also there are some changes due to hyperandrogenism. And these skin alterations are related to hypoxia, acne, male type of androgenital alopecia, two different syndromes such as the Hyeh-An syndrome characterized by hyperandrogenism, insulin resistance, and acanthosis nigricans, and the Sacha syndrome, which is characterized by seborrhea, acne, hyazotism, and alopecia.

Hyperinsulinemia increases the production of androgens and reduces the sex hormone-binding globulin in the patient with obesity. And this is maybe a contributing factor in association of beforehand mentioned disorders with increasing the body fat and the BMI. So here are some pictures from patients with hyazotism, acne, and the male type androgenic alopecia in women, shown here, and also in men.

Very commonly, we can see in our patients suffering from obesity, some skin infections. So they could be bacterial based on staphylococcal, cellulose, and streptococcus pyogenes infections. And they could be intratrigus, cellulitis, folliculitis, erythrosma, and some problems with lung healing.

And we also have skin infections which are due to candidiasis. So there is a many, many, many papers that shows that people suffering from obesity has increased risk for skin reactions. Intratrigus is one of these skin infections.

And I’m very happy that we started our webinar by Marie-Mère’s presentation as a patient to share with us her experience with this very unpleasant, let’s say, skin condition. And some etiological factors for intratrigus are related to excessive skin folds and bad hygiene, great friction, hyperhidrosis, and diabetes even worsens this skin infection. Another picture is from a patient with morbid obesity before bariatric surgery.

Of course, it’s not only the skin infections, but also some vascular problems could occur in patients with obesity. And the most commonly seen are the peripheral blood vessel disease, which is presented by viruses. 40% of people living with obesity suffer from viruses.

They also have chronic venous insufficiencies, which is characterized by different skin alterations and some very dangerous and bad skin disorders such as lymphedema and elephantiasis nostris verrucosa, which is characterized by pseudopapular hypertrophy, hyperkeratosis, and lymphedema. And here I can show you a patient of mine who was morbidly obese with BMI 58. And he has this elephantiasis nostris verrucosa.

Of course, he was in our clinic for bariatric surgery. But before the surgery, we refer our patient to dermatological care. And there’s some diseases that are worsened by obesity.

And the most commonly seen in the worldwide population are psoriasis and atopic dermatitis. And psoriasis is a chronic inflammatory disorder that shares pro-inflammatory mechanism with obesity. Psoriasis causes systemic inflammation.

That in turn stimulates the visceral fat tissue to produce a plethora of pro-inflammatory cytokines and cells such as tumor necrosis factor alpha, interleukin 6, interleukin 17a. And all these can promote cutaneous inflammation. So here is a nice diagram that depicts inflammation in the epidermis and dermis associated with psoriasis status and inflammatory molecules produced by the fat tissue, by the adipose tissue of individuals living with obesity.

And all these soluble molecules enter the systemic circulation. They alter, you can see here, the production of leptin, the production of adiponectin, all these hormones that are related to appetite regulation, and that are involved in the pathogenesis of obesity. And per se, those two factors, the inflammation in the skin and the inflammation in the fat tissue, could lead to overall altered metabolic and cardiovascular risk.

This man introduced in the early 20th century, that there is a balance between the pro-atherogenic or pro-inflammatory cytokines and molecules, and the potentially productive anti-inflammatory molecules such as adiponectin, interleukin 10, normal leptin function, and some other cytokines with potential beneficial metabolic effects. But in fact, it was confirmed that in obesity related to skin disorders, there is alterations in this balance, and there is a strong link between pro-inflammatory factors related to skin alteration and obesity. So, psoriatic plaque is a very similar characteristic to atherosclerotic plaque, and this picture shows you a comparison of the inflammatory nature of psoriasis and atherosclerosis.

And you can see that the main features are again related to the high incidence of pro-inflammatory cytokines and molecules such as Xanthalpha, interleukin 6, 17, 8, and others. And there is this connection between psoriasis and obesity with the main pathogenesis link based on the pro-inflammatory status. And what we know from the literature is that increasing the BMI worsens the psoriasis status, and also a weight loss leads to amelioration of the psoriasis by, of course, different dermatological indices.

And back to the stigma of psoriasis, because we started our webinar with a patient story, this personal story about skin disease and obesity. And I here show you a very nice study made by Hauro and co-authors, and they explore the different feelings of the people living with psoriasis. So, what, I’m sorry, I want to go back, what these patients experience more anticipation of rejection, feelings of being flayed, sensitivity to the opinions of others, guilt, shame, etc.

So, there is a statistically significant increase of all this emotional status in the patients living with psoriasis, but as Mary-Mette shared with us also with the skin, some other skin disorders, and the emotional status. A person living with psoriasis is often alexitory, pessimistic, anxious, they have difficulties in recognizing one’s body, and it is established that these people living with psoriasis, which is a chronic disorder, are prone to addictive behavior. Atopic dermatitis is another well-known dermatological condition, also related to obesity status, and it was shown in children, which are sedentary, which has a very low physical activity, and maybe also lower exposure to allergens, and a very poor, not balanced diet.

So, these two factors, sedentary diet and low, unbalanced diet, lead to gut, I’m sorry, lead to gut microbiota alterations, and this, in turn, together with increased leptin secretion, increased resistant bisphosphate secretion, and less adiponectin, this beneficial hormone from the fat tissue, increases the pro-inflammatory production by the muscles, by the skin, and also leads to atopic dermatitis. So, there is a strong link between obesity and atopic dermatitis. And here, I show you a nice study, which was recently published by a team working in the field of atopic dermatitis.

So, here, on A, the first graph, you can see the weight reduction group and weight maintenance group, and after 12 weeks of intervention, there is a significant decrease in the BMI in the weight reduction group, and this group also shows a significant decrease in AACI, and AACI is eczema area and severity index related to atopic dermatitis. So, to sum up, a weight loss leads to decrease or amelioration of the atopic dermatitis status. Furthermore, here, graph B, you can see that adiponectin levels are very low, statistically lower in people with atopic dermatitis and obesity in comparison to the normal weight patients.

And to end my presentation, I will just focus a little bit of the skin complication that could occur together in obesity treatment. So, some of the shown drugs here are not on the pharmaceutical markets nowadays, but I just put this information because I think that as physicians, we need a broader notion and knowledge on the way of obesity and its treatment. So, it was confirmed that olistat could lead to lichenoid direct eruption, dexfluramine to urticaria, and liraglutid, which is the GOP-1 receptor agonist, could lead to vasocapustular dermatosis.

And recently, with my team, we’ve published a paper showing a D8-type hypersensitivity on the ejection site of liraglutide for the treatment of obesity. And to sum up, obesity is a serious health and social problem, which has its skin stigmata, and there is a statistically significant correlation between the severity of some skin disorders and the rate of obesity. The most common skin alterations characterized by different diseases are plantar horseshoe-like hyperkeratosis, acanthosis nigricus, fibroma molle, which are expressed by hyperinsulinemia, stria distensae, and intertrigum.

Thank you for your attention. Thank you very much, Teodora. That was a really wonderful lecture, really summarizing a lot of the challenges, I guess, that we meet, but also really reminding us about the associations between skin and obesity, and I guess how much work that potentially we need to do to get more evidence, and also with regards to treatment, I guess.

We certainly need more clinical trials in this area to assess whether, for example, treatments with these new agents or weight loss by lifestyle or bariatric surgery, whether it actually improves these conditions. And I think there’s a little bit of evidence there in the literature, but I think we definitely need a lot more. But that was very, I thought that was excellent.

So I’m sure there’ll be lots of questions coming your way, but I think what we’ll do is we will, for the time being, we’ll move on to our next speaker first, and then if that’s all right, we’ll do the questions all at the end. So just before I do so, just to remind everybody about using person-first language in all our presentations. So we talk about people living with obesity rather than obese, so we should avoid those words.

So just reminding everybody, and I think hopefully Lisa will also put a link about the guidelines in the chat. So thank you, Lisa. Okay, so without further ado, we will move on to our final speaker, and her name is Ludovica Verde.

She’s a nutritionist, Dr. Ludovica Verde from the University of Naples, and she’s going to talk to us about a really interesting topic entitled clinical and medical management of very low calorie ketogenic diet in patients with psoriasis and obesity. So let’s see what the evidence is that they work for us. So Ludovica has recorded, and unfortunately, I know that she might not be able to answer questions live, but she’s very happy to answer questions in the chat, even if not during the webinar, because she needs to go off to something even more important.

So over to the webinar, please, and then we can do Qs at the end. Thank you very much. Thank you for the invitation to speak today.

I’m pleased to present on integrated management of psoriasis and obesity, highlighting the important roles of endocrinologists and nutritionists. In this presentation, we will focus on the clinical and medical management of very low calorie ketogenic diets in patients with this condition. Let’s begin with an overview of psoriasis.

Psoriasis is a chronic inflammatory skin disease characterized by red, scaly peaches on the skin. It’s not contagious and is caused by an imbalance in the immune system, particularly from the overactive Th1 and Th17 cells that trigger inflammation. The disease has four phases, a trigger, an innate immune response, a stimulated adaptive response, and excessive skin cell growth.

Understanding these phases help us to find better treatments to manage symptoms and improve the quality of life for those affected. Now, let’s discuss the factors influencing psoriasis onset and flare-ups. Both genetic and environmental factors play a role.

A family history of psoriasis increases the risk due to genetic predisposition, while environmental triggers like stress, infections, smoking, and certain medication can worsen symptoms. Additionally, diet matters. While non-specific foods directly cause psoriasis, a balanced diet rich in anti-inflammatory foods such fluids and vegetables may help to reduce flare-ups and improve skin health.

Importantly, psoriasis is now viewed as more than just a skin condition. It’s connected to chronic inflammation and metabolic syndrome. The inflammatory pathways driving psoriasis are similar to those involving metabolic syndrome, which includes obesity, insulin resistance, and cardiovascular disease.

These links suggest that psoriasis may not only be a skin disease but also a marker of systemic inflammation, highlighting the need for realistic treatment approaches that target inflammation throughout the body. Evidence shows a clear connection between body mass index and psoriasis. Research indicates that each one unit increase in BMI raises the risk of developing psoriasis by 9% and contributes to a 7% higher risk of worsening psoriasis severity, as measured by the psoriasis area and severity index.

This relationship again underscores the importance of managing ways to reduce both the risk of developing psoriasis and the progression of the disease. To better assess the health, risk, and nutritional status of patients with psoriasis, we need additional evaluation like body composition analysis and dietary intake assessments. This evaluation will help us design target interventions to improve overall health and effectively manage disease progression.

Hormones, particularly those from the adrenal axis, play a role in psoriasis and itching. Itching can be triggered by external factors like scratching, inflammation in skin lesions, and psychological stress. Scratching releases neuropeptides that send itch signals to the brain and in inflamed skin, immune cells release cytokines that worsen itch by increasing inflammation and acting directly on nerves.

Stress activates the APA axis, leading to the release of hormones that intensify itching. And finally, increasing blood flow also contributes by allowing more immune cells to reach the affected areas. Moreover, psoriasis is linked to a higher risk of cardiovascular disease.

Spreading inflammation from psoriasis can damage blood vessels, increasing the risk of hypertension, atherosclerosis, and heart events. This connection highlights again the importance of treatments that address both skin symptoms and cardiovascular risk to improve overall patient health. Psoriasis is also associated with lipoprotein dysfunction, including higher levels of triglyceride-rich VLDL particles.

High visceral fat contributes to systemic inflammation, increasing cardiometabolic risk along with traditional atherosclerosis risk factors. This combination can lead to greater non-calcified coronary artery burden and early signs of coronary artery disease. Managing psoriasis requires more than just medication.

A balanced diet rich in anti-inflammatory foods can significantly alleviate symptoms and enhance treatment efficacy. However, in many studies it’s challenging to separate the effects of weight loss from dietary changes. In dermatology, dietary modification, especially the ketogenic diet, have gained attention for treating skin disorders.

The ketogenic diet focuses on reducing carbohydrates, leading to a metabolic shift with increasing glucagon and decreased insulin. This change promotes the release of free fatty acid from fat stores, which the liver converts into ketone bodies, serving as an alternative fuel source. Very low-calorie ketogenic diets usually consist of fewer than 800 kilocalories daily, with about 0.8 to 1.2 grams of protein per kilogram of ideal body weight, and only 20 to 30 grams of carbohydrates each day.

Whole CKDs also have anti-inflammatory effects that can benefit conditions like psoriasis. Research shows that whole CKDs can significantly reduce inflammatory processes. The benefits for patients with psoriasis stem from two main factors.

Weight loss, particularly the reduction of fat mass and visceral adipose tissue, and the improvement of antioxidant and anti-inflammatory pathways. There is a close link between obesity and psoriasis, both involving shade-prone inflammatory pathways, and this relationship is bidirectional. Obesity can trigger psoriasis, while psoriasis can contribute to weight gain.

Finally, both conditions are associated with low-grade chronic systemic inflammation, driven by pro-inflammatory cytokines from both adipose tissue in obesity and from psoriasis itself. Despite limited studies on the efficacy of real CKDs in psoriasis, the scientific interest is growing due to the inflammatory connection between psoriasis, obesity, and related cardiometabolic issues. Given that both psoriasis and obesity involve inflammation, researchers are exploring how whole CKDs might help manage this condition together.

The first study assessed whole CKD efficacy in restoring a response to systemic therapy in a case report of a female patient with recurrent plaque psoriasis. This patient had been treated with biologic therapy for up to six months before starting the ketogenic diet. When her psoriasis rolled out, she followed a ketogenic diet for four weeks instead of switching to a second-line biologic.

After this protocol, she achieved significant weight loss and reduced visceral fat. Notably, her skin lesion improved, with a reduction in the PASI score of over 80%. The second study evaluated the ketogenic diet as a first-line treatment for psoriasis, including 37 adults with overweight or obesity and had never received systemic drugs for their condition.

By week 10, the ketogenic diet led to significant decrease in PASI scores and changes in body weight. Of note, the improvement in PASI scores was independent of participant weight status. In addition, the ketogenic diet resulted in significant improvements in all inflammatory parameters ensuring this study, demonstrating the efficacy of a ketogenic diet as a first-line dietary strategy for patients with psoriasis.

Our research group has published a practical guide for using very low-calorie ketogenic diets in psoriasis and obesity. It is essential that all CKDs be administered under the supervision of a nutrition specialist and closely monitored throughout the process. The regimen consists of three stages, the active phase, the re-education phase, and the maintenance phase, transitioning to a Mediterranean diet.

Finally, I would like to say something about physical activity. It is well established that physical activity is crucial for treating and managing psoriasis and metabolic diseases. Regular physical activity is an important part of the re-education phase of well-seeked diet.

It helps modulate inflammation and immune response mainly by activating T-lymphocytes. However, few studies have explored the molecular mechanism behind physical activity’s effects on psoriasis, making the relationship between exercise and the disease somewhat unclear. Moreover, many patients with moderate to severe psoriasis face challenges in maintaining regular physical activity.

In conclusion, nutrition plays a vital role in managing psoriasis. Evidence shows that very low-calorie ketogenic diets can reduce systemic inflammation and obesity, leading to positive effects on the condition. Since obesity is a significant risk factor for psoriasis, treatment plans should include specific dietary guidelines aimed at lowering inflammation.

Well-seeked diet has demonstrated significant benefits in reducing inflammation and helping patients lose weight, particularly fat mass. However, it’s crucial that well-seeked diet is prescribed and monitored closely by healthcare professionals to ensure safety and efficacy. By incorporating these dietary strategies, we can pave the way for new and effective treatments for psoriasis.

Again, thank you for the invite and for your attention. Brilliant. Thank you very much, Ludovica, for another really interesting talk.

It’s sort of looking at, I guess, a slightly different angle, but really very interesting again. And Ludovica, unfortunately, is not here to answer questions right now, but do post them in the chat for anybody that does have questions, and she will be delighted to answer these, and then we can attach them to the video recording. Okay, great.

So I’ve got my speakers back, and please do put questions in the chat so that we can have a good discussion. We’ve got about 15 minutes now. So, I mean, one of the questions that’s in the chat, somebody has raised, and this is a question to Theodora.

How do you deal with the skin reactions related to liraglutide treatment? Do you stop treatment intermittently and do you restart at a lower dose and uptitrate again? I mean, you showed us some images of the skin reactions. I don’t know whether it’s the same with some of the other newer pharmacotherapies, whether anybody’s seen similar reactions, and maybe some of you can share with us. Theodora? Thank you, Barbara, and thank you, Inge, for your question.

So what we did was not to stop the liraglutide treatment because we were fearing about the yo-yo effect after we stopped the treatment. We started by a steroid ointment for two weeks, followed by once daily another steroid ointment, and we continued the treatment with liraglutide at the maximum dose of three milligram daily. And the patient was able to tolerate the drug without any skin reactions.

Okay, great. That’s really useful information. So thank you for those tips.

Very useful. Okay, so a question to Mari Metti. So from your perspective, what do you think are some of the key barriers that people with obesity face in accessing timely and effective dermatological skin care? You know, give us your perspective on this.

Did you meet with barriers and what do you think those are? I think the main problem is that people living with obesity are being blamed for causing their illness themselves. We should just pull ourselves together, eat less and exercise more, and we would have no problems at all. So as long as living with obesity is considered as a moral condition and a choice, and not a medical condition, we will meet prejudices and obstacles everywhere, also in healthcare.

And you’re absolutely right. So obviously, you know, we see a lot of stigma, you know, everywhere in obesity. So independent of skin conditions, I think we see it all the time.

And I think that’s a huge barrier. You’re absolutely right. And I think there’s no doubt that we need to continue to educate healthcare professionals, but also patients and ensure that they don’t feel stigmatized and they understand that it’s not their fault.

And that’s a really strong point. Thank you very much. Do you think things have changed over the years? Or you don’t think we’ve seen much progress? It depends.

In Norway, we do have what we call the first line, which is general practitioners, and then you have the hospitals. Yes. You have the researchers.

And more the last group, there has been a change. It’s a new paradigm when it comes to understanding both the complexity and the causes and who’s to blame. But the main challenge, at least in Norway, is the rhetorics of war when we’re talking about obesity.

Obesity and overweight, the biggest threats against do-do-do, and won the battle against the kilos. And whenever talking about war, we need an enemy, but we don’t blame the industry, those who produce food, those who sell them, set the prices. We blame us, the people living with obesity.

So it’s a huge challenge to change the rhetorics and how we talk about it. You’re absolutely right. So you’re absolutely right.

And of course, there’s a lot that we need to do at government level, I guess, to try and implement some of those environmental changes that can be so challenging as well. But yes, it is a multi-system approach. You’re absolutely right.

So thank you for raising that for us today. So I’m going to go back to Professor Theodora. And one of the questions in the chat is, is there also an effect of anti-inflammatory drugs for atopic dermatitis psoriasis on the obesity of patients? We mostly talk of effect of diet on skin manifestations.

Thank you, Barbara. I like this, Professor Theodora. So back to the question of Diederik.

Thank you for the question indeed. So based on the literature, it was shown that the higher the BMI, the lower response of direct treatment of psoriasis or atopic dermatitis. So the first thing that we advise our patients is to lose weight because we all know that, for instance, in psoriasis treatment, the biologicals are more effective if we have less BMI.

So this is my answer. Okay. Yeah, that’s a good answer.

That’s a good answer. Do you think that there are any emerging therapeutic approaches or recent clinical findings that you’re excited about that could enhance, you know, skin care, dermatological care for people living with obesity? This is a question for me? Yes. Professor Theodora.

So the last question, you mean, is there any skin? So any emerging new therapeutic approaches or new medications or recent clinical trials or recent clinical findings that you, that are exciting that you think may be able to help people living with obesity? Yeah, I think that these are the biological drugs. Okay. Many, many data showing that they decrease the psoriasis status and of course, based on the patient’s characteristics, but they’re really very effective.

Yeah. And what about just weight loss drug themselves, not the biologics, you know, so the new, I don’t know, GLP ones or increasing therapies. Is there any evidence of clinical trials that they might, you know, that may be effective or even, I guess, looking at bariatric surgery, you know, can we get any clues from, from those data as to whether weight loss helps specifically to skin conditions? Yeah.

If I have to be honest, I don’t think that the big trials with drugs, I mean, at this moment, they are interested on skin conditions. So I don’t think that there’s data showing that the use of GLP one receptor agonies are beneficial to skin conditions. I’m not aware of that.

And I think you’re right. I don’t think, I mean, certainly I think I’ve seen possibly like systematic reviews and meta-analysis, but certainly not large randomized clinical trials. And it’s not one of these conditions that’s been prioritized in a sense.

I think we’re seeing obviously the use of these agents in other conditions, such as sleep apnea or fatty liver, you know, muscle D or mash, but certainly not skin. Do you know why that might be? Why skin conditions not being prioritized? Is it because the preliminary evidence is not strong enough or is it going to be the next thing? No, I think that this is the future. I think that now the trials are more focused on the cardioprotective and renal protective efficacy of all these drugs.

So I think that in the future, we’ll have more data on the efficacy of. And I think you’re absolutely right. So if you guys out there would like to set up some clinical trials, this is a good space to do some research, I think, with the new agents.

There’s also a question that’s asked, is there any skin conditions that are there any skin conditions due to nutritional deficiencies after bariatric surgery? This is a question to everyone. I’m just trying to think about skin conditions associated with bariatric surgery. So can we think of anything? I’m sure there probably is.

But top of my head, I would you know, Barbara, our patients after bariatric surgery, they are taking these food supplements with vitamins and minerals. Yeah. So really, this and this, the risk for deficiency is very, very low.

So in my perspective, from my clinical experience, I cannot say that there is a link. I mean, I think, you know, we certainly do see patients that do not take the supplements for whatever, you know, there’s a lot of people with iron deficiencies, vitamin C deficiencies, there’s definitely, you know, with vitamin C, there’s I remember, there’s a folliculitis that you can you can get with vitamin D. I’m just remembering some of the images. You can get some other tongue changes with, again, probably iron deficiency and nail changes as well with some of the vitamin deficiency.

So I think definitely some nail and skin changes, which are characteristics. But I guess in our clinical practice, because most of our patients are quite good at taking the supplements, but not everybody is. And so for sure, skin conditions and sometimes people can also present with, I guess, well, neuropathies as well, you know, you know, if they don’t take vitamin B12, for example, or if they’re deficient with other sort of minerals.

But that’s a good question. Barbara, could I please have a little input on this? Of course, absolutely. I’d love to hear from you.

And whether we get problems with our skin or not after bariatric surgery depends a lot on how much loose skin do we sit left with. I had bariatric surgery myself. And after losing 75 kilos, I had the body of one, but the skin of two.

It was this gigantic one piece of excess skin, which gave me even more problems than living with obesity and have this skin stuffed. But after I removed it, I’ve never had any problems. You’re absolutely right.

I mean, you know, this is obviously a huge issue after a lot of weight loss, which tradition is also has always been associated with bariatric surgery. But I guess now with more powerful medications as well, some people might get that. And for sure, underneath the skin folds, people can get a lot of a lot of issues, a lot of infection as well.

And it can be quite severe. In the UK, where I am, skin removal is not covered by the NHS, of course, unless it causes a lot of distress. And so individual cases have to be made.

But you’re absolutely right. And there’s a comment in the chat. Yes, of course, say something related to Marymette.

So, you know, that in the literature, there is lack on the threshold for weight loss and the alterations or beneficial effects on the skin. So I think that also this is a future consideration when talking about weight loss and skin diseases. So no threshold at all.

Absolutely. Yeah. And some really good comments in the chat, by the way, which I think are really important as we’re approaching the end, but I think important to read out.

So the, you know, there’s a comment from Kath Williamson to everyone as a nurse caring for people with obesity in the community, especially those who are housebound. There’s very little evidence or guidance to support good tissue viability or skin care and helping people to perform personal care of skin folds and manage issues of incontinence are largely unevidenced, leaving professionals and people living with obesity managing as best they can. This really affects confidence, especially when socializing, as mentioned by Marymette.

So that’s a really great comment. And also she continues to say there’s also very little evidence around pressure area care when people’s skin does break down and the evidence base is largely directed to people living with underweight, meaning staff like myself, I guess, think how to provide best care, a huge care of inequality in care provision. And I think that’s a really good point.

And something, you know, Lisa has added a great point, perhaps something that the ESO comms can work on together to provide evidence and practice into this area. So very good ideas that obviously come out of these webinars. And so thank you very much, Kath.

I don’t know whether you wanted to add anything else. We can now see you. So thank you for that, because they’re very important points.

So I think it’s now 12.28. I think I haven’t, I don’t see any other questions in the chat. So I’ll take this opportunity to thank all the speakers for their contributions today. You’ve been absolutely brilliant.

Thank you for answering the questions. And thank you for each and every one of you for joining today in what I think has been a really interesting webinar. Again, a reminder about the the events in September, the comms events.

And I think, Lisa, I don’t know whether you’ve signposted people to them, but certainly it’s on the website. If you want to go, the deadline is Thursday this week to apply for the comms meeting. So thank you very much, everybody.

I hope you have a wonderful day. And there will be a recording that you can access if you wanted to go back to those slides. Thank you, Professor Todora.

Thank you, Marianetti. And thank you, Ludovica. And everyone, have a great day.

Okay, thank you. Thank you. Bye bye.

Bye, everyone.