ISSN 0103-5150 Fisioter. Mov., Curitiba, v. 28, n. 4, p. 837-850, Oct./Dec. 2015 Licenciado sob uma Licença Creative Commons DOI: http://dx.doi.org.10.1590/0103-5150.028.004.AR02

[T] Dermatological aspects influencing the practice of physical activities by obese individuals

[I] Aspectos dermatológicos que influenciam a prática de atividades físicas em obesos

[A] Kátia Sheylla Malta Purim, Ana Cláudia Kapp Titski, Neiva Leite*

Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil

[R] Abstract Objective: The aim of this study was to perform a systematic review of the major diseases affecting Methods - tematically searching PubMed from 2000 to 2014, using the descriptors "skin diseases" and "", "skin obese individuals and their influence on physical activity. : Relevant articles were identified by sys

Results: disease" and "obesity", "skin diseases" and "physical activity", "skin disease" and "physical activity". The PEDro Scale (in Brazilian Portuguese) was used to rate the methodological quality of the studies. - A total of 320 articles were examined in the first phase. In the end, 11 articles met the proposed criteria and were included for analysis in the systematic review. We investigated cutaneous manifestations of dis eases and classified them according to their effects under 5 categories: metabolic (n = 10), aesthetic (n = obese were , acrochordon (skin tags), stretch marks, plantar keratodermia, intertrigo, 7), inflammatory (n = 6), mechanical (n = 5) and infectious (n = 3). The most frequent dermatoses among - Conclusion: Although neglected, skin are common in obesity and have implications bacterial and fungal infections. Acanthosis nigricans was found to be the most important metabolic implica tion of obesity.

* KSMP: PhD, e-mail: [email protected] ACKT: MSc, e-mail: [email protected] NL: PhD, e-mail: [email protected] Fisioter Mov. 2015 Oct/Dec;28(4):837-50 Purim KSM, Titski ACK, Leite N. 838

for physical activity because they cause pain, discomfort, friction, infection, inflammation, embarrassment, [P]limitation or difficulty of movement. Strategies to promote skin health may result in a better integration of physical activity into routine therapy and improve the quality of life of obese individuals. Keywords

[B] : Obesity. Skin diseases. Quality of life. Physical activity. Health. Resumo Objetivo: O objetivo deste trabalho foi realizar revisão sistemática das principais dermatoses no obeso e sua in- fluência na prática de atividades físicas. Método: Os artigos relevantes foram identificados por busca sistemática no Pubmed, publicados de 2000 a 2014, com os descritores “skin diseases” e “obesity”, “skin disease” e “obesity”, “skin diseases” e “physical activity”, “skin disease” e “physical activity Para a pontuação da qualidade metodo- lógica dos artigos foi utilizada a Escala de PEDro – Português (Brasil). Resultados: A fase inicial totalizou 320 artigos. Ao final, após a verificação dos critérios propostos, foram mantidos 11 artigos para análise na revisão sistemática, que investigaram manifestações cutâneas classificadas em repercussões metabólicas (n=10), estéti- cas (n = 7), inflamatórias (n = 6), mecânicas (n = 5) e infecciosas (n = 3). As dermatoses mais frequentes foram acantose nigricans, acrocordons, estrias, ceratodermia plantar, intertrigo, infecções bacterianas e fúngicas, sendo as repercussões metabólicas, em especial, a acantose nigricansa principal representante. Conclusão: Embora ne- gligenciadas, as lesões dermatológicas são comuns na obesidade e apresentam implicações nas atividades físicas pela dor, desconforto, atrito, infecção, inflamação, constrangimento, limitação ou dificuldade na execução dos movimentos. Ações de promoção da saúde cutânea podem resultar em melhor integração da atividade física na rotina terapêutica e na qualidade de vida do obeso. [K]

Palavras-chave: Obesidade. Dermatoses. Qualidade de vida. Atividade física. Saúde.

Introduction the practice of physical and sporting activities (3,

Obesity causes organic manifestations with vary- Studies have shown that skin disorders in obese - individuals4, 25-28). can vary in severity, prevalence and re- fects of obesity on skin physiology are related to the barriering impacts function, and repercussions the sebaceous (1-7). and sweat The main glands, ef the skin surface pattern ( pilaris, stretch the hairs, the structure and function of , the marks,sponse xanthomas,to treatment. acrochordons, They are caused gynecomastia) by changes (2, in cicatrization of wounds, the subcutaneous , the 29-31); hyperandrogenism and hyperinsulinemia lymphatic drainage and the microcirculation (2,4,8- (acanthosis nigricans, acne, hirsutism, androge-

individuals due to the large portions of skin that are infection (candidiasis, dermatophytosis, folliculitis, exposed16) Dermatoses to friction, are distension more evident and thein severeformation obese of furuncles,netic alopecia) erythrasma, (20, 32-35); erysipelas, increased cellulitis, prevalence necrotiz of-

develop diabetes, , metabolic, cardiovas- cularfolds. andIn addition, orthopedic these disorders, individuals as well are more as associated likely to ing fasciitis) (14, 36-38); decreased venous return They(chronic are venousalso associated insufficiency, with the lymphedema, occurrence stasisof in- - growndermatitis toenails, and delayedkeratodermas healing and of calluseswounds) on (13, the 36).feet comorbidities (5, 7, 17). as theirSkin lesionssocial, recreational generate significant and work costs relationships to all in (39-42), seborrhea (43-44) and diabetes symptoms (7,volved 18) Dermatosesand influence may patient's serve asquality metabolic of life, markers as well (14, 25); and worsening in the severity of of patients, cause discomfort, pain, ergonomic over- on their appearance, location and circumstances, they load(4, 23, and 35, mechanical 45). Skin lesions limitations may affectin performing the self-esteem certain canof obesity cause and embarrassment insulin resistance and (19-24).hinder orDepending prevent

Fisioter Mov. 2015 Oct/Dec;28(4):837-50 body movements. Dermatological aspects influencing the practice of physical activities by obese individuals 839 - This selection process was performed by two toses can play an important role in primary preven- independent reviewers and studies were included tionConsidering through the that encouragement the early identification of lifestyle of change, derma only after consensus review and agreement by all changesreception that of specific are related treatment to obesity, and emphasizing improvements their in reviewers. In cases of disagreement, a third reviewer- self-image (18, 46-49), this study discusses the skin mulationwas consulted. of fat in the adipose tissue, in body parts or in theObesity whole has body, been and defined a body asmass the index excessive exceeding accu influence on physical activity and aiming at health promotion and disease prevention. any movement that results in more energy expendi- Methods ture30 kg/m² than (3,rest 4). and Physical is the activityresult of has voluntary been defined muscle as

For the purposes of this study, dermatoses have Library of Medicine) from January 2000 to March contraction (51). We systematically searched PubMed (National- obese individuals and result in complaints, discom- nation: "Skin diseases" and "obesity"; "Skin disease" been defined as common skin changes that affect- and2014. "obesity"; The following "Skin descriptors diseases" andwere "physical used in combi activ- associatedfort or greater with demand obesity for was medical adapted care. from The the etiologi ABESO (Braziliancal and pathological Association classification for the Study of ofskin Obesity disorders and combinationity", "skin disease" of the andthree "physical keywords activity". ("skin diseases", A total of 320 articles were examined in the first phase. The - Metabolic Syndrome) (4). Dermatoses were divided the"obesity" analysis and because "physical they activity")did not meet resulted the eligibility in 246 according to their effects into 5 categories: 1) meta studies. However, these studies were not included in werebolic; analyzed2) mechanical; within 3) each infectious; group of 4) dermatoses inflammatory; ac- were manually searched to identify studies that 5) aesthetic. After this classification, skin problems criteria. The lists of references of systematic reviews Primary and secondary articles were included in the cording to their possible impact on physical activity. analysis,might have and been special overlooked attention inwas the given initial to originalsearch. Results

During the selection process, the papers found werestudies examined, related toscreened, the central and analyzedresearch forquestion. examina - criteria and were included for analysis in the system- tion if they met the eligibility and inclusion criteria Of 320 articles identified, 11 met the proposed Tables 2 and 3 separately show the summaries potentially eligible articles were screened by read- ofatic the review. studies (Figure that related1). obesity to skin diseases ingof this their study titles . After and removalabstracts of to duplicate check whether articles, the all and physical activity, according to their rating on the original articles published in Portuguese, English or Spanishstudies met from the 2000 inclusion to 2014 and and exclusion associating criteria. obesity Only PEDro scale. and physical activity with dermatoses were included Discussion meta-analyses, editorials, abstracts published in con- The growing modernization of societies, the in- gresses,in this systematic animal studies review. and Systematic articles on review skin diseases articles, crease in sedentary lifestyle and dietary changes have led obesity to reach epidemic proportions globally The PEDro Scale (in Brazilian Portuguese) was used - related to cancer were excluded. ing proportions in urban families with higher socio- according to seven aspects: 1) Control group; 2) Group (3). In recent decades obesity has reached worry Similarity;to rate the methodological3) Sample calculation quality performed;of the studies 4) (50), Use there is a higher prevalence of obesity in the South andeconomic Southeast, status including and levels among of education children (4). and In Brazil,youth of reliable assessment instruments; 5) Appropriate statistical analysis; 6) QUALIS B1 or higher; and 7) (27, 52).

Sample composed by more than 30 subjects. Fisioter Mov. 2015 Oct/Dec;28(4):837-50 Purim KSM, Titski ACK, Leite N. 840

“Skin disease” “Skin disease” “Skin disease” and “Skin disease” and and “obesity” and “obesity” “physical activity” “physical activity”

228 72 16 4

300 20

320 253 mwew excluded because they did not meer te inclusion criteria: -114: published before 2000 -6: repeated articles between the databases -32: case studies -95: review articles -5: editorial

68 -22: excluded after readind the abstract -35: escluded after reading the full article

11

Figure 1 - Selection process of the studies included in this systematic The PEDro Scale was used to rate the methodological quality of the studies (Table 1)

Table 1 - Methodological quality of the studies analyzed in the systematic review

Author 1 2 3 4 5 6 7 Total KALIL, G. + + + - - - + 4 SADEGHIAN, G. + + - - - + + 4 MUTAIRI, N. ------+ 1 BOZA, J. + + + + + + + 7 GUIDA, B. + + - + + + + 6 AL-SAEED, W. - + - - - - + 2 ERDOGAN, B. + + - + + + + 6 NAEINI, F. + + - - - - + 3 NINO, M. + + - + + - + 5 SABAT, R. + + - + + + + 6 SHARQUIE, K. + - - - - - + 2

Note: 1) Control group; 2) Group Similarity; 3) Sample calculation performed; 4) Use of reliable assessment instruments; 5) Appropriate statistical analysis; 6) QUALIS B1 or higher; and 7) Sample composed by more than 30 subjects.

Fisioter Mov. 2015 Oct/Dec;28(4):837-50 Dermatological aspects influencing the practice of physical activities by obese individuals 841 Obesity is related to changes in the skin that could be considered as markers of excessive weight. The degree of obesity influences the incidence of some associated dermatoses. Individuals with acne inversa have higher prevalence of metabolic syndrome than healthy individuals. Specific dermatoses such as acrochordons, stretch marks and plantar keratodermia can be considered as cutaneous stigmata of severe obesity. Individuals with skin lesions should be monitored due to the development of associated diseases. Conclusion Acrochordons (48%) Acrochordons (86.6%) Acantose nigricans (27.6%) Plantar (46.7%) (12.3%) Lymphedema (13.2%) Psoriasis pilaris (23.7%) Keratosis Bacterial infection (11.8%) Onychomycosis (19.7%) Stretch marks (68.4%) Acrochordons (40%) Plantar keratodermia (20%) Stretch marks (32%) Acne inversa (Hidradenitis suppurativa) (44.4%) Acantose nigricans (26.6%) Hyperhidrosis (26.6%) Plantar keratodermia (20%) pilaris (13.3%) Keratosis Hyperpigmentation (6%) Stretch marks (63.3%) Acrochordons (54.2%) Skin diseases related to obesity Classification of effects of dermatoses* Metabolic Mechanic Inflammatory Infectious Aesthetic Mechanic Aesthetic Metabolic Mechanic Inflammatory Aesthetic Metabolic Inflammatory Metabolic Methods 76 obese and 73 non-obese patients were included in the Skin examination was study. carried out by a specialist. All subjects were evaluated for the presence of metabolic syndrome. 60 obese and 20 non-obese individuals participated in the Skin examination was study. carried out by a specialist. 65 children with overweight and 30 children and obesity, with normal weight underwent 80 patients with acne inversa (hidradenitis suppurativa) and 100 healthy individuals (controls) participated in the study. 36 individuals with skin lesions and 22 controls were included Glucose tolerance, in the study. insulin, total cholesterol, HOMA-IR triglycerides, HDL-C, and BMI were assessed. - Summary of the articles relating obesity to skin diseases and physical activity, which were rated higher than 4 on PEDro scale Objective To assess the To prevalence of skin diseases in obese individuals compared to non-obese individuals. To highlight the To incidence of skin diseases in obese individuals and investigate the skin water barrier function in obese individuals. To investigate the To incidence of skin diseases and analyze investigate To the frequency of metabolic syndrome in patients with acne inversa (hidradenitis suppurativa). assess atherogenic To risk factors in patients with skin lesions. Table 2 Boza et al . (2012) Guida et al . (2010) Nino et al . (2012) Sabat et al . (2012) Erdogan et al . (2005) Authors/Year Note: * Classification of effects of the dermatoses analyzed in this systematic review: 1) metabolic, 2) mechanical, 3) infectious, 4) inflammatory, 5) aesthetic. Note: * Classification of effects the dermatoses analyzed in this systematic review: 1) metabolic, 2) mechanical, 3) infectious, 4) inflammatory,

Fisioter Mov. 2015 Oct/Dec;28(4):837-50 Purim KSM, Titski ACK, Leite N. 842 (to be continued) Hirsutism was more common in patients with higher body mass indexes. There is an increased prevalence of skin diseases in obese individuals compared to non-obese individuals. Plantar keratodermia may serve as a marker of obesity, whereas acanthosis nigricans and acrochordons might indicate underlying disease, such as diabetes and polycystic ovarian syndrome. Conclusion Hirsutism (50%) Acantose nigricans (48.4%) Acrochordons (16.1%) Hirsutism (7.5%) Skin xerosis (15%) Pruritus (10.7%) Plantar keratoderma (13.9%) Intertrigo (17.2%) Bacterial infection (22.6%) Furuncle (7.5%) (15%) Tinea Pedis Stretch marks (50.5%) Cellulitis (24.7%) Acantose nigricans (33%) Hirsutism (15.8%) Hyperhidrosis (8.5%) Acrochordons (30%) Plantar keratoderma (45.1%) Acne (21.5%) Intertrigo (22.2%) (11.2%) Folliculitis Tineacruris (9.6%) Stretch marks (23.3%) Skin diseases related to obesity Classification of effects of dermatoses* Metabolic Metabolic Mechanic Inflammatory Infectious Aesthetic Mechanic Inflammatory Infectious Aesthetic Metabolic Methods 800 individuals (400 women with hirsutism and 400 healthy women - control group) participated in the study. Hirsutism level was measured by score. Ferriman-Gallwey A retrospective cohort study of 2-year duration was conducted. 61 obese and 48 non-obese individuals partipated in the BMI, waist circumference, study. glucose levels and blood pressure were measured, and a dermatological examination performed. 437 subjects with overweight and obesity (200 men 237 women) aged between 18 and 74 years participated in the Lipid profile and fasting study. glucose levels were measured kidney and thyroid and liver, function tests were performed. Skin diseases were examined by dermatologists. - Summary of the articles relating obesity to skin diseases and physical activity, which were rated 4 or lower on PEDro scale Objective To assess the To relationship between body mass index and hirsutism in a representative sample of Iranian women. To describe obesity To pattern using BMI and to assess the association between obesity and certain skin diseases in adults. To determine the To spectrum of skin diseases in adult obese patients. Table 3 Naeini et al . (2012) Kalil et al . (2011) Mutairi et al . (2009) Authors/Year

Fisioter Mov. 2015 Oct/Dec;28(4):837-50 Dermatological aspects influencing the practice of physical activities by obese individuals 843 (conclusion) Acanthosis nigricans is a maker of insulin resistance in obese women. Obesity is associated with skin problems. Cutaneous manifestations are common in obese individuals. Conclusion Acantose nigricans (15.6%) Skin xerosis (16.4%) Acantose nigricans (98%) Alopecia (16.3%) Acrochordons (40.3%) Plantar keratodermia (50%) Eczema (35.5%) Seborrhea (41.1%) Acne (43.1%) (58.6%) Folliculitis Stretch marks (86.5%) Acantose nigricans (72%) Stretch marks (34.6%) Skin diseases related to obesity Classification of effects of dermatoses* Metabolic Metabolic Mechanic Inflammatory Aesthetic Aesthetic Metabolic Methods 66 obese women (32 with and 34 without acanthosis nigricans) participated Insulin in the study. resistance was determined by and glucose tolerance HOMA-IR, was evaluated. 2,239 students participated in Data were collected the study. through clinical examination and anthropometric measurements. 52 obese children, 94 overweight children, 100 children with - Summary of the articles relating obesity to skin diseases and physical activity, which were rated 4 or lower on PEDro scale Objective To compare insulin To resistance in obese women with and without acanthosis nigricans. To determine the To frequency of skin diseases in female obese students. To assess the To frequency of skin Table 3 Sadeghian et al . (2009) Al-Saeed et al . (2006) Sharquie et al. (2005) Authors/Year

Fisioter Mov. 2015 Oct/Dec;28(4):837-50 Purim KSM, Titski ACK, Leite N. 844 Progressive weight gain results from an imbalance between caloric intake and energy expenditure or is (27%). All of them have significant implications for - the practice of physical activity, as discussed below. pothalamicdue to hypothyroidism, tumors, genetic growth syndromes, ,deficiency, Metabolic skin changes related to obesity menopausepolycystic ovary or the syndrome, use of medications Cushing's such syndrome, as hy The following metabolic manifestations have been - detected in obese individuals: acanthosis nigricans, ingand signspsychotropics for dysmorphophibia, (3, 4). In sports cosmetic and in the doping fashion or acrochordons, hirsutism and androgenetic alopecia badindustry, diets suddenfollowed weight in an fluctuationsattempt to quickly serve as alter warn or

The main methods used to measure obesity are (1, 2, 29-31, 33, 37, 43, 48, 49). anthropometricshape the body (26,measurements, 53). such as body weight, Acanthosis nigricans subscapular/tricipital fold ratio, waist and hip cir- Obesity-related acanthosis nigricans (pseudo- acanthosis nigricans) is characterized by increased cumference, and body mass index (BMI) (3, 4). A BMI pigmentation of the skin in body folds of the armpits, between 18.5 and 24.9 is considered normal, between - the25.0 ideal and body29.9 isweight overweight, or having and a body30.0 ormass above index is fects men and women almost equally and is more (BMI)obese. > Morbid 40Kg/m obesity2 is defined as being 100 % over predominantthe neck, the ingroin brown- and and intertriginous black-skinned areas. individu It af-

index to the BMI in (2, the 18). assessment of obesity, which The waist-hip ratio (WHR) is a complementary thereals. Its is development the formation is of insidious dark brown and toassociated black, licheni with- insulin resistance. The condition is asymptomatic and is diagnosedDepending when on the WHR degree is ≥ of 0.80cm obesity in all women organ sysand- tems≥ 0.9 arecm involvedin men (3, and 4, show53). deviations from normal- thefied affected or vegetating, areas worsen rough plaques the situation, that give as well a "grimy" as the dimensionaspect to the and skin. evolution Weight gainof the and condition, the scratching making of with increased morbidity and mortality in adulthood ity. Overweight and its consequences are associated- cular, orthopedic, respiratory, endocrine, skin, psy- triggerthe skin skin surface irritation, rougher, bleeding, thicker anddiscomfort more irregular. and lo- chiatric,(54, 55). gastrointestinal Obese individuals and are liver prone disorders, to cardiovas as well Rubbing, friction, sweating and ill-fitting sportswear as to carcinogenesis (gallbladder, , ) (4, weight improves acanthosis nigricans (1, 2, 30, 37, - cal pain during physical activities. Reduction in body opted - often without proper planning - in the pursuit 56).of weight On the loss other lead hand, to the various development restrictive of nutritional diets ad 43, 48, 49). Acrochordons For some obese individuals, the appearance of theirdeficiencies skin only and worsens psycho-affective pre-existing disorders stigmas and (7, 46).their Acrochordons are small, benign, solid, elevated, suffering, with negative consequences in the emotion- pedunculated, non-contagious lesions, represented by asymptomatic, skin-color or dark brown, thread- is a lack of studies on the impact of dermatoses on like papules located in the cervical and axillary re- al state and in everyday life (46, 57). However, there In this systematic review, we found that the inci- individuals and is usually associated with acanthosis denceparticipation of certain in physical dermatological activity by manifestations obese individuals. (al- nigricans,gions. This endocrine condition affectsdiseases both or healthy personal and charac obese- though they are not pathognomonic of obesity) was higher in the study group than in the control group trauma due to sport, as well as scratching, can cause teristics of unknown etiology. Friction, rubbing and - size, and need to be examined by a physician in order (1, 2, 29-31, 33, 37, 43, 47-49). The dermatoses were toinflammation be differentiated of the fromlesions other and dermatoses changes in color (1, 2, and 29, classified as metabolic in ten articles (91%), as aes thetic in seven (64%), as inflammatory in six (55%),

asFisioter mechanical Mov. 2015 in Oct/Dec;28(4):837-50 five (45%), and as infectious in three 31, 36, 37, 43, 58). Dermatological aspects influencing the practice of physical activities by obese individuals 845 Hirsutism and Androgenetic Alopecia negatively affect self-image and self-esteem, causing to regular exercise programs. These manifestations waist circumference (> 88 cm) or increased waist/ - hipHyperandrogenemia ratio, insulin resistance, is associated glucose intolerance with increased and ieswork show difficulties, that physical and feelings activity of focused insecurity, on individual rejection needs,and unhappiness abilities and (7, purposes 46). On thebring other immediate hand, stud and elevateddyslipidemia. total Laboratoryand/or free tests testosterone show that levels a reduction lead to hirsutismin sex-hormone-binding-globulin symptoms (32), acne and levels androgenic (SHBG) aloand- helpslong-term obese benefits individuals to weight control control, associated depending diseases on - andthe organic reduce adaptationirreversible to and the effortharmful (53). consequences The exercise tude, mood disorders such as anxiety and depression, andpecia. reduced Hirsute willingness women usually to perform show simple a reserved everyday atti and complications. associated or not with polycystic ovary syndrome, Mechanical skin changes related to obesity tasks or exercise (1, 33, 37, 59). The presence of acne, mayAndrogenetic worsen patients' alopecia perception in obese of the women disease, or theirmen maysymptoms, produce functionality or be accompanied and emotions by varying (1, 4, degrees 43). conditionThe main is usuallymechanical accompanied manifestation by ingrown identified nail, in of emotional, social, family and professional impact obese individuals was plantar keratodermia (25). This individuals with obesity and baldness are susceptible chronic venous insufficiency and lymphedema (20). to(43). sunburn In addition, and actinic during keratoses physical onactivities the exposed outdoors, and Plantar keratodermia unprotected areas of the scalp and need to use ad- The thickening of the plantar stratum corneum (plantar or thick heel) is considered equate photoprotection 60. by some authors to be an obesity stigma, although it Diabetic dermopathy response to the excessive and repetitive overload to In predisposed individuals, obesity is a trig- theis not plantar exclusive aspect of thisof the disorder. heel may It representis a multifactorial a risk of - disseminatedgering factor forannular diabetes , (56). Dermatoses diabetic bullous act as gaitdevelopment disorders, of which foot injuries. limits physical This condition activity is (1, usu 2, disease,specific markersscleredema, of diabetes acanthosis ( nigricans, lipoidica, eruptive ally associated with , fissures, infections and markers of diabetes (acrochordons, generalized 25, 30, 37). itching,xanthoma, palmar/facial diabetic dermopathy); and nail erythema, as non-specific pigmen- Ingrown nail tary purpura); and as markers of complications, Ingrown or incarnated nails (onychocryptosis) are frequently found in the hallux of obese individu- diabeticcomorbidities, neuropathy infections in obese and drug patients reactions favors (35). the als due to factors such as foot shape, nail anatomy, developmentThe involvement of injuries, of the superficial chronic ulcers, innervation perforat by- use of tight shoes, hygiene habits, skin or systemic - Physical activity, together with health education ticipation due edema, pain, local infection, muscu- programs,ing plantar healthy disease diets and recurrentand the use erysipelas medication, (23). is diseases. Ingrown nails hinder physical activity par required in order to control diabetes and obesity, - mas,loskeletal nail traumaand joint and overload, plantar andkeratodermia, postural changes. which, As noted earlier, metabolic cutaneous manifesta- inWeight turn, lossimproves leads adhesionto the improvement to walking andof foot exercise ede tionsand achieve are grounds a healthy for complaints lifestyle. of discomfort and pain, and cause poor adherence of obese individuals programs. The recovery of gait autonomy facilitates obesity control (3-5).

Fisioter Mov. 2015 Oct/Dec;28(4):837-50 Purim KSM, Titski ACK, Leite N. 846 Chronic venous insufficiency and lymphedema cervical, axillary, inguinal, inframammary and inter- digital regions, and it is viewed as a main gateway to Obesity is a risk factor for chronic venous insuf- that constant sweating of obese individuals favors the abdominal pressure increases resistance to venous developmentskin infections of (1, intertriginous 30, 37). It is important lesions, and to highlight hinders returnficiency and in leadsboth tomen the and development women. Increasedof stasis eczema, intra- the use of sports equipments and accessories, and ocher , lymphedema, leg ulcers and recur- causes physical, social and psychological disorders

edema, pain and discomfort, resulting in a negative cyclerent infections.of decreased This mobility, condition increased is associated inactivity with and (30). Hidradenitis suppurativa or post-surgical situations, the drastic interruption of physicalweight gain effort (2). and In casesthe decreased of infections energy and expenditure orthopedic - at work and in daily life - associated with psychologi- It isHidradenitis secreting and suppurativa debilitating (acne condition inversa) that is a multi is re- A multiprofessional treatment together with the factorial chronic disease of the apocrine sweat glands. prescriptioncal factors - contribute of physical toactivity weight according gain (4, 53).to the pro- is associated with furuncles, recurrent abscesses and lated to diabetes mellitus and obesity. The condition capacity, endurance, balance, joint mobility, agility, file of each case improves ergonomic fit, muscular recurrentfistulas in infection,the axillary dystrophic and inguinal , regions suffering, of young social vital importance for weight loss and general health, adults with oily skin. It progresses with pain, swelling, andwalking is a speeddetermining and overall factor coordination. for long-term This mainte is of- causes emotional, aesthetic, sexual, and economic isolation and depression. Hidradenitis suppurativa conglobata, pilonidal cyst and dissecting folliculitis of nance of body mass (51, 53). disorders. Severe forms are accompanied by acne Infectious skin changes related to obesity There are rare reports of malignant transformation intothe scalp, squamous forming cell the carcinoma "tetrad andof follicular systemic occlusion". complica- Studies with obese patients indicate an increased tions such as anemia, hypoproteinemia, arthropathy incidence of candidiasis, dermatophytosis, folliculi- tis, furuncles, erythrasma, hidradenitis suppurativa, and amyloidosis (2, 47). patients may be instructed to temporarily avoid the Seborrheic Dermatitis practiceerysipelas of and physical cellulitis. activities During ininfectious order to processes prevent worsening of the condition and disease dissemination Seborrheic dermatitis is a common non-con-

associated with extra local care aids in the control of to the community (5, 8). However, weight reduction characterizedtagious chronic by inflammatory oily, erythematous, skin condition scaly plaques that term adherence to physical exercise shows positive onaffects the scalp,predisposed face, neck, individuals, back, breast, obese armpits or not. Itand is infections and in the prevention of conditions. Long- scaly appearance of the skin can cause discomfort, impact on patient health. groin. Dandruff is its most common symptom. The Inflammatory skin changes related to obesity prejudice and social difficulty, hindering the practice Intertrigo of physicalPsoriasis activities in public (2, 43).

Intertrigo is frequently foun in obese individuals Studies have shown that obesity contributes to the - skin folds due to the combination of skin friction, heat ence of dry and excessive scales on the skin affects the and results from chronic or acute inflammation of qualitydevelopment of life orof exacerbationpeople with psoriasis of psoriasis. and Thethe pres- erosion, crusting, oozing, itching and burning in the and sweating. It is characterized by redness, scaling,

Fisioter Mov. 2015 Oct/Dec;28(4):837-50 ence of arthritis may be limiting (34). Appropriate Dermatological aspects influencing the practice of physical activities by obese individuals 847 approaches help prevent arthralgia, reduce postural feelings of inferiority, inadequacy and deprecia-

The dissatisfaction with the body and sometimes difficulties, raise self-esteem and tolerance to pain by rejectiontion due toof negativethe body, externalthe occurrence judgments of social, (26, pro46).- onreducing the functionality barriers to physicalof patients activity. due to pain, suffer- fessional or family disturbances, and the presence ing,Inflammatory embarrassment, skin prejudicechanges have and profound discrimination, effects of existing comorbidities and skin diseases affects which decrease motivation and adherence to physi- the lifestyle of obese individuals and may jeopar- dize their ability to perform daily tasks and their exercise programs may help overcome limitations, minimizingcal activities losses (2, 39-42). in daily In theselife, personal cases, personalized and profes- inhibition occurs due to shame, frustration, hope- sional relationships, recreation, mental health and lessness,motivation stigmatization, to practice physical segregation, activities. depression Social vitality, and favoring medical treatment. improveand anxiety body (18). image, encourages socialization Aesthetic skin changes related to obesity andHowever, long-term proper adherence exercise to prescriptionexercise and helps may help gradually increase positive attitudes toward Stretch marks and cellulitis

Stretch marks are linear, elevated pink to viola- weight control and health care (36). ceous lesions that occur most commonly after ex- Future prospects atrophic wrinkled lines and their pathogenesis is not The increasing changes in eating habits and cessive dermal stretching. They develop into white energy expenditure patterns, resulting from in- associated with obesity, pregnancy, pubertal growth dustrial and technological advances are likely to in- completely understood. Stretch marks are observed crease the tendency toward obesity or overweight aesthetic placement of breast implants and rapid in genetically susceptible individuals exposed to spurts, Cushing's syndrome, use of , most commonly observed on the abdomen, breast, - muscle increase (26). In obese individuals, they are courageunfavorable daily environmental physical activity factors and cardiovascular (3, 4, 15). Control and reduction of excess weight may prevent low-impactThe fight exerciseagainst physical in a playful inactivity and pleasurableneeds to en upper arms, lower back, buttocks, thighs, and groin.- - logical resources have been proposed for their treat- bined with increased physical activity and multi- their evolution. Several drugs, cosmetics and techno disciplinaryway. Studies support show that is the dietary most re-education effective approach com curative and absolutely exempt from risks or adverse ment. However, so far no intervention has proven Paying attention to skin diseases related to Gynoid lipodystrophy (cellulitis) has an unknown obesityin the medium is of paramount to long term importance (4, 28, 51, in 52). order to effects (1, 2, 26, 30, 43, 49). transmit positive signals to the individual regard- - ing his/her condition as a person, restore his/her sity,etiology heredity, and isage, common sex, pregnancy, in women use after of hormonal . health and improve his/her self-image, self-esteem contraceptives,Cellulitis is influenced hormonal by disorders, sedentary smoking, lifestyle, inadobe- equate nutrition, circulatory changes and mechani- and emotional stability. Regular physical activity the size of the thighs, the abdomen and the gluteal minimizesis essential or in eliminates this process. damage, It is recommended injuries, emotion for- region,cal factors. giving It changes a corrugated the appearance, nodular (orange the shape peel-like) and fitness, therapy, recreation and socialization, and and pain, this condition tends to be underdiagnosed al andThis financial review costsshowed to currentthat there or formeris a high obese fre- becauseappearance patients to the are skin. often Despite too embarrassed causing discomfort to seek individuals, their families and the community. - fectious and aesthetics disorders in obese individu- The symbolic representation of the obese body alsquency and ofthat metabolic, such disorders mechanical, should inflammatory, be considered in withmedical skin attention. diseases is probably associated with

when analyzingFisioter adherence Mov. 2015 to physicalOct/Dec;28(4):837-50 activities. Purim KSM, Titski ACK, Leite N. 848 The most commonly found conditions were: acan- thosis nigricans, acrochordons, stretch marks, plantar 11. Mathur AN, Goebel L. Skin findings associated with obesity. Adolesc Med State Art Rev. 2011;22(1):146-56. Considering that the approach to individuals with obesitykeratodermia, includes intertrigo the implementation and skin infections. of strategies for 12. Rivers JJ. Addressing obesity related skin-disease. the promotion, protection and recovery of health, the Cutan Med Surg. 2012;16(6):381-4. reduction of dermatologically-related limitations to- 13. Scheinfeld NS, Parish DH, Parish LC. A primer of skin gether with the personalized prescription of regular diseases associated with obesity. Expert Rev Dermatol. physical activity play an important role in promoting 2007;2:409-15. -

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