Obesity: Skin issues and skinfold management Nurses can help reduce injury through proactive assessment and early intervention. By Armi S. Earlam, DNP, MPA, BSN, RN, CWOCN, and Lisa Woods, MSN, RN, CWOCN 42 American Nurse Journal Volume 15, Number 6 MyAmericanNurse.com ACCORDING to the Centers for Disease Con- Impaired mobility among adults who are trol and Prevention (CDC), 39.8% of adults in obese can contribute to pressure injuries. the United States are obese. (See Obesity and Sources of pressure include the surface the BMI.) Obesity and obesity-related condi- patient is sitting or lying on, such as beds and tions—including diabetes, heart disease, hy- wheelchairs, as well as medical equipment pertension, stroke, elevated cholesterol, sleep and devices such as catheter tubing. In addi- apnea, musculoskeletal issues, and poor qual- tion, some patients may be unable to reach ity of life—are estimated to cost the country parts of their bodies, leading to poor hygiene. $147 billion to $210 billion per year. Adults A common misconception is that adults who are obese also experience skin issues who are obese can’t experience malnourish- such as candidiasis, dermatitis, and pressure ment because their weight suggests excess injuries. In addition, they frequently have mul- caloric intake. However, their diets may be tiple skinfolds, some located in atypical loca- deficient in proteins and other nutrients essen- tions that pose additional challenges when tial to healing. Nutrient and vitamin deficien- providing nursing care. cies impact skin health and hinder healing when skin injuries occur. Skin issues: Contributing factors Unusually deep skinfolds are unique to Excessive adipose tissue, impaired mobility, adults who are obese. In addition to skinfolds malnourishment, and skinfolds all contribute in expected areas of the body, they also may to skin issues in adults who are obese. Exces- occur in atypical areas such as the neck, arms, sive adipose tissue has a poor blood supply, breasts, abdomen, legs, and ankles. These leading to inadequate oxygenation, which can folds are at risk for shearing and friction, impair wound healing. Adipose tissue also which can contribute to more skin problems. insulates the body, trapping heat, increasing patients’ core temperatures, and causing ex- Common skinfold issues and cessive sweating. The result is increased mois- skinfold care ture, especially in skinfolds, that leads to fun- Skinfold issues in adults who are obese re- gal or bacterial growth. quire care and monitoring. Nurses should un- derstand assessment and treatment for each of these. Moisture control The warm, moist, and dark skinfold environ- ment is ideal for microorganism growth. A common culprit is Candida albicans, which can result in candidiasis. This condition pres- ents as bright red, eroded skin that may in- clude papules, plaques, pustules, and clas- sic satellite lesions. Odor frequently is noted Obesity and BMI with candidiasis, which many patients find Obesity is categorized by body mass index (BMI), distressing. which is calculated by dividing a person’s weight To control moisture, advise patients to (in kilograms) by height (in meters squared). avoid tight clothing; use pH-balanced liquid soap, cleansers, or disposable wipes; and pat Category BMI skinfolds dry, rather than aggressively rub- bing. Hair dryers set on cold also can be used Underweight < 18.5 to dry skinfolds. Daily inspection of the skin, Normal weight 18.5-24.9 routine cleansing, and moisturizing as needed Overweight 25-29.9 by patients and caregivers is beneficial. Topical antifungals, such as nystatin pow- Class I obesity 30-34.9 der, frequently are used to treat candidiasis. Class II obesity 35-39.9 If topical therapy fails, a short-term oral anti- Class III obesity ≥ 40 fungal may be necessary. However, antifun- gals address only the microorganism; mois- MyAmericanNurse.com June 2020 American Nurse Journal 43 “kissing” side of the skinfold. The condition, which can be painful, may develop as a sec- ondary infectious process caused by C. albi- cans or bacteria. Caring for intertrigo includes moisture control, which can involve zinc ox- ide–based barrier creams or absorbent dress- ings depending on the condition’s severity. Pannus care The abdominal pannus (fold of excess ab- dominal fat and skin) is a common problem area for adults who are obese. (See Abdomi- nal pannus grading.) A large pannus can sig- nificantly limit mobility, causing gait alter- ations and pain with ambulation. In addition, the pannus may lead to pressure injury forma- Abdominal pannus grading tion, friction and shearing, moisture trapping, An abdominal pannus can be described using a grading scale from 1 to 5, hygiene difficulty, and lymphatic changes that where 5 is the most severe. contribute to skin breakdown and infection (panniculitis). Grade Description Pannus assessment requires lifting it to 1 Covers the pubic hairline but not the entire mons pubis visualize the base of the skinfold. In some cases, multiple staff and lifting devices or 2 Extends to cover the entire mons pubis slings may be needed. Watch for pannus 3 Extends to cover the upper thigh skin irritation and skin breakdown, includ- 4 Extends to midthigh ing intertrigo, candidiasis, and painful skin erosions. Panniculitis can be difficult to pre- 5 Extends to the knee and beyond vent and treat, and it may recur. Treatment Source: Blackett et al. for panniculitis typically involves systemic antibiotics and skinfold care. In extreme cases, surgical debridement or removal of ture management is required to resolve the the pannus (panniculectomy) may be con- infection. sidered. Keeping the pannus clean and dry Other products are available for patients is the best way to prevent infection and oth- who have refractory skin issues despite er issues. good standard care. For example, a poly- ester knit textile product impregnated with Perineal care silver can help absorb and wick away mois- Genital and perineal skin can be especially ture and control odor. This product also challenging to care for in patients who are provides antimicrobial action for up to 5 obese. They may have deep skinfolds in the days. It’s placed at the base of the skinfold, groin and buttocks with high friction and in- extending about 2 inches beyond the fold. creased moisture from perspiration, which This product can be expensive and may not may be compounded by incontinence. Per- be necessary for everyone; reserve its use ineal care requires carefully assessing these for special cases, including patients with an- areas while respecting a patient’s modesty and tifungal allergies. comfort. Cleaning and drying the skin gently but thoroughly and applying barrier products Intertriginous dermatitis (films or creams) after any incontinent Intertriginous dermatitis (intertrigo) is an in- episodes are recommended. flammatory condition in skinfolds. It may Barrier products can protect skin from re- present as mild to moderate redness with skin peated exposure to bodily fluids, especially erosion, drainage, maceration, and crusting. It urine and feces, that can irritate the skin; usually is partial thickness and mirrors the wicking fabrics are impractical because of toi- pattern of skin breakdown on the opposite or leting or incontinence. Note that ingredients 44 American Nurse Journal Volume 15, Number 6 MyAmericanNurse.com in some barrier products can impair the ab- skin and wound care management). Proper sorbency of incontinence products. Using too care also requires clinician education and at- much product can cause skin cracking and tention to patient, personal caregiver, and cli- discomfort, and some products can obscure nician safety. skin assessment. Also consider patient aller- gies when choosing a barrier product. Clinician education Hygiene after toileting can be challenging All clinicians should receive education that ad- for patients who are obese, increasing the risk dresses unconscious bias that may affect their of skin breakdown or infection in the genital communication and care. Sensitivity training and perineal area. Washcloths or premoist- can help increase awareness and compassion. ened wipes may be preferable to toilet paper, Listen to patients, make eye contact with them, and using a handheld showerhead when and involve them in care plans. Find opportu- bathing may aid hygiene. nities to ensure patient dignity. For example, encourage toileting or scheduled toileting rather Pressure injuries than adult diapers. Foreign objects, such as catheter tubing or a cell phone, can get trapped between skin- Safety folds and lead to device-related pressure in- When assessing and cleaning skinfolds, take juries. In addition, atypical pressure injuries steps to ensure patient, caregiver, and clini- may occur because of pressure from bed cian safety. For very heavy skinfolds, mobi- rails, chair arms, or wheelchair foot and calf lization devices such as pannus lifts may be rests. Immobile patients may develop pres- necessary. Enlist a sufficient number of sure injuries on their heels and sacrum. Pro- trained staff to slowly and carefully move the vide floating heels as indicated and help pa- patient and skin. If the patient is at home, tients turn and reposition. train dependable family members and respon- sible caregivers to properly use any special Acanthosis nigricans equipment. Acanthosis nigricans is characterized by areas Appropriate-size lift equipment may be of dark, velvety discoloration in skinfolds and necessary to turn and mobilize patients out of creases; it’s sometimes mistakenly associated bed. Bariatric chairs and beds are recom- with poor hygiene because of the dark color mended, as are toilet risers with handrails or and skin thickening. The condition, which bariatric commodes or toilets that can accom- may be seen in the neck, axilla, and inguinal modate the patient’s size and weight. Inappro- folds, is common among people with darker priate-size equipment may increase pressure skin pigmentation. No cure exists for this con- injury risk or other harm (for example, falling dition, but glucose control and weight loss out of an inappropriate-size chair).