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Skin changes after bariatric surgery* * Work performed at the Dermatology Service at Porto Alegre Federal University of Health Sciences (UFCSPA) - Porto Alegre (RS), Brazil.

Ana Paula Dornelles da Silva Manzoni Magda Blessmann Weber About the authors

Abstract

Today, obesity is considered an epidemic all over the world and it is recognized as one of the major public health problems. Bariatric surgery is considered an appropriate therapeutic option for obesity with progressively increasing demands. The changes resulting from massive weight loss after bariatric surgery are related to numerous complications. This article will present the dermatological alterations that can be found after bariatric surgery. They will be subdivided into dermatoses that are secondary to metabolic and nutritional disorders, those derived from cutaneous structural modifications after major weight loss and the influence the latter may have in improving of certain dermatoses.

Bariatric surgery; Skin; Skin diseases


INTRODUCTION

Obesity is currently considered an epidemic that affects approximately 300 million people worldwide and is recognized as one of the major public health problems.1Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288:1723-7.,2Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294:1909-17. Bariatric surgery (BS) is considered an appropriate therapeutic option for obesity with steadily increasing demands for it.3Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-37. Patients undergoing bariatric surgery experience significant improvement in medical co-morbidities, and also changes in patterns of hunger and satiety.2Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294:1909-17.,3Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-37. Surgeries with the best outcomes can reduce body weight by up to 30% and 40% with results sustained for long periods. 2Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294:1909-17.,3Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-37.

Changes resulting from extensive weight loss after bariatric surgery are linked to numerous complications that should be prevented and treated.3Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-37. In addition, new diseases are gradually being described, whilst physiopathogenic aspects resulting from the procedure and major weight loss are elucidated.2Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294:1909-17. From the dermatological point-of-view, reports are still sparse on this subject, but dermatologists should be prepared to understand the mechanisms by which bariatric surgery can cause cutaneous disorders and be attentive to diagnose and treat them.

The different techniques used to perform BS and the subsequent complications that may arise are discussed below to improve the understanding of their cutaneous effects.

TYPES OF BARIATRIC SURGERY

Bariatric surgeries are traditionally divided into three categories: restrictive procedures, malabsorptive procedures, and a combination of them.

Restrictive surgeries: include vertical banded gastroplasty with non-adjustable ring, laparoscopic adjustable gastric banding and sleeve gastrectomy. These techniques do not alter the qualitative or quantitative absorption of nutrients.4Maglione MA, Gibbons MM, Livhits M, Ewing B, Hu J, Ruelaz Maher A, et al. Bariatric Surgery and Nonsurgical Therapy in Adults With Metabolic Conditions and a Body Mass Index of 30.0 to 34.9 kg/m2. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013.,5Neff KJH, Roux CW. Bariatric Surgery. J Clin Pathol. 2013;66:90-8.

Malabsorptive surgeries: include biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPD/DS). These procedures cause malabsorption of both macro and micronutrients.4Maglione MA, Gibbons MM, Livhits M, Ewing B, Hu J, Ruelaz Maher A, et al. Bariatric Surgery and Nonsurgical Therapy in Adults With Metabolic Conditions and a Body Mass Index of 30.0 to 34.9 kg/m2. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013.,5Neff KJH, Roux CW. Bariatric Surgery. J Clin Pathol. 2013;66:90-8.

Mixed procedures: Roux-en-Y gastric bypass (RYGB) surgery combines the procedures described above and induces changes in neurohormonal pathways that regulate energy balance. Malabsorption after RYGB is essentially limited to micronutrients and there is a lifelong need for vitamins and minerals supplementation to prevent deficiencies. Roux-en-Y complications are diverse and include distension of the remaining stomach, stoma stenosis, formation of marginal ulcers, cholelithiasis, ventral hernias, internal hernias, hypoglycemia, dumping, metabolic and nutritional disorders and weight regain.4Maglione MA, Gibbons MM, Livhits M, Ewing B, Hu J, Ruelaz Maher A, et al. Bariatric Surgery and Nonsurgical Therapy in Adults With Metabolic Conditions and a Body Mass Index of 30.0 to 34.9 kg/m2. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013.,5Neff KJH, Roux CW. Bariatric Surgery. J Clin Pathol. 2013;66:90-8.

GENERAL COMPLICATIONS OF BARIATRIC SURGERY

Metabolic and nutritional diseases are among the main complications of bariatric surgery.4Maglione MA, Gibbons MM, Livhits M, Ewing B, Hu J, Ruelaz Maher A, et al. Bariatric Surgery and Nonsurgical Therapy in Adults With Metabolic Conditions and a Body Mass Index of 30.0 to 34.9 kg/m2. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013. These are secondary to decreased oral intake, as well as alterations in food absorption in the stomach and small intestine areas.5Neff KJH, Roux CW. Bariatric Surgery. J Clin Pathol. 2013;66:90-8.,6Santo MA, Pajecki D, Riccioppo D, Cleva R, Kawamoto F, Cecconello I. Early complications in bariatric surgery: incidence, diagnosis and treatment. Arq Gastroenterol. 2013;50:50-5.,7Hammer HF. Medical complications of bariatric surgery: focus on malabsorption and dumping syndrome. Dig Dis. 2012;30:182-6. Patients may also experience diarrhea, nausea and vomiting which may trigger fluid and electrolyte imbalance and that can persist for more than five years after surgery.4Maglione MA, Gibbons MM, Livhits M, Ewing B, Hu J, Ruelaz Maher A, et al. Bariatric Surgery and Nonsurgical Therapy in Adults With Metabolic Conditions and a Body Mass Index of 30.0 to 34.9 kg/m2. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013.,5Neff KJH, Roux CW. Bariatric Surgery. J Clin Pathol. 2013;66:90-8..6Santo MA, Pajecki D, Riccioppo D, Cleva R, Kawamoto F, Cecconello I. Early complications in bariatric surgery: incidence, diagnosis and treatment. Arq Gastroenterol. 2013;50:50-5.

The dietary approach after bariatric surgery is performed in stages, to ensure proper surgical wound healing and help developing good eating habits throughout life.2Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294:1909-17.,8Fujioka K, DiBaise JK, Martindale RG. Nutrition and metabolic complication after bariatric surgery and their treatment. JPEN J Parenter Enteral Nutr. 2011;35:52S-9S. However, when that does not occur, the body struggles to adapt and interpret its new physiological behavior, leading to secondary problems. Among those is the dumping syndrome, which occurs in approximately 50% of patients after RYGB.6Santo MA, Pajecki D, Riccioppo D, Cleva R, Kawamoto F, Cecconello I. Early complications in bariatric surgery: incidence, diagnosis and treatment. Arq Gastroenterol. 2013;50:50-5.,7Hammer HF. Medical complications of bariatric surgery: focus on malabsorption and dumping syndrome. Dig Dis. 2012;30:182-6. It is characterized by symptoms such as nausea, tremors, sweating, diarrhea, dizziness, flushing, tachycardia, and syncope resulting from the ingestion of food containing large quantities of refined sugars and also, from food eaten too quickly.7Hammer HF. Medical complications of bariatric surgery: focus on malabsorption and dumping syndrome. Dig Dis. 2012;30:182-6. Some authors consider this a positive effect after RYGB, particularly in patients who are partial to sweets, since it results in an aversion to the consumption of such foods.3Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-37.,7Hammer HF. Medical complications of bariatric surgery: focus on malabsorption and dumping syndrome. Dig Dis. 2012;30:182-6.,8Fujioka K, DiBaise JK, Martindale RG. Nutrition and metabolic complication after bariatric surgery and their treatment. JPEN J Parenter Enteral Nutr. 2011;35:52S-9S.

Another complication reported is the development of depression and sadness secondary to massive weight loss and the small amount of food that can be ingested due to the limited-size of the gastric pouch after surgery.5Neff KJH, Roux CW. Bariatric Surgery. J Clin Pathol. 2013;66:90-8.,9Sarwer DB, Dilks RJ, West-Smith L. Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success. Surg Obes Relat Dis. 2011;7:644-51. The loss of food as an emotional support can result in illness and somatization.5Neff KJH, Roux CW. Bariatric Surgery. J Clin Pathol. 2013;66:90-8.

DERMATOLOGICAL COMPLICATIONS OF BARIATRIC SURGERY

Publications loss and its influence on the improvement of certain dermatoses.

Metabolic and Nutritional Disorders

Micronutrient and mineral nutritional deficiencies occur after bariatric surgery, especially after malabsorptive procedures. These disorders derive from inadequate food intake, changes in the digestive system's anatomy and high levels of oxidative stress that also interfere with the absorptive process.5Neff KJH, Roux CW. Bariatric Surgery. J Clin Pathol. 2013;66:90-8.,1010 Hng KN, Ang YS. Overview of bariatric surgery for the physician. Clin Med. 2012;12:435-40. For example, in biliopancreatic diversion and biliopancreatic diversion with duodenal switch patients are at risk for protein malnutrition, so supplementation of 1.5 grams of protein per kg may be necessary.4Maglione MA, Gibbons MM, Livhits M, Ewing B, Hu J, Ruelaz Maher A, et al. Bariatric Surgery and Nonsurgical Therapy in Adults With Metabolic Conditions and a Body Mass Index of 30.0 to 34.9 kg/m2. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013.,5Neff KJH, Roux CW. Bariatric Surgery. J Clin Pathol. 2013;66:90-8.,1111 Bordalo LA, Mourão DM, Bressan J. Nutritional deficiencies after bariatric surgery: why they happen? Acta Med Port. 2011;24:1021-8. Micronutrient deficiencies are not commonly seen in gastric band procedures, however folate deficit has been described and should be regularly monitored, especially in women of childbearing age. Typically, patients undergoing RYGB show decreased absorption of liposoluble vitamins, iron, vitamin B12, A, D, E, K, folic acid and thiamine.1111 Bordalo LA, Mourão DM, Bressan J. Nutritional deficiencies after bariatric surgery: why they happen? Acta Med Port. 2011;24:1021-8.,1212 Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21:S1-27.

Nutrients that may be lacking after bariatric surgery and that affect the skin are discussed below (Chart 1 and Table 1).

CHART 1
Correlation of nutrient deficiency and its cutaneous repercussions

VITAMIN A OR RETINOL

Retinol is a liposoluble vitamin that is vital for retinal photoreceptors and the immune system functioning, as well as skin keratinization and the process of embryogenesis.1313 Zalesin KC, Miller WM, Franklin B, Mudugal D, Rao Buragadda A, Boura J, et al. Vitamin A Deficiency after Gastric Bypass Surgery: An Underreported Postoperative Complication. J Obes. 2011;2011. pii: 760695.,1414 Ocón Bretón J, Cabrejas Gómez MC, Altermir Trallero J. Frinoderma secundario a déficit de vitamina A en un paciente con derivación biliopancreática. Nutr Hosp. 2011;26:421-4.,1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85. It is usually found in foods derived from animal sources, such as cow's milk, liver, eggs and fish oils, besides β-carotene-containing vegetables or those with green and brightly-colored leaves, fruits like mango, damask, carrots and tomatoes. 1313 Zalesin KC, Miller WM, Franklin B, Mudugal D, Rao Buragadda A, Boura J, et al. Vitamin A Deficiency after Gastric Bypass Surgery: An Underreported Postoperative Complication. J Obes. 2011;2011. pii: 760695.,1414 Ocón Bretón J, Cabrejas Gómez MC, Altermir Trallero J. Frinoderma secundario a déficit de vitamina A en un paciente con derivación biliopancreática. Nutr Hosp. 2011;26:421-4.,1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.

Vitamin A intake may be inadequate in patients with restrictive diets and eating disorders as can be seen after bariatric surgery.1313 Zalesin KC, Miller WM, Franklin B, Mudugal D, Rao Buragadda A, Boura J, et al. Vitamin A Deficiency after Gastric Bypass Surgery: An Underreported Postoperative Complication. J Obes. 2011;2011. pii: 760695. Vitamin A deficiencies can also be associated with fat malabsorption (necessary for this vitamin assimilation) as occurs after intestinal bypass surgery.1313 Zalesin KC, Miller WM, Franklin B, Mudugal D, Rao Buragadda A, Boura J, et al. Vitamin A Deficiency after Gastric Bypass Surgery: An Underreported Postoperative Complication. J Obes. 2011;2011. pii: 760695.

Slater et al. observed decreased plasma levels of vitamin A in up to 69% of patients undergoing biliopancreatic diversion and clinical manifestations of this deficiency are present in as much as 10% of cases. 1616 Slater GH, Ren CJ, Siegel N, Williams T, Barr D, Wolfe B, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8:48-55. Another factor commonly seen after BS, which may be involved in this hypovitaminosis, is the diminished absorption of protein, necessary for vitamin A assimilation. 1313 Zalesin KC, Miller WM, Franklin B, Mudugal D, Rao Buragadda A, Boura J, et al. Vitamin A Deficiency after Gastric Bypass Surgery: An Underreported Postoperative Complication. J Obes. 2011;2011. pii: 760695.,1616 Slater GH, Ren CJ, Siegel N, Williams T, Barr D, Wolfe B, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8:48-55.

Xerophthalmia is the most important manifestation of vitamin A deficiency and it can cause blindness. 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85. Phrynoderma is the cutaneous finding classically associated with the lack of this vitamin (Chart 1 and Table 1). 1414 Ocón Bretón J, Cabrejas Gómez MC, Altermir Trallero J. Frinoderma secundario a déficit de vitamina A en un paciente con derivación biliopancreática. Nutr Hosp. 2011;26:421-4.,1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85. It is characterized by follicular and keratotic papules that usually affect the anterolateral surface of thighs and arms. Lesions may overtake the extensor surface of upper and lower limbs, shoulders, abdomen, dorsal area, buttocks and neck. It is important to note that, in the past, phrynoderma has been considered pathognomonic of vitamin A deficiency, but it probably represents a nonspecific finding common to cases of nutritional insufficiencies, as it was later associated to fatty acid, vitamin E and vitamin B2 deficiencies (Chart 1 and Table 1).1313 Zalesin KC, Miller WM, Franklin B, Mudugal D, Rao Buragadda A, Boura J, et al. Vitamin A Deficiency after Gastric Bypass Surgery: An Underreported Postoperative Complication. J Obes. 2011;2011. pii: 760695.,1414 Ocón Bretón J, Cabrejas Gómez MC, Altermir Trallero J. Frinoderma secundario a déficit de vitamina A en un paciente con derivación biliopancreática. Nutr Hosp. 2011;26:421-4.,1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85. Other cutaneous manifestations associated with vitamin A deficiency are xeroderma, and thinning, brittle or corkscrew hair. The correlation between low plasma concentrations of vitamins A and E and the development of acne has been recently speculated. 1717 El-Akawi Z, Abdel-Latif N, Abdul-Razzak K. Does the plasma level of vitamins A and E affect acne condition? Clin Exp Dermatol. 2006;31:430-4.

TABLE 1
Correlation of nutrient deficiency and recommended treatment

VITAMIN B2 OR RIBOFLAVIN

Riboflavin, in its biologically active forms, is an essential cofactor in the metabolism of numerous oxidative reactions.1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85. It is also involved in the conversion of pyridoxine phosphate into vitamin B6. The main sources of riboflavin are milk and dairy products, fish, eggs, leafy greens and whole grains. The site of greatest absorption of this vitamin is the proximal small intestine. Deficiency may be caused by inadequate intake and intestinal malabsorption.1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1818 Aasheim ET, Björkman S, Søvik TT, Engström M, Hanvold SE, Mala T, et al. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Am J Clin Nutr. 2009;90:15-22,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260 Recently, cases of hypovitaminosis have been described after bariatric surgery with techniques that lead to macro and micronutrients malabsorption.1818 Aasheim ET, Björkman S, Søvik TT, Engström M, Hanvold SE, Mala T, et al. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Am J Clin Nutr. 2009;90:15-22,2020 Koch TR, Finelli FC. Postoperative metabolic and nutritional complications of bariatric surgery. Gastroenterol Clin North Am. 2010;39:109-24. Cutaneous manifestations associated with B2 deficiency are mucositis, angular and lip cheilitis, glossitis, xerosis, seborrheic dermatitis, scrotal and vulvar eczema, erythrodermia and toxic epidermal necrolysis.1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1818 Aasheim ET, Björkman S, Søvik TT, Engström M, Hanvold SE, Mala T, et al. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Am J Clin Nutr. 2009;90:15-22,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260,2020 Koch TR, Finelli FC. Postoperative metabolic and nutritional complications of bariatric surgery. Gastroenterol Clin North Am. 2010;39:109-24. The severity of symptoms depends on the degree of riboflavin deficiency (Chart 1 and Table 1).1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,2020 Koch TR, Finelli FC. Postoperative metabolic and nutritional complications of bariatric surgery. Gastroenterol Clin North Am. 2010;39:109-24.

VITAMIN B3 OR NIACIN

Vitamin B3 is converted into nicotinamide, which is an essential cofactor for human metabolism. It is easily found in meat, poultry, nuts, eggs, fish, coffee and beans. Intestinal bacteria convert nicotinamide in nicotinic acid that is transported to the liver, kidneys and intestines. 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260

Niacin deficiency is endemic in areas with low intake of meat, but may be associated with anorexia nervosa, alcoholism, food allergies, colitis, carcinoid syndrome, use of medications such as isoniazid, sulfonamides, anticonvulsants, antidepressants, azathioprine and chloramphenicol, and also, after gastrointestinal surgeries such as bariatric surgery. 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1818 Aasheim ET, Björkman S, Søvik TT, Engström M, Hanvold SE, Mala T, et al. Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch. Am J Clin Nutr. 2009;90:15-22,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260,2020 Koch TR, Finelli FC. Postoperative metabolic and nutritional complications of bariatric surgery. Gastroenterol Clin North Am. 2010;39:109-24.

Pellagra is the dermatosis typically associated with niacin deficit, with a classic triad consisting on the presence of dementia, dermatitis and diarrhea.1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260 It is characterized by a symmetrical eruption resembling sunburn on sun-exposed areas. The dorsal areas of the hands are the most affected sites, which may present a glove-like distribution; the classic Casal necklace, and neck lesions are also seen. 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260 Other skin manifestations linked to niacin deficit are glossitis and angular and lip cheilitis (Chart 1 and Table 1). 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260

VITAMIN B5 OR PANTOTHENIC ACID

Coenzyme A (CoA) is the biologically active form of pantothenic acid. 2121 Plesofsky-Vig N, Brambl R. Pantothenic acid and coenzyme A in cellular modification of proteins. Annu Rev Nutr. 1988;8:461-82. It is an essential cofactor in many acetylation reactions. Its main food sources are egg yolk, liver, kidney, broccoli, chicken and beef, milk, potatoes and whole grains. 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,2121 Plesofsky-Vig N, Brambl R. Pantothenic acid and coenzyme A in cellular modification of proteins. Annu Rev Nutr. 1988;8:461-82.

CoA is hydrolyzed in the small intestine and absorbed in the jejunum. 2121 Plesofsky-Vig N, Brambl R. Pantothenic acid and coenzyme A in cellular modification of proteins. Annu Rev Nutr. 1988;8:461-82. It plays a crucial role in the synthesis of vitamins A, D, cholesterol, steroids, hemoglobin, fatty acids, amino acids and proteins. Coenzyme A is also important in the cycles of several hormones. 2121 Plesofsky-Vig N, Brambl R. Pantothenic acid and coenzyme A in cellular modification of proteins. Annu Rev Nutr. 1988;8:461-82.

Vitamin B5 deficiency is related to the presence of purpuric lesions, leukotrichia, seborrheic dermatitis, angular stomatitis and glossitis. Another clinical manifestation is the "burning feet syndrome" marked by the presence of paresthesia and dysesthesia (Chart 1 and Table 1). 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260

VITAMIN B6 OR PYRIDOXINE

Vitamin B6 has three biologically active forms that are pyridoxine, pyridoxal and pyridoxamine. They are involved in the decarboxylation of amino acids, gluconeogenesis, conversion of tryptophane into niacin, sphingolipid biosynthesis, neurotransmitters synthesis, immunologic functions and modulation of steroid hormones. 2222 Leklem, JE. Vitamin B6. In: Machlin LJ. Handbook of Vitamins. 2nd ed. New York: Marcel Dekker; 1991. This vitamin is predominantly found in food sources like meat, whole grains and nuts. 2222 Leklem, JE. Vitamin B6. In: Machlin LJ. Handbook of Vitamins. 2nd ed. New York: Marcel Dekker; 1991.

Vitamin B6 present in the food is phosphorylated by intestinal phosphatases and absorbed in the jejunum and ileum. Its deficiency is associated with inadequate diet (e.g. anorexia and alcoholism), malabsorption (e.g. bariatric surgery, Crohn's disease and celiac disease) and the use of drugs (e.g. isoniazid, hydralazine, contraceptives, penicillamine, theophylline). 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260,2222 Leklem, JE. Vitamin B6. In: Machlin LJ. Handbook of Vitamins. 2nd ed. New York: Marcel Dekker; 1991.

Characteristically, pyridoxine deficiency manifests itself through extensive seborrheic eczema. Glossitis, ulceration of the oral mucosa, lip and angular cheilitis may appear later. Severe cases may simulate pellagra and be accompanied by neurological symptoms such as drowsiness, confusion, and peripheral neuropathy. Hypochromic microcytic anemia may occur (Chart 1 and Table 1). 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260,2222 Leklem, JE. Vitamin B6. In: Machlin LJ. Handbook of Vitamins. 2nd ed. New York: Marcel Dekker; 1991. There are reports on pyridoxine cytotoxicity induced by UVA radiation. 2322 Leklem, JE. Vitamin B6. In: Machlin LJ. Handbook of Vitamins. 2nd ed. New York: Marcel Dekker; 1991.

VITAMIN B9 OR FOLIC ACID AND VITAMIN B12 OR COBALAMIN

Vitamins B9 and B12 are analyzed collectively, because their deficiencies lead to similar clinical manifestations.1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260 Lack of vitamin B12 is usually due to inadequate absorption of nutrients associated with pernicious anemia or gastric disorders. In contrast, deficiency of folic acid is generally attributable to inappropriate diet and/or alcoholism. Both insufficiencies can coexist in some patients with malabsorption, such as those undergoing surgical gastrectomy, with celiac disease or chronic diarrhea.8Fujioka K, DiBaise JK, Martindale RG. Nutrition and metabolic complication after bariatric surgery and their treatment. JPEN J Parenter Enteral Nutr. 2011;35:52S-9S.,1111 Bordalo LA, Mourão DM, Bressan J. Nutritional deficiencies after bariatric surgery: why they happen? Acta Med Port. 2011;24:1021-8.,1212 Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21:S1-27. Some medications, such as methotrexate, trimethoprim, oral contraceptives, pyrimethamine, anticonvulsants like phenobarbital and phenytoin also act as folic acid antagonists.1212 Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21:S1-27.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260 Some articles herald vitamin B12 deficiency as the most commonly found after BS. This would occur due to decreased gastric acidity. 2424 Coupaye M, Puchaux K, Bogard C, Msika S, Jouet P, Clerici C, et al. Nutritional consequences of adjustable gastric banding and gastric bypass: a 1-year prospective study. Obes Surg. 2009;19:56-65.,2525 de Luis DA, Pacheco D, Izaola O, Terroba MC, Cuellar L, Cabezas G. Micronutrient status in morbidly obese women before bariatric surgery. Surg Obes Relat Dis. 2013;9:323-7.

The manifestations of folate and vitamin B12 deficits in other systems are: megaloblastic anemia and neurological manifestations, such as paresthesia, generalized weakness, symmetrical ataxia, spasticity, paraplegia, apathy, somnolence, irritability, memory loss, dementia, and psychosis. 8Fujioka K, DiBaise JK, Martindale RG. Nutrition and metabolic complication after bariatric surgery and their treatment. JPEN J Parenter Enteral Nutr. 2011;35:52S-9S. It is worth remembering that pernicious anemia related to vitamin B12 deficiency, may be associated with autoimmune diseases such as thyroiditis and vitiligo (Chart 1 and Table 1). 2626 Sawicki J, Siddha S, Rosen C. Vitiligo and associated autoimmune disease: retrospective review of 300 patients. J Cutan Med Surg. 2012;16:261-6.

BIOTIN

Biotin is an essential cofactor in the metabolism of amino acids. It is synthesized from ingested foods by intestinal bacteria; its main dietary sources being egg yolks, liver, nuts, peanuts, mushrooms, cow's milk and soy.2727 Mock, D. Biotin. In: Shils, M, Modern Nutrition in Health and Disease. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2000. p.459.,2828 Lanska DJ. The discovery of niacin, biotin, and pantothenic acid. Ann Nutr Metab. 2012;61:246-53. This deficiency can be hereditary and rarely acquired. Prolonged total parenteral nutrition without addition of biotin, use of anticonvulsants (e.g., valproic acid, carbamazepine, phenytoin), factors that alter the intestinal flora (e.g., bariatric surgery) are among some of the causes of the acquired form. 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,2727 Mock, D. Biotin. In: Shils, M, Modern Nutrition in Health and Disease. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2000. p.459.,2828 Lanska DJ. The discovery of niacin, biotin, and pantothenic acid. Ann Nutr Metab. 2012;61:246-53.

Alopecia, glossitis, keratosis pilaris, periorificial dermatitis, seborrheic dermatitis and erythroderma are dermatologic disorders associated with biotin deficiency. Systemic manifestations that may accompany them are conjunctivitis, vomiting, hypotonia, lethargy and metabolic acidosis (Chart 1 and Table 1).1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260,2828 Lanska DJ. The discovery of niacin, biotin, and pantothenic acid. Ann Nutr Metab. 2012;61:246-53.

VITAMIN C OR ASCORBIC ACID

Vitamin C supports osteoblast formation in bones and teeth. It is an essential cofactor for the synthesis of carnitine, and catecholamines such as dopamine and norepinephrine. 2929 Lindblad M, Tveden-Nyborg P, Lykkesfeldt J. Regulation of Vitamin C Homeostasis during Deficiency. Nutrients. 2013;5:2860-79.,3030 Mandl J, Szarka A, Bánhegyi G. Vitamin C: update on physiology and pharmacology. Br J Pharmacol. 2009;157:1097-110. Ascorbic acid has an anti-oxidant action, stabilizes vitamin E and folic acid and also acts as a cofactor for the enzyme that catalyzes the formation of hydroxylysine and hydroxyproline. 2929 Lindblad M, Tveden-Nyborg P, Lykkesfeldt J. Regulation of Vitamin C Homeostasis during Deficiency. Nutrients. 2013;5:2860-79.,3030 Mandl J, Szarka A, Bánhegyi G. Vitamin C: update on physiology and pharmacology. Br J Pharmacol. 2009;157:1097-110.,3131 Jacob R. Vitamin C. In: Shils M, Olson J, Shike M, Ross AC, editors. Modern nutrition in health and disease. Philadelphia: Lippincott; 2000. p.467 Flaws in this process interfere with collagen synthesis, which hinders skin healing, tooth formation, osteoblast and fibroblast production. Ascorbic acid is part of the metabolism of prostaglandins and prostacyclins, which when inadequately produced can generate decreased inflammatory response and increased immunological susceptibility. 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,2929 Lindblad M, Tveden-Nyborg P, Lykkesfeldt J. Regulation of Vitamin C Homeostasis during Deficiency. Nutrients. 2013;5:2860-79.,3030 Mandl J, Szarka A, Bánhegyi G. Vitamin C: update on physiology and pharmacology. Br J Pharmacol. 2009;157:1097-110.

Vitamin C intake is dependent on the ingestion of citrus fruits, strawberries, tomatoes, vegetables and potatoes.3131 Jacob R. Vitamin C. In: Shils M, Olson J, Shike M, Ross AC, editors. Modern nutrition in health and disease. Philadelphia: Lippincott; 2000. p.467 It is absorbed in the upper third of the intestine and its deficiency is rare in developed countries. However, it can arise from improper diets as occur in situations of poverty, alcoholism, lack of access to fresh produce, anorexia nervosa, ulcerative colitis, Crohn's disease, Whipple's disease, kidney failure and bariatric surgery.3131 Jacob R. Vitamin C. In: Shils M, Olson J, Shike M, Ross AC, editors. Modern nutrition in health and disease. Philadelphia: Lippincott; 2000. p.467,3232 Riess KP, Farnen JP, Lambert PJ, Mathiason MA, Kothari SN. Ascorbic acid deficiency in bariatric surgical population. Surg Obes Relat Dis. 2009;5:81-6. It is worth noting that smoking decreases the intestinal absorption of vitamin C and increases its catabolism.3333 Cepeda-Lopez AC, Aeberli I, Zimmermann MB. Does obesity increase risk for iron deficiency? A review of the literature and the potential mechanisms. Int J Vitam Nutr Res. 2010;80:263-70.

Scurvy is the most severe expression of vitamin C deficiency. Its clinical manifestations tend to occur 1-3 months after the start of a deficient diet. The first signs are fatigue, malaise and lethargy. The first cutaneous disorder is keratosis pilaris on the lateral and posterior areas of the arms, buttocks and thighs. These lesions may become hemorrhagic particularly in areas of pressure.1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260 The main changes in the oral cavity are the presence of edematous, erythematous and friable gingivae with tendency to bleeding. Symptoms can mimic Sjögren's syndrome with xerosis and keratoconjunctivitis.1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260,2929 Lindblad M, Tveden-Nyborg P, Lykkesfeldt J. Regulation of Vitamin C Homeostasis during Deficiency. Nutrients. 2013;5:2860-79. Other findings include conjunctival and gastrointestinal bleedings, ungual linear hemorrhages reflecting the weakness of blood vessel walls, besides osteochondral changes and thinning hair in corkscrew (Chart 1 and Table 1). 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260 Anemia, secondary to blood loss, is a common finding in scurvy and it is usually associated with folate and iron deficiencies. 3131 Jacob R. Vitamin C. In: Shils M, Olson J, Shike M, Ross AC, editors. Modern nutrition in health and disease. Philadelphia: Lippincott; 2000. p.467

IRON DEFICIENCY

Iron is a vital mineral for cell homeostasis. It is essential for oxygen transportation, DNA synthesis and energy metabolism. It is an important cofactor for nitrogen fixation and mitochondrial respiratory chain enzymes. In mammals, it is mainly used in the synthesis of hemoglobin (Hb) in erythrocytes, myoglobin in muscle cells and liver cytochromes.3333 Cepeda-Lopez AC, Aeberli I, Zimmermann MB. Does obesity increase risk for iron deficiency? A review of the literature and the potential mechanisms. Int J Vitam Nutr Res. 2010;80:263-70.,3434 Theil EC. Iron homeostasis and nutritional iron deficiency. J Nutr. 2011;141:724S-728S. Iron absorption is carried out in the duodenal epithelium and some aspects, such as acidity and the presence of solubilizing agents like sugars, facilitate the intestinal absorption.3434 Theil EC. Iron homeostasis and nutritional iron deficiency. J Nutr. 2011;141:724S-728S. One third of the iron acquired through diet is in the heme form, derived from the breakdown of hemoglobin and myoglobin contained in red meat. Eggs and dairy products provide smaller amounts of this form of iron, which is better absorbed than the inorganic form.3434 Theil EC. Iron homeostasis and nutritional iron deficiency. J Nutr. 2011;141:724S-728S.

Iron deficiency has consequences for the whole organism with anemia being the most relevant manifestation3333 Cepeda-Lopez AC, Aeberli I, Zimmermann MB. Does obesity increase risk for iron deficiency? A review of the literature and the potential mechanisms. Int J Vitam Nutr Res. 2010;80:263-70. Dietary iron absorption is reduced after bariatric surgery, as a result of the smaller amount of gastric acids and the rapid transit through the main absorption sites.3535 Basfi-Fer K, Rojas P, Carrasco F, Valencia A, Inostroza J, Codoceo J, et al. Evolution of the intake and nutritional status of zinc, iron and copper in women undergoing bariatric surgery until the second year after surgery. Nutr Hosp. 2012;27:1527-35.,3636 Jáuregui-Lobera I. Iron deficiency and bariatric surgery. Nutrients. 2013;5:1595-608. Iron deficiency is considered, by some publications, as the most common one after BS affecting up to 52% of patients. 3737 Brody F, Flood M, Richards NG, Vaziri K, Garey C, LeBrun C. A novel single agent for nutritional supplementation following Roux-en-Y gastric bypass. J Laparoendosc Adv Surg. 2013;23:596-600,3838 Beckman L, Earthman C. Nutritional implications of bariatric surgery and the role of registered dietitians. J Acad Nutr Diet. 2013;113:398-9. Prophylactic iron supplementation has been shown to effectively reduce the incidence of iron deficiency and the subsequent anemia. 3337 Brody F, Flood M, Richards NG, Vaziri K, Garey C, LeBrun C. A novel single agent for nutritional supplementation following Roux-en-Y gastric bypass. J Laparoendosc Adv Surg. 2013;23:596-60037,3838 Beckman L, Earthman C. Nutritional implications of bariatric surgery and the role of registered dietitians. J Acad Nutr Diet. 2013;113:398-9.,3838 Beckman L, Earthman C. Nutritional implications of bariatric surgery and the role of registered dietitians. J Acad Nutr Diet. 2013;113:398-9.,3939 John S, Hoegerl C. Nutritional deficiencies after gastric bypass surgery. J Am Osteopath Assoc. 2009;109:601-4. Iron deficiency is considered, by some publications, as the most common one after BS affecting up to 52% of patients. 37,38 Prophylactic iron supplementation has been shown to effectively reduce the incidence of iron deficiency and the subsequent anemia. 3737 Brody F, Flood M, Richards NG, Vaziri K, Garey C, LeBrun C. A novel single agent for nutritional supplementation following Roux-en-Y gastric bypass. J Laparoendosc Adv Surg. 2013;23:596-600,3838 Beckman L, Earthman C. Nutritional implications of bariatric surgery and the role of registered dietitians. J Acad Nutr Diet. 2013;113:398-9.,3939 John S, Hoegerl C. Nutritional deficiencies after gastric bypass surgery. J Am Osteopath Assoc. 2009;109:601-4.

Secondary dermatologic manifestations to iron decrease described in the literature are pallor, glossitis and koilonychia (Chart 1 and Table 1). 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260

COPPER DEFICIENCY

Copper is one of the primary metals detected in the human body. It is found in the plasma, erythrocytes, cerebrospinal fluid, saliva and gastric secretions. Its absorption occurs through the ingestion of meat, seafood, some vegetables, grains and nuts. 4040 Danks DM. Copper deficiency in humans. Annu Rev Nutr. 1988;8:235-57.,4141 Harvey LJ, Ashton K, Hooper L, Casgrain A, Fairweather-Tait SJ. Methods of assessment of copper status in humans: a systematic review. Am J Clin Nutr. 2009;89:2009S-2024S.

The main consequences of copper deficiency are neurological and hematopoietic disorders, but depigmented and brittle hair is also described.1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260 Pallor may be a clinical manifestation secondary to anemia (Chart 1 and Table 1).4242 Griffith DP, Liff DA, Ziegler TR, Esper GJ, Winton EF. Acquired copper deficiency: a potentially serious and preventable complication following gastric bypass surgery. Obesity (Silver Spring). 2009;17:827-31.,4343 Prodan CI, Bottomley SS, Vincent AS. Copper deficiency after gastric surgery: a reason for caution. Am J Med Sci. 2009;337:256-8. There are also reports that suggest that low serum copper levels can delay wound healing. 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260

Studies estimate that approximately 70% of women experience copper deficiency after BS. 4343 Prodan CI, Bottomley SS, Vincent AS. Copper deficiency after gastric surgery: a reason for caution. Am J Med Sci. 2009;337:256-8.,4444 Griffith DP, Liff DA, Ziegler TR, Esper GJ, Winton EF. Acquired copper deficiency: a potentially serious and preventable complication following gastric bypass surgery. Obesity (Silver Spring). 2009;17:827-31. Publications also associate the reduced albumin absorption, often seen after bariatric surgery, as the cause of serum copper deficiency. 2525 de Luis DA, Pacheco D, Izaola O, Terroba MC, Cuellar L, Cabezas G. Micronutrient status in morbidly obese women before bariatric surgery. Surg Obes Relat Dis. 2013;9:323-7.,4545 Basfi-Fer K, Rojas P, Carrasco F, Valencia A, Inostroza J, Codoceo J, et al. Evolución de la ingesta y del estado nutricional de zinc, hierro y cobre en mujeres sometidas a cirugía bariátrica hasta el segundo año postoperatorio. Nutr Hosp. 2012:27:1527-35.,4646 Chan CP, Wang BY, Cheng CY, Lin CH, Hsieh MC, Tsou JJ, et al. Randomized controlled trials in bariatric surgery. Obes Surg. 2013;23:118-30.

VITAMIN D DEFICIENCY

Vitamin D synthesis starts in epidermal keratinocytes and dermal fibroblasts with the photoisomerization of 7-dehydrocholesterol (7-DHC or provitamin D3) to pre-vitamin D3. Eighty percent of this conversion occurs in the epidermis and requires ultraviolet light B. It can also be obtained through dietary sources as ergocalciferol (vitamin D2) or be synthesized endogenously as cholecalciferol (vitamin D3).4747 Ben-Shoshan M. Vitamin D deficiency/insufficiency and challenges in developing global vitamin D fortification and supplementation policy in adults. Int J Vitam Nutr Res. 2012;82:237-59.,4848 Battault S, Whiting SJ, Peltier SL, Sadrin S, Gerber G, Maixent JM. Vitamin D metabolism, functions and needs: from science to health claims. Eur J Nutr. 2013;52:429-41. Fish oils have the highest quantity of available vitamin D, but egg, liver, shiitake mushrooms, and fortified products such as milk and orange juice are additional dietary sources. 4747 Ben-Shoshan M. Vitamin D deficiency/insufficiency and challenges in developing global vitamin D fortification and supplementation policy in adults. Int J Vitam Nutr Res. 2012;82:237-59.,4848 Battault S, Whiting SJ, Peltier SL, Sadrin S, Gerber G, Maixent JM. Vitamin D metabolism, functions and needs: from science to health claims. Eur J Nutr. 2013;52:429-41.

Fat malabsorption may predispose to vitamin D deficiency. The main causes are celiac disease, gastro surgical bypass, biliary atresia, cystic fibrosis, Crohn's disease, pancreatic and biliary illnesses. 4747 Ben-Shoshan M. Vitamin D deficiency/insufficiency and challenges in developing global vitamin D fortification and supplementation policy in adults. Int J Vitam Nutr Res. 2012;82:237-59.,4949 Cashman KD, Kiely M. Towards prevention of vitamin D deficiency and beyond: knowledge gaps and research needs in vitamin D nutrition and public health. Br J Nutr. 2011;106:1617-27. Hepatic and renal diseases, and the use of anticonvulsant drugs may also interfere with vitamin D metabolism. 4949 Cashman KD, Kiely M. Towards prevention of vitamin D deficiency and beyond: knowledge gaps and research needs in vitamin D nutrition and public health. Br J Nutr. 2011;106:1617-27.

Slater et al. observed decreased plasma levels of vitamin D in up to 63% of patients submitted to biliopancreatic diversion with duodenal switch.1616 Slater GH, Ren CJ, Siegel N, Williams T, Barr D, Wolfe B, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8:48-55. This vitamin deficiency is asymptomatic in 65% of patients despite routine supplementation. About 71% of women have vitamin D deficiency after BS. 2525 de Luis DA, Pacheco D, Izaola O, Terroba MC, Cuellar L, Cabezas G. Micronutrient status in morbidly obese women before bariatric surgery. Surg Obes Relat Dis. 2013;9:323-7.

Regarding the impact of vitamin D in dermatology, literature indicates that 1,25 dihydroxyvitamin D3 influences cell growth regulation and differentiation in keratinocytes and other cell types. Therefore, vitamin D analogues have been introduced for the treatment of psoriasis and other skin conditions. 5050 Stefanic M, Rucevic I, Barisic-Drusko V. Meta-analysis of vitamin D receptor polymorphisms and psoriasis risk. Int J Dermatol. 2013;52:705-10. Vitamin D was recently identified in sebaceous cells, indicating that it may be effective in treating acne. 5151 Reichrath J. Vitamin D and the skin: an ancient friend, revisited. Exp Dermatol. 2007;16:618-25. Vitamin D also has activity on the immune system, thus influencing the protection against skin cancer and autoimmune diseases (Chart 1 and Table 1). 5252 Nürnberg B, Gräber S, Gärtner B, Geisel J, Pföhler C, Schadendorf D, et al. Progression of malignant melanoma is associated with reduced 25-hydroxyvitamin D serum levels. Anticancer Res. 2009;29:3669-74.

Recently, literature has been emphasizing the impact of vitamin D in the pathogenesis of atopic dermatitis (AD).5353 Samochocki Z, Bogaczewicz J, Jeziorkowska R, Sysa-Jedrzejowska A, Glinska O, Karczmarewicz E, et al. Vitamin D effects in atopic dermatitis. J Am Acad Dermatol. 2013;69:238-44. Considering the immunological mechanisms involved in AD pathogenesis, it is possible that vitamin D may influence it through immunomodulatory properties. It is known that the active form of vitamin D [1,25 (OH) 2 D3] increases the expression of antibacterial peptides preventing cutaneous infections. Some studies have demonstrated the link between vitamin D and Toll-like receptors, cathelicidin production and the increased susceptibility to bacterial infections. 5454 Bergstrom KG. Evidence for supplement use in atopic dermatitis. J Drugs Dermatol. 2012;11:1245-7.,5555 Roider E1, Ruzicka T, Schauber J. Vitamin D, the cutaneous barrier, antimicrobial peptides and allergies: is there a link? Allergy Asthma Immunol Res. 2013;5:119-28. In addition, vitamin D stimulates the synthesis of proteins such as filaggrin, which is essential to the formation of stratum corneum. Thus, vitamin D deficiency may exacerbate AD by altering the skin barrier and undermining the immune system leading to subsequent increase in the risk of infections (Chart 1). 5353 Samochocki Z, Bogaczewicz J, Jeziorkowska R, Sysa-Jedrzejowska A, Glinska O, Karczmarewicz E, et al. Vitamin D effects in atopic dermatitis. J Am Acad Dermatol. 2013;69:238-44.,5555 Roider E1, Ruzicka T, Schauber J. Vitamin D, the cutaneous barrier, antimicrobial peptides and allergies: is there a link? Allergy Asthma Immunol Res. 2013;5:119-28. Clinical observations investigate the relationship between disease exacerbation in winter and less exposure to solar radiation. Epidemiological studies have shown a higher prevalence of atopic dermatitis in countries with greater latitudes. 5454 Bergstrom KG. Evidence for supplement use in atopic dermatitis. J Drugs Dermatol. 2012;11:1245-7.,5555 Roider E1, Ruzicka T, Schauber J. Vitamin D, the cutaneous barrier, antimicrobial peptides and allergies: is there a link? Allergy Asthma Immunol Res. 2013;5:119-28. The study by Lee found an inverse correlation between vitamin D serum concentrations and disease severity (Chart 1). 5656 Lee SA, Hong S, Kim HJ, Lee SH, Yum HY. Correlation between serum vitamin D level and the severity of atopic dermatitis associated with food sensitization. Allergy Asthma Immunol Res. 2013;5:207-10.

Research has also been evaluating the role of vitamin D in hair growth regulation. Hydroxyvitamin D3 is the most active metabolite of vitamin D, and its primary function is calcium homeostasis regulation. Various tissues are involved in calcium metabolism, so the genetic inactivation of vitamin D receptor genes in mice resulted in hypocalcemia, secondary hyperparathyroidism, osteomalacia, rickets and alopecia. 5757 Bollag WB. Mediator1: an important intermediary of vitamin D receptor-regulated epidermal function and hair follicle biology. J Invest Dermatol. 2012;132:1068-70.

VITAMIN E

Vitamin E is widely found in various foods, especially vegetable oils. Vitamin E's active form is an antioxidant with stabilizing action against unsaturated lipids. It accumulates in cell membranes and lipoproteins.5858 Niki E, Traber MG. A history of vitamin E. Ann Nutr Metab. 2012;61:207-12.,5959 Dror DK, Allen LH. Vitamin E deficiency in developing countries. Food Nutr Bull. 2011;32:124-43.,6060 Javanbakht MH, Keshavarz SA, Djalali M, Siassi F, Eshraghian MR, Firooz A, et al. Randomized controlled trial using vitamins E and D supplementation in atopic dermatitis. J Dermatolog Treat. 2011;22:144-50. Membranes that protect lipoproteins and fatty acid from peroxidation reactions provide a high level of skin protection against ultraviolet radiation, and enhance the immune response. 1717 El-Akawi Z, Abdel-Latif N, Abdul-Razzak K. Does the plasma level of vitamins A and E affect acne condition? Clin Exp Dermatol. 2006;31:430-4.,5959 Dror DK, Allen LH. Vitamin E deficiency in developing countries. Food Nutr Bull. 2011;32:124-43.

Studies report that low plasma concentrations of vitamins A and E may lead to the development of acne.1717 El-Akawi Z, Abdel-Latif N, Abdul-Razzak K. Does the plasma level of vitamins A and E affect acne condition? Clin Exp Dermatol. 2006;31:430-4. Others emphasize the beneficial effects of vitamin D and E in the treatment of atopic dermatitis (Chart 1 and Table 1). 5959 Dror DK, Allen LH. Vitamin E deficiency in developing countries. Food Nutr Bull. 2011;32:124-43.,6060 Javanbakht MH, Keshavarz SA, Djalali M, Siassi F, Eshraghian MR, Firooz A, et al. Randomized controlled trial using vitamins E and D supplementation in atopic dermatitis. J Dermatolog Treat. 2011;22:144-50.

VITAMIN K

Vitamin K is essential to the synthesis of several coagulation factors such as II, VII, IX, X, protein C and protein S. It is found in leafy greens, vegetables, liver, lentil, and soy and vegetable oils. Its absorption occurs via active transportation in the first third of the small intestine. Gastrointestinal bacteria synthesize approximately 50% of daily needs.6161 Shearer MJ, Fu X, Booth SL. Vitamin K nutrition, metabolism, and requirements: current concepts and future research. Adv Nutr. 2012;3:182-95.

Clinical deficiency of vitamin K may be secondary to low intake (e.g., anorexia, elderly patients, alcoholics), fat malabsorption (e.g., cystic fibrosis, biliary atresia, gastrointestinal surgeries as BS), use of antibiotics that alter the intestinal bacterial flora (e.g., cephalosporins, isoniazid, rifampicin) and vitamin K-inhibiting drugs (e.g., phenytoin, cholestyramine). 6161 Shearer MJ, Fu X, Booth SL. Vitamin K nutrition, metabolism, and requirements: current concepts and future research. Adv Nutr. 2012;3:182-95.

Diminished plasma levels of vitamin K may occur in up to 69% of patients having biliopancreatic deviation with duodenal switch. Deficiency of this vitamin is asymptomatic in 65% of patients despite routine supplementation.3939 John S, Hoegerl C. Nutritional deficiencies after gastric bypass surgery. J Am Osteopath Assoc. 2009;109:601-4. The main cutaneous manifestations secondary to vitamin K deficiency are related to the extravasation of blood into the skin as occurs in purpura, petechiae, ecchymoses, and bruising (Chart 1 and Table 1). 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260

ZINC DEFICIENCY

Zinc is a primordial element to the structural and regulatory functions of over 200 enzymes participating in biochemical pathways. 6262 Tuerk MJ, Fazel N. Zinc deficiency. Curr Opin Gastroenterol. 2009;25:136-43. It is found in most products of animal origin, legumes, whole grains and dairy products, however, its absorption is limited.6262 Tuerk MJ, Fazel N. Zinc deficiency. Curr Opin Gastroenterol. 2009;25:136-43.,6363 Schwartz JR, Marsh RG, Draelos ZD. Zinc and skin health: overview of physiology and pharmacology. Dermatol Surg. 2005;31:837-47.

Zinc deficiency can be genetic or acquired. Whilst acrodermatitis enteropathica is its most important feature, the acquired form arises from low food intake, intestinal malabsorption (e.g., gastric bypass, inflammatory bowel disease, celiac disease, chronic diarrhea) or increased depletion (e.g., alcoholism, neoplasms, burns, infections, pregnancy, nephropathy and stress).6262 Tuerk MJ, Fazel N. Zinc deficiency. Curr Opin Gastroenterol. 2009;25:136-43.,6363 Schwartz JR, Marsh RG, Draelos ZD. Zinc and skin health: overview of physiology and pharmacology. Dermatol Surg. 2005;31:837-47. Medications such as penicillamine, diuretics, antimetabolites, iron and valproate can lower serum zinc levels. 6262 Tuerk MJ, Fazel N. Zinc deficiency. Curr Opin Gastroenterol. 2009;25:136-43. The classic clinical triad of acrodermatitis enteropathica is comprised of diarrhea, alopecia and acral and periorificial rash. 6464 Cunha SF, Gonçalves GA, Marchini JS, Roselino AM. Acrodermatitis due to zinc deficiency after combined vertical gastroplasty with jejunoileal bypass: case report. Sao Paulo Med J. 2012;130:330-5. This rash tends to be symmetrical, eczematous and erosive. The hair can become dry, brittle and thin. Other cutaneous features caused by zinc deficiency are vitiligo-like lesions, delayed wound healing, paronychia, stomatitis, psoriasiform dermatitis, angular cheilitis and blepharitis (Chart 1 and Table 1).1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260,6363 Schwartz JR, Marsh RG, Draelos ZD. Zinc and skin health: overview of physiology and pharmacology. Dermatol Surg. 2005;31:837-47.,6464 Cunha SF, Gonçalves GA, Marchini JS, Roselino AM. Acrodermatitis due to zinc deficiency after combined vertical gastroplasty with jejunoileal bypass: case report. Sao Paulo Med J. 2012;130:330-5. There are also reports that low zinc serum levels may delay wound healing. 6565 Mirastschijski U, Martin A, Jorgensen LN, Sampson B, Ågren MS. Zinc, copper, and selenium tissue levels and their relation to subcutaneous abscess, minor surgery, and wound healing in humans. Biol Trace Elem Res. 2013;153:76-83.

The reduction in zinc serum levels after BS has been documented in the literature.6666 Pires LV, Martins LM, Geloneze B, Tambascia MA, Monte SJ, Nogueira N, et al. The effect of Roux-en-Y gastric bypass on zinc nutritional status. Obes Surg. 2007;17:617-21.,6767 Cominetti C, Garrido AB Jr, Cozzolino SM. Zinc nutritional status of morbidly obese patients before and after Roux-en-Y gastric bypass: a preliminary report. Obes Surg. 2006;16:448-53. The rates can be as high as 74% of women with zinc deficiency after bariatric surgery. 2525 de Luis DA, Pacheco D, Izaola O, Terroba MC, Cuellar L, Cabezas G. Micronutrient status in morbidly obese women before bariatric surgery. Surg Obes Relat Dis. 2013;9:323-7. It is believed that in cases of protein malnutrition secondary to surgery, there are changes in the intestinal structure and functions, with decrease of villi culminating in a reduced capacity of zinc absorption. Moreover, it is likely that the decline in gastric secretion and the oxidative stress resulting from surgery add to the metabolic demand, which also contribute to this diminished absorption.6464 Cunha SF, Gonçalves GA, Marchini JS, Roselino AM. Acrodermatitis due to zinc deficiency after combined vertical gastroplasty with jejunoileal bypass: case report. Sao Paulo Med J. 2012;130:330-5.

SELENIUM

Selenium's best-known function is that of an antioxidant, carried out by its association with glutathione peroxidase enzyme. Besides acting in the detoxification of hydrogen peroxide and other organic peroxides, glutathione peroxidase also maintains vital sulfhydryl groups in the reduced form, and it also acts on the synthesis of arachidonic acid-derived hormones and in the metabolism of extraneous compounds. 6868 Rayman MP. Selenium and human health. Lancet. 2012;379:1256-68.,6969 Weeks BS, Hanna MS, Cooperstein D. Dietary selenium and selenoprotein function. Med Sci Monit. 2012;18:RA127-132. Selenium can be found in rice, beans and flour.6969 Weeks BS, Hanna MS, Cooperstein D. Dietary selenium and selenoprotein function. Med Sci Monit. 2012;18:RA127-132.

Selenium deficiency is already clearly related to increased risk of heart disease, immunodeficiency, male infertility and cancer. 7070 Cassidy PB, Fain HD, Cassidy JP Jr, Tran SM, Moos PJ, Boucher KM, et al. Selenium for the prevention of cutaneous melanoma. Nutrients. 2013;5:725-49. Alasfar et al found that morbidly obese women seeking BS as treatment had significantly reduced serum levels of selenium. 7171 Alasfar F, Ben-Nakhi M, Khoursheed M, Kehinde EO, Alsaleh M. Selenium is significantly depleted among morbidly obese female patients seeking bariatric surgery. Obes Surg. 2011;21:1710-3. Cutaneous repercussions of selenium deficiency are decreased wound healing, increased risk of psoriasis and skin cancer (both melanoma and non-melanoma types) (Chart 1 and Table 1). 6565 Mirastschijski U, Martin A, Jorgensen LN, Sampson B, Ågren MS. Zinc, copper, and selenium tissue levels and their relation to subcutaneous abscess, minor surgery, and wound healing in humans. Biol Trace Elem Res. 2013;153:76-83.,7070 Cassidy PB, Fain HD, Cassidy JP Jr, Tran SM, Moos PJ, Boucher KM, et al. Selenium for the prevention of cutaneous melanoma. Nutrients. 2013;5:725-49.,7272 Naziroglu M, Yildiz K, Tamtürk B, Erturan I, Flores-Arce M. Selenium and psoriasis. Biol Trace Elem Res. 2012;150:3-9.,7373 Vinceti M, Dennert G, Crespi CM, Zwahlen M, Brinkman M, Zeegers MP, et al. Selenium for preventing cancer. Cochrane Database Syst Rev. 2014;3:CD005195.

ENERGY-PROTEIN MALNUTRITION

Energy-protein malnutrition (EPM) can be classified into marasmus, kwashiorkor and marasmuskwashiorkor. Marasmus refers to a global and chronic deficiency of nutrients due to lack of food intake or absorption. Kwashiorkor refers to a disproportionately greater absorption or ingestion of carbohydrates compared to fat and protein intake. Marasmus-kwashiorkor is an intermediate state between them. 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260 EPM is uncommon in adults, but it has been associated with anorexia nervosa and malabsorptive disorders like Crohn's disease, cystic fibrosis and post bariatric surgery. 1212 Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21:S1-27. Kwashiorkor is the type of EPM most commonly seen in adults. 7474 Lewandowski H1, Breen TL, Huang EY. Kwashiorkor and an acrodermatitis enteropathica-like eruption after a distal gastric bypass surgical procedure. Endocr Pract. 2007;13:277-82.

A study shows that patients undergoing BS have about 6% albumin and 21% prealbumin deficiencies. 2525 de Luis DA, Pacheco D, Izaola O, Terroba MC, Cuellar L, Cabezas G. Micronutrient status in morbidly obese women before bariatric surgery. Surg Obes Relat Dis. 2013;9:323-7. From a dermatological point-of-view, the following manifestations can be found: dry, wrinkled skin giving a more aged appearance, erythematous or hypochromic lesions seen mostly in areas of friction or flexures, that over time become very evident, hyper-pigmented, with smooth, fissured or erosive surfaces. Nails are brittle, slow growing and with areas of onychomadesis. Areas of follicular hyperkeratosis, pale extremities accompanied by swelling may also occur.1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260 The hair can be dry, brittle, dull, thin, with a red-brownish color before becoming grayish-white. The flag sign depicts alternate dark and light bands in the hair (Chart 1 and Table 1).1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260,7575 Rojas P, Gosch M, Basfi-fer K, Carrasco F, Codoceo J, Inostroza J, et al. Alopecia in women with severe and morbid obesity who undergo bariatric surgery. Nutr Hosp. 2011;26:856-62. Angular cheilitis, xerophthalmia, stomatitis and vulvovaginitis may be seen as well. 1515 Jen M, Yan AC. Syndromes associated with nutritional deficiency and excess. Clin Dermatol. 2010;28:669-85.,1919 Palint JP. Physical Finding in Nutritional Deficiency. Ped Clin North Am. 1998:245-260

EPM treatment should be individualized according to the type and severity of presented manifestations. However, it is essential to correct their cause and supplement the deficient macronutrients.2020 Koch TR, Finelli FC. Postoperative metabolic and nutritional complications of bariatric surgery. Gastroenterol Clin North Am. 2010;39:109-24.

PSORIASIS X BARIATRIC SURGERY

Psoriasis is an inflammatory skin disease, for which obesity is considered a risk factor. Obese patients with psoriasis tend to have conditions that are more resistant to conventional treatments.7676 Halawi A, Abiad F, Abbas O. Bariatric surgery and its effects on the skin and skin diseases. Obes Surg. 2013;23:408-13.

Studies have suggested that gastric bypass surgery in patients with psoriasis can result in complete remission. The improvement starts immediately after surgery, before any weight loss. Medical literature postulates that it is secondary to increased levels of glucagon-like peptide-1 (GLP-1) produced by the intestine. Levels of GLP-1 may increase up to 20 times after gastric bypass surgery. This hormone is not hypersecreted after a purely restrictive gastric reduction, so treatment with gastric band does not lead to improvement of the disease. 7777 Pérez-Pérez L, Allegue F, Caeiro JL, Zulaica JM. Severe psoriasis, morbid obesity and bariatric surgery. Clin Exp Dermatol. 2009;34:e421-2.,7878 Bozkurt S, Coskun H, Kadioglu H, Memmi N, Cipe G, Ersoy YE, et al. Remission of Ulcerated Necrobiosis Lipoidica Diabeticorum after Bariatric Surgery. Case Rep Dermatol Med. 2013;2013:352579.

Although data on GLP-1 immunological actions are scarce in animal models or in vitro, there is a potential immunological effect that represents a link between bariatric surgery, GLP-1 and psoriasis. However, this hormone also acts directly on the skin as demonstrated in a study on the expression of GLP-1 receptor in hair follicles of mice. 7676 Halawi A, Abiad F, Abbas O. Bariatric surgery and its effects on the skin and skin diseases. Obes Surg. 2013;23:408-13.,7777 Pérez-Pérez L, Allegue F, Caeiro JL, Zulaica JM. Severe psoriasis, morbid obesity and bariatric surgery. Clin Exp Dermatol. 2009;34:e421-2.

NECROBIOSIS LIPOIDICA X BARIATRIC SURGERY

Diabetes mellitus type 2 (DM2) is one of the most important comorbidities associated with obesity. The improvement of DM2 after bariatric surgery is a fact and therefore it has been publicized as "a metabolic surgery." The explanation for this is still unclear, since there is an assumption that it is not exclusively correlated with the weight loss. 7979 Dixon JB, le Roux CW, Rubino F, Zimmet P. Bariatric surgery for type 2 diabetes. Lancet. 2012 Jun 16;379:2300-11.

Necrobiosis lipoidica (NL), a dermatosis associated with diabetes, is characterized by single or multiple atrophic, erythematous-brownish, granulomatous lesions, which are located most often in the pretibial region; its precise etiology tough, remains unknown. Literature reported cases of NL remission after bariatric surgery. 8080 Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis Am J Med. 2009;122:248-256.e5. However, there is still much to be elucidated about the true mechanisms leading to this process. 7979 Dixon JB, le Roux CW, Rubino F, Zimmet P. Bariatric surgery for type 2 diabetes. Lancet. 2012 Jun 16;379:2300-11.

POST-BARIATRIC SURGERY EXCESS SKIN

After the massive weight loss following bariatric surgery, about 90% of patients tend to display the negative effects secondary to the large amount of redundant skin. 5Neff KJH, Roux CW. Bariatric Surgery. J Clin Pathol. 2013;66:90-8.,8181 Aldaqal SM, Makhdoum AM, Turki AM, Awan BA, Samargandi OA, Jamjom H. Post-bariatric surgery satisfaction and body-contouring consideration after massive weight loss. N Am J Med Sci. 2013;5:301-5. In addition to the aesthetic problems, this leads to functional problems, dermatoses and difficulties in carrying on personal hygiene. 1010 Hng KN, Ang YS. Overview of bariatric surgery for the physician. Clin Med. 2012;12:435-40.,8181 Aldaqal SM, Makhdoum AM, Turki AM, Awan BA, Samargandi OA, Jamjom H. Post-bariatric surgery satisfaction and body-contouring consideration after massive weight loss. N Am J Med Sci. 2013;5:301-5.

The treatment of redundant skin is a necessary and essential step to improve the quality of life of patients after bariatric surgery. Nevertheless, there is clinical evidence on the differences in the healing and recovery processes of patients with massive weight loss after BS. 8181 Aldaqal SM, Makhdoum AM, Turki AM, Awan BA, Samargandi OA, Jamjom H. Post-bariatric surgery satisfaction and body-contouring consideration after massive weight loss. N Am J Med Sci. 2013;5:301-5.,8282 Singh D, Forte AJ, Zahiri HR, Janes LE, Sabino J, Matthews JA, et al. Prognostication for body contouring surgery after bariatric surgery. Eplasty. 2012;12:e46. Recent studies demonstrated that major weight loss is associated with damage in some components of the cutaneous extracellular matrix, particularly elastin fibers and collagen, which leads to higher rates of complications and poorer aesthetic results. 8282 Singh D, Forte AJ, Zahiri HR, Janes LE, Sabino J, Matthews JA, et al. Prognostication for body contouring surgery after bariatric surgery. Eplasty. 2012;12:e46.,8383 Mitchell JE, Crosby RD, Ertelt TW, Marino JM, Sarwer DB, Thompson JK, et al. The desire for body contouring surgery after bariatric surgery. Obes Surg. 2008;18:1308-12.

After BS, the patient's skin presents lower concentrations of heparan sulfate, perlecan and increase in type III collagen. Heparan sulfates are attached to different proteins in the nucleus and they can be found on the cell surface and extracellular matrix, such as the basement membrane. They can interact with a wide range of proteins inducing biological activities such as cell proliferation, inflammation, hemostasis and angiogenesis, among others. Perlecan is a primary component of the basement membrane.8282 Singh D, Forte AJ, Zahiri HR, Janes LE, Sabino J, Matthews JA, et al. Prognostication for body contouring surgery after bariatric surgery. Eplasty. 2012;12:e46. It interacts with various growth factors such as vascular endothelial growth factor (VEGF)-A, which is essential for epidermal formation. 8181 Aldaqal SM, Makhdoum AM, Turki AM, Awan BA, Samargandi OA, Jamjom H. Post-bariatric surgery satisfaction and body-contouring consideration after massive weight loss. N Am J Med Sci. 2013;5:301-5.,8383 Mitchell JE, Crosby RD, Ertelt TW, Marino JM, Sarwer DB, Thompson JK, et al. The desire for body contouring surgery after bariatric surgery. Obes Surg. 2008;18:1308-12. Xing et al. also demonstrated, through an immunofluorescence study, the increased expression of type III collagen in the skin of patients after bariatric surgery. This is an immature collagen with less healing capacity. 8282 Singh D, Forte AJ, Zahiri HR, Janes LE, Sabino J, Matthews JA, et al. Prognostication for body contouring surgery after bariatric surgery. Eplasty. 2012;12:e46. However, these studies were performed in vitro and further investigation on this topic is still necessary.

DERMATOLOGICAL FOLLOW-UP POST-BS

We suggest that the dermatologist watch out for the following points in patients submitted to bariatric surgery:

a. Anamnesis data: type of surgery performed (restrictive or not), current nutritional therapy, general symptoms (e.g., weakness, vomiting, diarrhea, neurological disorders, bleeding), history of recurrent cutaneous infections

b. Physical exam data: complete examination of the skin, mucosae and hairs.

c. Educate patients about personal hygiene cares on redundant skin.

d. Routinely prescribe moisturizers, since there are many deficiencies that can lead to xeroderma.

e. Beware of delayed healing in case of surgical procedures.

about cutaneous manifestations after to bariatric surgery are still sparse. At present, findings are restricted to changes due to metabolic and nutritional disorders, alterations in the skin structure after massive weight.

  • How to cite this article: Manzoni APDS, Weber MB. Skin changes after bariatric surgery. An Bras Dermatol. 2015;90(2):157-68.
  • *
    Work performed at the Dermatology Service at Porto Alegre Federal University of Health Sciences (UFCSPA) - Porto Alegre (RS), Brazil.

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Publication Dates

  • Publication in this collection
    Mar-Apr 2015

History

  • Received
    13 Sept 2013
  • Accepted
    10 Oct 2013
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