Dear Doctor, I notice that I am getting a rash in a skin fold. Will the rash just go away on its own?

Answer provided by Walter Medlin, MD, FACS

Fall 2014

There are several different skin issues that occur before and after bariatric surgery. There are ways to combat individual issues, but no single answer – except that surgery is ultimately the durable solution when the problem is excess skin. Keep in mind, however, that even normal weight folks can have skin problems. Other conditions will not be discussed here, except to mention that psoriasis and other problems may change their episodes for better and worse during the first year of weight-loss, and that long term malnutrition protein and vitamin deficiencies can show up with various skin signs and problems.

Skin Concerns

Skin cancer is the most common type of malignancy, and can show up in many unusual ways. Dermatologists are there for a reason – ask your primary caregiver for a referral if things don’t improve. Also, remember that melanoma has doubled in our generation – stop tanning and get covered up! It’s too late for me to undo the dozens of sunburns I had as a kid, but that’s no excuse not to take care of myself today.

Most common is intertriginous dermatitis, or intertrigo. Diaper rash is a type of intertrigo, but any skin fold can have it. Odor is probably the cause of the most anxiety, and while “poor hygiene” is often blamed, some excessive measures can actually make odor worse by damaging skin – creating an even better micro environment for yeast and bacteria that cause most odor.

Causes of Skin Irritation

Chafing
First is simple irritation from friction – chafing! While it is very easy to describe, solutions may be challenging. If you are unable to change activities or clothing to minimize, then consider Body Glide, or similar skin lubricant that work for long distance runners. It’s very important to PLAN AHEAD with lubricant, though. Often, Lycra-type clothing can reduce rubbing, as can adjusting other factors, such as time of day you are moving. Under breasts and armpits are hardest to get dry again, though thigh chafing is the painful first area for many of us.

Chronic (long term) chafing can lead to skin that has now been damaged, and now is at risk of yeast or bacterial infection. In the short term, infection may require appropriate antibiotics or anti-fungal meds (oral if a deeper infection, usually cream if just mild or on unbroken skin). See your doctor if any concern of deeper infection. Steroid creams can help reduce inflammation, but long term use is a no-no without a doctor and a specific plan with monitoring!

Moisture
Long term (chronic) moisture alone can cause skin surface breakdown and open the door for infection. The skin has a dead layer of cells (epidermis) that give us a “waxy” coating that protects from losing moisture, but this can become locally disturbed, and leave the deeper layer open and vulnerable.

Trying to just “dry” things up aggressively may just make more damage. BE VERY CAREFUL in how you combat chronic moisture! If urine or feces is involved, definitely see your doctor. If sweat seems to be the main cause, you can try to minimize the issue. First, keep things dry from the start – using a cool setting on a hair dryer (again, avoid heat damage). Some astringents, like Witch Hazel or rubbing alcohol, can temporarily dry the skin but may lead to a vicious cycle and cause acne. Some protective creams can reinforce the waxy epidermal barrier, like petroleum jelly (Vaseline) or some lotions, but please start slow and cautious.

Many folks with chronic issues will place absorbent cloth under certain skin folds. The area under the breasts or tummy work well for this. Open-toed shoes can help if the issue is between toes or avoiding tight clothes if in armpits or groin. Remember that not all skin problems are simple – do not try to do too much on your own if you have any questions.

Treatment and Insurance Coverage

The medical (and insurance) term for long term skin breakdown and rash from skin fold problems is “intertrigo” or “intertriginous dermatitis.” MAKE SURE YOUR PRIMARY CAREGIVER USES THIS CODE! While almost no insurance covers cosmetic procedures, many who have paid out-of-pocket feel it was worth the expense. The good news is that many insurers WILL cover simple skin removal to improve the moisture related problems. Please consider getting professional help with insurance appeals, and do not expect that all your wishes will come true! Most covered procedures are the “simplest,” and not automatically that extreme makeover.

The other good news is that many skin problems improve as skin does tighten some throughout that first 18 months after bariatric surgery, almost always slower than the weight-loss. Muscle development cannot hurt, but sit-ups and tricep extensions do NOT give local skin tightening. Also, remember that skin is very sensitive to smoking! You will not get the best shrinkage if you are lighting up. Sun exposure in the past will change your skin, and ongoing exposure, including tanning beds, is not a good idea (age and genetics are factors, but we cannot change those).

Finally, surgery really is the most reliable “cure,” but remember that not all problems have to be fixed immediately, and give yourself some room on this journey. Body image issues can get tied up in this; do not try to make it a separate issue from your ongoing lifelong care and health!

About the Author:
Walter Medlin, MD, FACS, is a bariatric surgeon and sleeve gastrectomy patient now five years post-op. He is a member of the OAC National Board of Directors and tweets @bonuslife.

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