Prurigo Pigmentosa Following Bariatric Surgery: A Comprehensive Clinicopathological Review

Prurigo pigmentosa: Case series and differentiation from confluent and reticulated papillomatosis

Prurigo pigmentosa (PP) is a rare, inflammatory, idiopathic skin disorder, which typically presents as symmetrically scattered pruritic erythematous reticulated papules with occasional vesicles. PP has been primarily a disease of the trunk and the neck, and, to the authors’ knowledge, there has been only two reported cases of PP where the forehead/facial areas were involved worldwide. Interestingly, there have not been any reported cases of after bariatric surgery PP with facial involvement. Herein, we present a case of PP after laparoscopic sleeve gastrectomy with involvement of the face, chest, and back.

Hyperketonemia is a risk factor for prurigo pigmentosa; therefore, diabetic ketosis and ketoacidosis as background diseases are more frequent in prurigo pigmentosa. However, it is underrecognized by clinicians and easily missed. Herein, we present a case of diabetic ketoacidosis in which prurigo pigmentosa was recognized as a dermadrome. A 37-year-old woman with no medical history presented with thirst, polydipsia, and polyuria approximately 1 month prior to transport. and a pruritic skin rash on both shoulders 1 week later. After no diagnosis by a local dermatologist, the patient was diagnosed with diabetic ketoacidosis, and insulin therapy was initiated at our hospital. Based on the patient's history, post-hospitalization course, and pathological findings, the pruritic skin rash was diagnosed as prurigo pigmentosa. The clinical course suggested that prurigo pigmentosa is a dermadrome of diabetic ketosis and ketoacidosis. The medical clinicians' awareness of its relevance is crucial for designing therapeutic interventions for diabetic ketosis and ketoacidosis.

Keto Rash: Ketoacidosis-Induced Prurigo Pigmentosa

BACKGROUNDLaparoscopic sleeve gastrectomy (LSG) has been established as an effective means of weight loss. Multiple studies report LSG as a cost-effective procedure with few perioperative complications.OBJECTIVESReport long-term weight changes after LSG in a single center in Kuwait.DESIGNRetrospective analysis of data collected 5–8 years after surgery.SETTINGA single medical center.PATIENTS AND METHODSAll patients that had undergone LSG between December 2008 and December 2011.MAIN OUTCOME MEASURESWeight changes, short-term complications following surgery (within one month).SAMPLE SIZE187.RESULTSThe mean age at the time of the surgery was 36.5 (10.3) years. Females composed 71.6% of this study population. Two patients (1.1%) presented with a leak within 30 days of the surgery. Twenty-one (11.2%) patients underwent revisional bariatric surgery after LSG. Mean (SD) BMI decreased from 47.1 (8.3) kg/m2 before surgery to 34.3 (7) kg/m2 5–8 years after surgery. Mean (SD) body weight decreased from 126.3 (25.3) kg to 91.6 (19.9) kg 5–8 years following LSG. The mean excess body weight loss was 58.8% (29.2%).CONCLUSIONLSG is a bariatric procedure with low complications and mortality in relation to other forms of bariatric surgery. It is associated with a significant improvement in weight loss in the long term.LIMITATIONSRecall bias due to the nature of collecting the data, small sample size.

A 19-year-old woman presented with three episodes of intensely pruritic rash on her back, and weight loss of > 40 kg in 5 months. There was no personal or family history of similar skin conditions or atopy, and she was not on any medication. She had a background history of anorexia and bulimia nervosa necessitating admissions for starvation ketosis. The rash flared up during periods of extreme starvation and improved spontaneously with food intake. Skin examination showed erythematous papules and brown macules on her back in a reticular pattern. Blood tests were normal except for elevated serum ketone levels (6.2 mmol L−1, reference 0.6–1.6). Skin biopsy showed mild hyperkeratosis and acanthosis with marked infiltrate of neutrophils and eosinophils with dermal necrosis. A diagnosis of prurigo pigmentosa secondary to starvation ketosis was made based on the clinical and pathological findings. The rash resolved with hyperpigmentation following improvement in food intake and follow-up with the mental health team. Prurigo pigmentosa is a rare inflammatory dermatosis associated with ketosis, first described by Nagashima et al. in 1971 (Nagashima M, Ohshiro A, Simizu N. A peculiar pruriginous dermatosis with gross reticular pigmentation. Jpn J Dermatol 1971; 81: 38–9). The majority of the reports are from East Asia, and described in young female patients in late adolesce or early adulthood. However, it has been described in people of all ages, sex and ethnicities. Over 300 cases of prurigo pigmentosa have been reported in the literature. The exact pathogenesis remains unclear. Metabolic disorders such as poorly controlled diabetes, intake of low-carbohydrate diets, anorexia nervosa and fasting have been suggested as possible triggers, as they increase serum ketones, which in turn induce neutrophilic inflammation. Between 2015 and 2021, 19 cases of pruritus pigmentosa induced by ketogenic diet were reported, with a significant female preponderance and an age range of 16–43 years [Xiao A, Kopelman H, Shitabata P et al. Ketogenic diet-induced prurigo pigmentosa (the keto rash): a case report and literature review. J Clin Aesthet Dermatol 2021; 14: S29–32]. The rash usually appears within weeks of initiating a ketogenic or restrictive diet and resolves upon discontinuing the ketogenic diet or consumption of a high-calorie diet. Prurigo pigmentosa presents with erythematous, coalescing papules typically on the upper back, rarely affecting the face and limbs. The inflammatory phase resolves with postinflammatory reticulated hyperpigmentation. Most cases of prurigo pigmentosa resolve spontaneously. Treatment with tetracycline antibiotics or dapsone has been shown to reduce the duration of the inflammatory phase. The residual hyperpigmentation usually persists for many months. This case is presented to enhance awareness, and facilitate early identification and appropriate treatment of this characteristic inflammatory dermatosis.

Comment on: Hormone changes and diabetes resolution following biliopancreatic diversion and laparoscopic sleeve gastrectomy. A comparative prospective study

Introduction Gallbladder disease (GBD) encompasses several medical conditions, including gallbladder stone formation, biliary colic, and cholecystitis. These conditions may arise following bariatric surgery, including bypass or laparoscopic sleeve gastrectomy (LSG). The development of GBD after surgery may be attributed to various factors, including the formation of stones shortly after the procedure, the exacerbation of existing stones due to the surgery, or inflammation of the gallbladder. Rapid weight loss after surgery has also been proposed as a contributing factor. Methodology This observational study consisted of a review of retrospective hospital patient medical records of 350 adult participants who underwent LSG, with 177 participants included in the study after excluding those with cholecystectomy or GBD prior to surgery. The participants were followed for a median of two years, during which we recorded any hospitalizations, emergency department visits, clinic visits, and incidents of cholecystectomy or abdominal pain due to GBD. The participants were grouped into two: those with GBD and those without GBD after bariatric surgery, and quantitative data were summarized using mean and standard deviations. The data were analyzed using IBM SPSS Statistics for Windows, Version 20.0. (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp), with a statistical significance of P<0.05. Results In our retrospective study of 177 patients who underwent LSG, the incidence of GBD after bariatric surgery was 4.5%. Most patients with GBD after bariatric surgery were White, but this difference was not statistically significant. Patients with type 2 diabetes had a higher incidence of GBD after bariatric surgery than those without diabetes (8.3% vs. 3.6%, P=0.355). Patients with HTN had a lower incidence of GBD after bariatric surgery than those without HTN (1.1% vs. 8.2%, P=0.032). Anti-hyperglycemia medication use did not significantly increase the risk of GBD after bariatric surgery (7.5% vs. 3.8%, P=0.389). None of the patients on weight loss medication developed GBD after bariatric surgery, compared to 5% of patients who did not take weight loss medication. Our sub-data analysis showed that patients who developed GBD after bariatric surgery had a high BMI (above 40 kg/m2) before surgery, which decreased to 35 kg/m2 and below 30 kg/m2 at six months and 12 months post-surgery, respectively. Conclusions Our findings demonstrate that the prevalence of GBD after LSG is low and comparable to the general population without LSG. Thus, LSG does not increase the risk of GBD. We found that rapid weight loss after LSG is a significant risk factor for GBD. These findings suggest that patients who undergo LSG should be informed of the risks of GBD and undergo careful screening before surgery to detect any pre-existing gallbladder issues. Overall, our study highlights the importance of continued research into the factors associated with GBD after bariatric surgery and the need for standardized prophylactic measures to prevent this potentially serious complication.

A 22-year-old single female presented to primary care Wazarat Health Center at Prince Sultan Military Medical City in Riyadh, with a 3 weeks history of itchy erythematous papules and vesicles and papulo-vesicles over the neck, chest, and upper back and face, which started 4 to 5 days after bariatric surgery. The patient on daily multivitamin supplements, vitamin D (50,000 IU, weekly / 2 months). The patient has lost 4kg since the operation, family history of atopy was positive regarding the mother physical examination shows erythematous papules and vesicles and papulo-vesicles over the neck with crust, chest, and upper back, Based on medical history and clinical presentation a provisional diagnosis was Prurigo Pigmentosa. The patient was prescribed topical mometasone furoate cream (BID for one week). Two -week follow-up showed improvement of the eruption. The course of the disease was shorter than usual in such cases the patient response to treatment was reactive to the topical mometasone without taking the oral minocyline, which major of such cases need in the late course of the disease The patient starts to improve within 2 weeks compared to others who need an average of 6 weeks to improve in such cases

Background/Aims: Prurigo pigmentosa (PP) is an uncommon inflammatory disease with pruritic reddish papules, papulovesicules or vesicules that are symmetrically localized on the trunk and nape, accompanied by reticular hyperpigmentation. Currently available therapeutic options seem somewhat unsatisfying. Herein, we report an 18-year-old female with PP successfully treated with low-dose isotretinoin. Methods: The patient presented with a symmetrical pruritic eruption on the lateral sides of her trunk with erythematous papules on a hyperpigmented background. Based on the typical clinical and associated histological findings, the patient was diagnosed as PP and a treatment with low-dose isotretinoin 0.3 mg/kg/day (20 mg/day) was started. Results: After a total of 3 months of 20 mg/day isotretinoin therapy, all erythematous macules and papules resolved and the residual pigmentation had almost disappeared. Conclusion: Low-dose isotretinoin is not only adequate for the improvement of erythematous lesions, it also helps resolve the reticular hyperpigmentation of PP. Further studies are needed to observe the efficacy of isotretinoin in the treatment of PP.

Bariatric surgery is an effective intervention for severe obesity and related comorbidities. The global increase in obesity has led to a rise in bariatric procedures, highlighting the need for the evaluation and management of postoperative complications. These complications vary from minor issues to life-threatening events. Prurigo pigmentosa (PP), also known as Nagashima disease, is an acquired dermatological condition characterized by a markedly pruritic eruption of erythematous papules and papulovesicles on the back, neck, and chest and improved leaving macular reticulated hyperpigmentation. First described in 1971 by Japanese dermatologist Masaji Nagashima, the condition was initially observed among eight patients of Asian descent. PP has been strongly associated with ketosis and a ketogenic diet; however, its precise etiology remains unclear. The condition predominantly affects young women of Asian descent. Here, we report a case of PP in a Libyan male, which developed 13 days post-bariatric surgery. This presentation could be suggestive of a stronger relationship between PP and the metabolic state of the body. It also outlines the effectiveness of treatment options currently in use for treating PP.

A122 - Taste and Olfactory Changes Following Laparoscopic Gastric Bypass and Sleeve Gastrectomy

Alterations in taste/smell after bariatric surgery have been observed, but few data is available. Some authors documented these changes and their role on weight loss but there is no evidence after laparoscopic sleeve gastrectomy (LSG). Cohort study with patients submitted to laparoscopic gastric bypass (LGBP) and LSG that were asked to participate in a validated survey. The primary objective was to determinate the differences between procedures for taste and smell changes; a demographic and anthropometric analysis were also performed. Secondarily, the relation between food aversion and weight loss was also obtained. Final analysis was based on 154 patients (104 LGBP and 50 LSG). The overall mean time between surgery and questionnaire was 10 ± 6.7months. Most of the patients (87.6%) experienced some taste/smell change. There were no differences between procedures for any change, taste or smell change. More patients submitted to LGBP referred that food smelled different (51.9 vs 34% for the LSG group; p = 0.040). Higher %EWL was observed for patients presenting food aversion (73.3 ± 19.7 vs 65.8 ± 19.4% for those without aversion; p = 0.046). Based on type of surgery, the LGBP group had the same trend (%EWL of 78.2 ± 17.3 vs 70.4 ± 18.6% for those without aversion; p = 0.044). The majority of patients presented taste and olfactory changes soon after surgery independently of type of procedure. Patients submitted to LGBP referred more often a different smell in food. Higher %EWL was observed in patients presenting any food aversion, especially in the LGBP group.

Standard bariatric surgeries include biliopancreatic diversion (BPD), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and adjustable gastric banding (AGB). Laparoscopic sleeve gastrectomy (LSG) is currently favored due to safety, efficacy, and shorter operation time. However, previous literature shows 75.6% weight regain post LSG. Introducing Laparoscopic band sleeve gastrectomy (LBSG) to maintain pouch size is proposed to improve outcomes and reduce weight regain. This study aims to compare the safety and efficacy of LSG vs. LBSG in obese patients. A comprehensive search strategy was executed to identify pertinent literature comparing LBSG and LSG in obese patients. Eligible studies underwent independent screening, and pertinent data were systematically extracted. The analysis employed pooled risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous variables, each accompanied by their respective 95% confidence intervals (CI). Our systematic review and meta-analysis included 15 studies encompassing 3929 patients. Regarding body mass index (BMI), at six, 12, and 24 months, no substantial differences were found between LBSG and LSG groups (p < 0.05). Still, at 36 months, LBSG exhibited significantly lower BMI than LSG (MD = -2.07 [-3.84, -0.29], p = 0.02). Excess Weight Loss (EWL) favored LBSG at 12, 24, and 36 months with MD of 3.30 [0.42, 6.18], 4.13 [1.44, 6.81], and 18.43 [9.44, 27.42], p = 0.02, 0.003, < 0.00001, respectively). Operative time did not significantly differ between the procedures (MD = 2.95, 95%CI [-0.06, 5.95], p = 0.05). Resolution of comorbidities, overall complications, post-operative bleeding, reflux, and early complications did not significantly differ between LBSG and LSG. However, LBSG showed higher post-operative regurgitation than LSG (RR = 2.38, 95%CI [1.25, 4.54], p = 0.008). LBSG showed a substantial decrease in BMI at three-year follow-up and higher EWL at one, two, and three years. However, LBSG procedures exhibited a higher incidence of post-operative regurgitation symptoms than LSG. No substantial differences were noted in BMI at six, 12, or 24 months, EWL at six months, operative time, bleeding, reflux, or overall complications.

Prurigo pigmentosa is a rare inflammatory dermatosis that predominantly affects East Asian populations, with very few reported cases in individuals with darker skin tones. The condition is characterized by pruritic, erythematous papules that evolve into a distinct, net-like pattern of hyperpigmentation. Due to its rarity in non-Asian populations, prurigo pigmentosa is often underdiagnosed or misclassified as other hyperpigmented dermatoses. We present the case of a 33-year-old African-Canadian woman who developed prurigo pigmentosa following prolonged fasting, contributing to the limited literature on this condition in skin of color. This report aims to raise awareness of prurigo pigmentosa in underrepresented populations.