The Integumentary System

 The integumentary system is the body's largest organ system, encompassing the skin, hair, nails, and associated glands. Its primary function is to protect the body from external factors such as pathogens, UV radiation, and physical injury, while also helping to regulate temperature and maintain hydration.

The skin, consisting of the epidermis, dermis, and subcutaneous tissue, acts as a barrier against harmful substances and prevents excessive water loss. It also contains sensory receptors that detect stimuli like touch, pressure, temperature, and pain. Hair and nails, derived from specialized skin cells, provide additional protection and sensory functions.

Furthermore, the integumentary system includes various glands such as sweat glands, sebaceous glands, and mammary glands, which secrete substances like sweat, oil, and milk, respectively. These secretions play roles in temperature regulation, lubrication, and antimicrobial defense.

Overall, the integumentary system is crucial for maintaining homeostasis, protecting the body's internal environment, and facilitating sensory experiences essential for survival and interaction with the external world.

 Several major disorders can affect the integumentary system, ranging from relatively common conditions to more severe diseases:

1. Acne: A common skin condition characterized by inflamed sebaceous glands and plugged hair follicles, leading to pimples and cysts.
2. Eczema: Also known as dermatitis, eczema causes inflammation of the skin, leading to redness, itching, and sometimes blistering or scaling.
3. Psoriasis: An autoimmune disease causing rapid skin cell growth, resulting in thick, scaly patches on the skin's surface.
4. Skin Cancer: Including melanoma, basal cell carcinoma, and squamous cell carcinoma, these cancers develop in the skin due to prolonged exposure to UV radiation or genetic factors.
5. Rosacea: A chronic inflammatory skin condition characterized by redness, visible blood vessels, and sometimes acne-like bumps, primarily affecting the face.
6. Dermatitis: Various forms of dermatitis, including contact dermatitis (caused by contact with allergens or irritants) and atopic dermatitis (chronic and itchy inflammation), affect the skin's integrity and function.
7. Burns: Thermal, chemical, or radiation burns damage the skin, leading to pain, blistering, and potential infection.
8. Impetigo: A highly contagious bacterial skin infection causing red sores or blisters, commonly found around the nose and mouth, and in young children.

These disorders can vary in severity and require different treatment approaches, including medications, topical treatments, lifestyle modifications, and sometimes surgical intervention. Regular skincare practices and sun protection are essential for preventing some integumentary disorders.

Hyperinsulinemia, insulin resistance, and metabolic syndrome are all interconnected conditions that can contribute to various disorders of the integumentary system through several mechanisms:

1. Inflammation: Insulin resistance and hyperinsulinemia can trigger low-grade inflammation throughout the body, including the skin. Chronic inflammation is a contributing factor to conditions such as acne, eczema, and psoriasis.
2. Increased sebum production: Insulin can stimulate the production of sebum, an oily substance produced by the sebaceous glands in the skin. Elevated levels of insulin, as seen in hyperinsulinemia and insulin resistance, can lead to excess sebum production, contributing to acne development.
3. Altered skin cell growth: Insulin resistance and hyperinsulinemia may disrupt the normal growth and turnover of skin cells, leading to conditions like psoriasis, where there is an abnormal increase in skin cell proliferation.
4. Impaired wound healing: Insulin resistance can impair the body's ability to heal wounds effectively. Chronic wounds, such as those resulting from diabetic ulcers often seen in metabolic syndrome, can lead to complications and delayed healing.
5. Increased oxidative stress: Insulin resistance and hyperinsulinemia are associated with increased oxidative stress, which can damage skin cells and contribute to premature skin aging and the development of skin cancers.
6. Altered hormone levels: Metabolic syndrome and insulin resistance can disrupt hormone levels, including androgens, which play a role in conditions like acne and hirsutism (excessive hair growth).
7. Dysregulated immune response: Insulin resistance and metabolic syndrome can dysregulate the immune response, making individuals more susceptible to infections and inflammatory skin conditions.

Overall, the dysregulation of insulin and metabolic processes seen in hyperinsulinemia, insulin resistance, and metabolic syndrome can contribute to the development and exacerbation of various integumentary disorders through multiple pathways. Disorders of the integumentary system can affect these structures and may manifest as various skin conditions. 

Several integumentary disorders are closely associated with insulin resistance, hyperinsulinemia, or metabolic syndrome:

1. Acanthosis Nigricans: This condition is characterized by thick, dark, velvety patches of skin, commonly found in skin folds such as the neck, armpits, and groin. Acanthosis nigricans is strongly associated with insulin resistance and is often seen in individuals with obesity or type 2 diabetes.
2. Skin Tags (Acrochordons): Skin tags are small, benign growths that commonly occur in areas of friction, such as the neck, armpits, and groin. They are more prevalent in individuals with insulin resistance and metabolic syndrome, likely due to hormonal and metabolic factors.
3. Hidradenitis Suppurativa: This chronic skin condition involves inflamed, painful nodules or abscesses in areas with apocrine sweat glands, such as the armpits, groin, and buttocks. Hidradenitis suppurativa is associated with metabolic syndrome, obesity, and insulin resistance, suggesting a link between these conditions and the development of the disease.
4. Androgenetic Alopecia: Commonly known as male or female pattern baldness, androgenetic alopecia is a type of hair loss that occurs due to genetic and hormonal factors, including androgen hormones like testosterone. Insulin resistance and metabolic syndrome have been implicated in the pathogenesis of androgenetic alopecia, particularly in women.
5. Cutaneous Candidiasis: This fungal infection of the skin, caused by Candida species, is more common in individuals with diabetes and obesity, both conditions associated with insulin resistance and metabolic syndrome. Elevated blood sugar levels provide an environment conducive to fungal growth, leading to increased susceptibility to cutaneous candidiasis.
6. Striae (Stretch Marks): Stretch marks are streaks or bands on the skin caused by rapid stretching or tearing of the dermis, often due to rapid weight gain or growth. Individuals with insulin resistance and metabolic syndrome may be more prone to developing stretch marks, particularly in areas with increased adiposity.

These integumentary disorders underscore the systemic nature of insulin resistance, hyperinsulinemia, and metabolic syndrome, emphasizing the importance of comprehensive management strategies targeting both metabolic and dermatological aspects of these conditions.

1. Fomin DA, Handfield K. The ketogenic diet and dermatology: a primer on current literature.Cutis. 2020;105(1):40-43. PMID: 32074146 PDF
2. Bragazzi  NL, Sellami M, Salem I, et al. Fasting and Its Impact on Skin Anatomy,  Physiology, and Physiopathology: A Comprehensive Review of the  Literature. Nutrients. 2019;11(2). doi:10.3390/nu11020249
3. Binobead, M.A. et al. (2023) ‘Effect of Low-Carbohydrate Diet on Beta-Hydroxybutyrate  Ketogenesis Metabolic Stimulation and Regulation of NLRP3 Ubiquitination  in Obese Saudi Women’, Nutrients, 15(4), p. 820. Available at: https://doi.org/10.3390/nu15040820.
4. Misitzis  A, Cunha PR, Kroumpouzos G. Skin Disease Relating to Metabolic Syndrome  in Women. International Journal of Women’s Dermatology. July 2019. doi:10.1016/j.ijwd.2019.06.030 
5. Nakamura  H, Shimoji K, Kouda K, Tokunaga R, Takeuchi H. An adult with atopic  dermatitis and repeated short-term fasting. J Physiol Anthropol Appl  Human Sci. 2003;22(5):237-240.doi:  https://doi.org/10.2114/jpa.22.237 PDF
6. Nosrati  A, Afifi L, Danesh MJ, et al. Dietary modifications in atopic  dermatitis: patient-reported outcomes. J Dermatolog Treat.  2017;28(6):523-538. doi:10.1080/09546634.2016.1278071
7. Fomin  DA, McDaniel B, Crane J. The promising potential role of ketones in  inflammatory dermatologic disease: a new frontier in treatment research.  Journal of Dermatological Treatment. 2017;28(6):484-487. doi:10.1080/09546634.2016.1276259 ABSTRACT
8. Aoki M, Murase T. Obesity-associated insulin resistance adversely affects skin function. PLOS ONE. 2019;14(10):e0223528. doi:10.1371/journal.pone.0223528 PDF
9. de Carvalho JF, Pereira CP, Torales MBP. Nummular Eczema Successfully Treated with a Gluten- free Diet: First Description.. IMAJ 2021; 23: 329–330
10. Usher B. THE RELATION OF CARBOHYDRATE METABOLISM TO ECZEMA: AN EXPERIMENTAL STUDY. Arch Derm Syphilol. 1928;18(3):423-428. doi:10.1001/archderm.1928.02380150089012 ABSTRACT

Excessive adiposity can lead to stretch marks, skin tags, and increased sweating due to enlarged fat cells and hormonal changes. 

 iabetes can cause diabetic dermopathy, skin infections, and slow wound healing due to impaired blood flow and nerve damage. 

Acne is a common skin condition characterized by the presence of pimples, blackheads, whiteheads, and inflamed lesions on the skin, typically occurring on the face, neck, chest, and back. While hyperinsulinemia, characterized by elevated levels of insulin in the blood, is not a direct cause of acne, it may contribute to its development and exacerbation through several mechanisms. Insulin resistance, a hallmark of hyperinsulinemia and metabolic syndrome, is associated with elevated levels of insulin and insulin-like growth factor 1 (IGF-1), which can stimulate the production of androgens (male hormones) in the body. Androgens play a role in increasing sebum (oil) production and promoting the proliferation of skin cells, which can contribute to the formation of acne lesions. Additionally, hyperinsulinemia may promote inflammation and oxidative stress, further exacerbating acne symptoms. Furthermore, insulin resistance can lead to fluctuations in blood sugar levels, which may trigger hormonal imbalances and skin inflammation, potentially worsening acne. Therefore, managing hyperinsulinemia through lifestyle modifications, insulin-sensitizing medications, and appropriate skincare practices may help improve acne symptoms. Additionally, individuals with acne should work closely with dermatologists to develop personalized treatment plans targeting the underlying causes and symptoms of their condition.

1. Smith  RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. A low-glycemic-load  diet improves symptoms in acne vulgaris patients: a randomized  controlled trial. Am J Clin Nutr. 2007;86(1):107-115. doi:10.1093/ajcn/86.1.107
2. Fabbrocini  G, Izzo R, Faggiano A, et al. Low glycaemic diet and metformin therapy:  a new approach in male subjects with acne resistant to common  treatments. Clin Exp Dermatol. 2016;41(1):38-42. doi:10.1111/ced.12673
3. Kwon  HH, Yoon JY, Hong JS, Jung JY, Park MS, Suh DH. Clinical and  histological effect of a low glycaemic load diet in treatment of acne  vulgaris in Korean patients: a randomized, controlled trial. Acta Derm  Venereol. 2012;92(3):241-246. doi:10.2340/00015555-1346
4. Smith  RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. The effect of a  high-protein, low glycemic–load diet versus a conventional, high  glycemic–load diet on biochemical parameters associated with acne  vulgaris: A randomized, investigator-masked, controlled trial. Journal  of the American Academy of Dermatology. 2007;57(2):247-256. doi:10.1016/j.jaad.2007.01.046  ABSTRACT
5. Barrea, L. et al. (2023) ‘The effect of the ketogenic diet on Acne: Could it be a therapeutic tool?’, Critical Reviews in Food Science and Nutrition, 0(0), pp. 1–20. Available at: https://doi.org/10.1080/10408398.2023.2176813.
6. Paoli  A, Grimaldi K, Toniolo L, Canato M, Bianco A, Fratter A. Nutrition and  Acne: Therapeutic Potential of Ketogenic Diets. Skin pharmacology and  physiology. 2012;25:111-117. doi:10.1159/000336404
7. Melnik  BC. Diet in acne: further evidence for the role of nutrient signalling  in acne pathogenesis. Acta Derm Venereol. 2012;92(3):228-231. doi:10.2340/00015555-1358 
8. Nagpal  M, De D, Handa S, Pal A, Sachdeva N. Insulin Resistance and Metabolic  Syndrome in Young Men With Acne. JAMA Dermatol. 2016;152(4):399-404.  doi:10.1001/jamadermatol.2015.4499
9. Romańska-Gocka  K, Woźniak M, Kaczmarek-Skamira E, Zegarska B. The possible role of  diet in the pathogenesis of adult female acne. Postepy Dermatol Alergol.  2016;33(6):416-420. doi:10.5114/ada.2016.63880
10. Çerman  AA, Aktaş E, Altunay İK, Arıcı JE, Tulunay A, Ozturk FY. Dietary  glycemic factors, insulin resistance, and adiponectin levels in acne  vulgaris. J Am Acad Dermatol. 2016;75(1):155-162. doi:10.1016/j.jaad.2016.02.1220  ABSTRACT
11. Md SSH. A case report of successful acne treatment following Ramadan fasting. Research. Published online April 11, 2014.doi: http://dx.doi.org/10.13070/rs.en.1.684

 Acanthosis nigricans is a skin condition characterized by dark, velvety  patches of skin, often found in body folds and creases such as the neck,  armpits, groin, and sometimes on the elbows, knees, and knuckles. While  not directly caused by hyperinsulinemia, acanthosis nigricans is  commonly associated with insulin resistance and conditions such as  obesity, type 2 diabetes, and metabolic syndrome. Insulin resistance  leads to increased insulin levels, which can stimulate the growth of  skin cells and the production of pigment, resulting in the  characteristic darkening and thickening of the skin. Managing insulin  resistance through lifestyle changes, weight loss, and treatment of  underlying conditions can help improve acanthosis nigricans.  Additionally, addressing any hormonal imbalances or other contributing  factors may also be beneficial. It's important for individuals with  acanthosis nigricans to consult with healthcare professionals for proper  diagnosis and management. 

The  prevalence of obesity has increased worldwide in recent years. Some  authors have described skin conditions associated with obesity, but  there is little evidence on the association between insulin levels and  such disorders.

To describe the skin disorders present in overweight and obese patients and analyze their association with insulin levels.

The  study included nondiabetic male and female patients over 6 years of age  who were seen at our hospital between January and April 2011. All the  patients were evaluated by a dermatologist, who performed a physical  examination, including anthropometry, and reviewed their medical history  and medication record; fasting blood glucose and insulin were also  measured. The patients were grouped according to degree of overweight or  obesity and the data were compared using analysis of variance or the χ2 test depending on the type of variable. The independence of the associations was assessed using regression analysis.

In  total, 109 patients (95 adults and 13 children, 83.5% female) were  studied. The mean (SD) age was 38 (14) years and the mean body mass  index was 39.6 ± 8 kg/m2. The skin conditions observed were  acanthosis nigricans (AN) (in 97% of patients), skin tags (77%),  keratosis pilaris (42%), and plantar hyperkeratosis (38%). Statistically  significant associations were found between degree of obesity and AN (P = .003), skin tags (P = .001),  and plantar hyperkeratosis. Number of skin tags, AN neck severity  score, and AN distribution were significantly and independently  associated with insulin levels.

AN and skin tags should be considered clinical markers of hyperinsulinemia in nondiabetic, obese patients. 

 Acrochordons, commonly known as skin tags, are small, benign growths that typically appear as soft, hanging pieces of skin. While the exact cause of acrochordons is not fully understood, they are often associated with friction or rubbing of the skin, such as in areas where skin folds or creases occur. Additionally, acrochordons may be more common in individuals with certain conditions such as obesity, insulin resistance, and metabolic syndrome. Although hyperinsulinemia itself isn't a direct cause of acrochordons, it is often associated with insulin resistance, which may play a role in their development. Insulin resistance can lead to changes in skin structure and metabolism, possibly contributing to the formation of acrochordons. While acrochordons are typically harmless and may not require treatment, they can be removed if they cause discomfort or cosmetic concerns. It's essential for individuals with acrochordons to consult with healthcare professionals for proper evaluation and management.

described skin conditions associated with obesity, but  there is little evidence on the association between insulin levels and  such disorders.

To describe the skin disorders present in overweight and obese patients and analyze their association with insulin levels.

The  study included nondiabetic male and female patients over 6 years of age  who were seen at our hospital between January and April 2011. All the  patients were evaluated by a dermatologist, who performed a physical  examination, including anthropometry, and reviewed their medical history  and medication record; fasting blood glucose and insulin were also  measured. The patients were grouped according to degree of overweight or  obesity and the data were compared using analysis of variance or the χ2 test depending on the type of variable. The independence of the associations was assessed using regression analysis.

In  total, 109 patients (95 adults and 13 children, 83.5% female) were  studied. The mean (SD) age was 38 (14) years and the mean body mass  index was 39.6 ± 8 kg/m2. The skin conditions observed were  acanthosis nigricans (AN) (in 97% of patients), skin tags (77%),  keratosis pilaris (42%), and plantar hyperkeratosis (38%). Statistically  significant associations were found between degree of obesity and AN (P = .003), skin tags (P = .001),  and plantar hyperkeratosis. Number of skin tags, AN neck severity  score, and AN distribution were significantly and independently  associated with insulin levels.

 AN and skin tags should be considered clinical markers of hyperinsulinemia in nondiabetic, obese patients. 

Hidradenitis suppurativa (HS) is a chronic, inflammatory disease of the pilosebaceous unit. Patients with HS present – often after a diagnostic delay – with multiple, recurrent inflammatory nodules, abscesses and sinus tracts in intertriginous skin.1 Data suggest that the prevalence of HS varies between 0.14% and 4% globally (Table 1).

Malta is a small Mediterranean country with an estimated population of 493 559 inhabitants.2 The country is in a unique position as all dermatology referrals made in the national healthcare system are received and pooled by a single dermatology centre (Sir Paul Boffa Hospital, SPBH) and distributed equally between dermatologists without bias. Follow‐up care is also carried out at SPBH. We carried out a study to establish the prevalence of HS in Malta.

Between 1 January 2019 and 31 December 2019, a single dermatologist (Dillon MIntoff) working at SPBH reviewed 2034 patients referred for a dermatological opinion. Patients not residing in Malta and patients who were referred directly to the auditing dermatologist with an established or suspected diagnosis of HS were excluded from the study to avoid bias.

 Hidradenitis suppurativa (HS) is a chronic skin condition characterized  by the development of painful, inflamed lesions, typically in areas  where skin rubs together, such as the armpits, groin, buttocks, and  under the breasts. While the exact cause of HS is not fully understood,  it is believed to involve a combination of genetic, hormonal, and  environmental factors. While hyperinsulinemia isn't a direct cause of  HS, it may contribute to its development or exacerbation.  Hyperinsulinemia, often associated with insulin resistance and obesity,  can lead to increased levels of insulin and insulin-like growth factor 1  (IGF-1), which may stimulate inflammation and abnormal skin cell  growth. Additionally, insulin resistance is associated with chronic  low-grade inflammation, which may further contribute to the inflammatory  process in HS. Managing hyperinsulinemia through lifestyle  modifications, such as weight loss, dietary changes, and  insulin-sensitizing medications, may help improve symptoms and reduce  the severity of HS. Additionally, individuals with HS should work  closely with healthcare professionals to develop a personalized  treatment plan that addresses their specific needs and symptoms. 

" Hidradenitis suppurativa is a chronic, inflammatory, recurrent,  debilitating skin disease characterized by recurrent abscesses, draining  sinuses, and scarring, affecting principally areas of body friction "

 "Hidradenitis suppurativa (HS) is a chronic-relapsing inflammatory skin  disease. It usually appears in the second and third decades, but a  smaller proportion of patients develop late-onset HS .  Hidradenitis suppurativa (HS) is associated with comorbidities  that contribute to poor health, impaired life quality, and mortality  risk.  HS is associated with Acne, dissecting cellulitis of the scalp, pilonidal disease, pyoderma  gangrenosum, depression, generalized anxiety disorder, suicide, smoking,  substance use disorder, polycystic ovary syndrome, obesity,  dyslipidemia, diabetes mellitus, metabolic syndrome, hypertension,  cardiovascular disease, inflammatory bowel disease, spondyloarthritis,  and sexual dysfunction.  "

"There are associations between HS and other cardiovascular disease  (CVD) risk factors, including type 2 diabetes and metabolic syndrome.  People with HS have double the risk of death from CVD compared with  those without HS and 1·5 times the risk compared with patients with psoriasis. Depression and anxiety are associated with HS and completed  suicide rates in those with HS are more than double the rates in  controls. Associations exist between HS and other chronic inflammatory  conditions, particularly inflammatory bowel disease and inflammatory  arthritis. Case-control studies demonstrate associations with pilonidal  sinus, polycystic ovary syndrome, Down syndrome, obstructive sleep  apnoea and pyoderma gangrenosum. "

  Hidradenitis suppurativa (HS) often coexists with obesity, metabolic  syndrome, diabetes mellitus, or impaired glucose tolerance and insulin  resistance and polycystic ovarian syndrome. 

 "Four studies (106 patients) documented improvement, 1 documented  treatment failure, and 1 had mixed results. Only mild and transient side  effects were noted. Metformin has been tried in few HS patients with  acceptable efficacy in a fair number of them"

 " The association of the metabolic syndrome (MetS) and its components with  immune-mediated chronic inflammatory disorders has attracted much  interest within the last two decades. In addition to the  well-established association of psoriasis with MetS, recent data point  to an association between MetS and hidradenitis suppurativa, as well.  The association of hidradenitis suppurativa with MetS and its  components, such as diabetes, obesity, and dyslipidemia, has been  consistently identified in controlled studies. This relationship is not  only limited to older individuals but also applicable to younger  patients and those with mild disease. "

1. Damiani  G, Mahroum N, Pigatto PDM, et al. The Safety and Impact of a Model of  Intermittent, Time-Restricted Circadian Fasting (“Ramadan Fasting”) on  Hidradenitis Suppurativa: Insights from a Multicenter, Observational,  Cross-Over, Pilot, Exploratory Study. Nutrients. 2019;11(8):1781. doi:10.3390/nu11081781
2. Yar, N. et al. (2022) ‘Consuming an All-Meat Ketogenic Diet for the Long-Term  Management of Candida Vulvovaginitis and Vaginal Hidradenitis  Suppurativa: A 47-Month Follow-Up Case Report’, Cureus [Preprint]. Available at: https://doi.org/10.7759/cureus.30510.
3. Danby  FW. Diet in the prevention of hidradenitis suppurativa (acne inversa).  Journal of the American Academy of Dermatology. 2015;73(5, Supplement  1):S52-S54. doi:10.1016/j.jaad.2015.07.042  ABSTRACT
4. Vilanova  I, Hernández JL, Mata C, et al. Insulin resistance in hidradenitis  suppurativa: a case-control study. J Eur Acad Dermatol Venereol.  2018;32(5):820-824. doi:10.1111/jdv.14894 PDF "

Psoriasis is a chronic autoimmune skin condition characterized by the rapid overproduction of skin cells, leading to the formation of thick, red, scaly patches on the skin. It is a non-contagious condition that affects about 2-3% of the global population.

The exact cause of psoriasis is not fully understood, but it is believed to involve a combination of genetic, environmental, and immune system factors. In people with psoriasis, the immune system mistakenly attacks healthy skin cells, causing them to proliferate rapidly. This results in the formation of plaques, which can appear anywhere on the body but are most commonly found on the elbows, knees, scalp, and lower back.

Psoriasis can vary in severity, with some individuals experiencing only mild symptoms and others experiencing more severe symptoms that significantly impact their quality of life. In addition to the physical symptoms, psoriasis can also have psychological and emotional effects, including feelings of self-consciousness, embarrassment, and depression.

Common types of psoriasis include:

1. Plaque psoriasis: This is the most common type of psoriasis, characterized by raised, red patches covered with silvery scales.
2. Guttate psoriasis: This type of psoriasis appears as small, dot-like lesions on the skin. It often occurs suddenly and may be triggered by bacterial infections, such as strep throat.
3. Inverse psoriasis: Inverse psoriasis affects skin folds such as the armpits, groin, and under the breasts. It appears as smooth, red patches of skin that may be irritated by friction and sweating.
4. Pustular psoriasis: This type of psoriasis is characterized by pus-filled blisters surrounded by red skin. It can be localized to certain areas of the body or generalized, covering large areas of the body.
5. Erythrodermic psoriasis: Erythrodermic psoriasis is a rare but severe form of psoriasis that can cover the entire body with a red, peeling rash. It can cause severe itching, pain, and discomfort and may require hospitalization.

Treatment for psoriasis aims to reduce inflammation, slow down the growth of skin cells, and alleviate symptoms. This may include topical treatments (such as corticosteroids, vitamin D analogs, and retinoids), phototherapy (exposure to ultraviolet light), oral medications (such as methotrexate, cyclosporine, and biologics), and lifestyle modifications (such as stress management, avoiding triggers, and maintaining a healthy lifestyle). While there is no cure for psoriasis, treatment can help control symptoms and improve quality of life for individuals with the condition

 "For anyone who suffers from an inflammatory (even autoimmune) disease, a ketogenic diet should be considered. Mounting evidence reveals a direct effect of ketones inhibiting inflammation. This study explored two psoriasis conditions [skin (PSO) and joint (PSA); autoimmune related] and compared the effects of a Mediterranean and Ketogenicc Diet and concluded "...the combined 22-week MD–KD program for patients with PSO and PSA on stable anti-psoriatic pharmacological treatment led to weight loss and enhancements in clinical and biochemical markers of inflammation. However, these favorable effects were mainly attributed to KD, as statistically significant reductions in clinical scores of disease activity and inflammatory markers were observed only in this dietary regimen."  Ben Bikamn 

" The effect of different diet patterns on psoriasis (PSO) and psoriatic  arthritis (PSA) is unknown. Τhe aim of our study was to evaluate the  effectiveness of a Mediterranean diet (MD) and Ketogenic diet (KD), in  patients with PSO and PSA. Twenty-six patients were randomly assigned to  start either with MD or KD for a period of 8 weeks. After a 6-week  washout interval, the two groups were crossed over to the other type of  diet for 8 weeks. At the end of this study, MD and KD resulted in  significant reduction in weight (p = 0.002, p < 0.001, respectively), in BMI (p = 0.006, p < 0.001, respectively), in waist circumference (WC) (p = 0.001, p < 0.001, respectively), in total fat mass (p = 0.007, p < 0.001, respectively), and in visceral fat (p = 0.01, p < 0.001, respectively), in comparison with baseline. After KD, patients  displayed a significant reduction in the Psoriasis Area and Severity  Index (PASI) (p = 0.04), Disease Activity Index of Psoriatic Arthritis (DAPSA) (p = 0.004), interleukin (IL)-6 (p = 0.047), IL-17 (p = 0.042), and IL-23 (p = 0.037), whereas no significant differences were observed in these markers after MD (p > 0.05), compared to baseline. The 22-week MD–KD diet program in  patients with PSO and PSA led to beneficial results in markers of  inflammation and disease activity, which were mainly attributed to KD." 

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2. Castaldo  G, Galdo G, Rotondi Aufiero F, Cereda E. Very low-calorie ketogenic  diet may allow restoring response to systemic therapy in relapsing  plaque psoriasis. Obes Res Clin Pract. 2016;10(3):348-352. doi:10.1016/j.orcp.2015.10.008
3. Castaldo  G, Pagano I, Grimaldi M, et al. Effect of Very-Low-Calorie Ketogenic  Diet on Psoriasis Patients: A Nuclear Magnetic Resonance-Based  Metabolomic Study. J Proteome Res. Published online November 9, 2020. doi:10.1021/acs.jproteome.0c00646
4. Barrea, L. et al. (2022) ‘Clinical and nutritional management of very-low-calorie  ketogenic diet (VLCKD) in patients with psoriasis and obesity: a  practical guide for the nutritionist’, Critical Reviews in Food Science and Nutrition, pp. 1–17. Available at: https://doi.org/10.1080/10408398.2022.2083070.
5. Castaldo  G, Rastrelli L, Galdo G, Molettieri P, Aufiero FR, Cereda E. Aggressive  weight loss program with a ketogenic induction phase for the treatment  of chronic plaque psoriasis: a proof-of-concept, single-arm, open label  clinical trial. Nutrition. February 2020:110757. doi:10.1016/j.nut.2020.110757 ABSTRACT
6. Peralta  C, Hamid P, Batool H, Al Achkar Z, Maximus P. Psoriasis and Metabolic  Syndrome: Comorbidities and Environmental and Therapeutic Implications.  Cureus. 2019;11(12):e6369. doi:10.7759/cureus.6369 
7. Barrea  L, Megna M, Cacciapuoti S, et al. Very low-calorie ketogenic diet  (VLCKD) in patients with psoriasis and obesity: an update for  dermatologists and nutritionists. Crit Rev Food Sci Nutr. Published  online September 24, 2020:1-17. doi:10.1080/10408398.2020.1818053
8. Brazzelli  V, Maffioli P, Bolcato V, et al. Psoriasis and Diabetes, a Dangerous  Association: Evaluation of Insulin Resistance, Lipid Abnormalities, and  Cardiovascular Risk Biomarkers. Front Med (Lausanne). 2021;8. doi:10.3389/fmed.2021.605691
9. Aalemi AK, Bahain MB, Hamdard AG. Metabolic Syndrome and Psoriasis: A Case-Control Study in Kabul, Afghanistan. Diabetes Metab Syndr Obes. 2021;14:1465-1471. doi:10.2147/DMSO.S305806
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Striae, commonly known as stretch marks, are thin, linear streaks or  bands that develop on the skin when it is stretched rapidly, causing the  collagen and elastin fibers in the dermis to break or tear. While  hyperinsulinemia isn't a direct cause of striae, it may contribute to  their development or exacerbation. Hyperinsulinemia, often associated  with insulin resistance and obesity, can lead to increased levels of  insulin and insulin-like growth factor 1 (IGF-1), which may affect the  skin's elasticity and repair processes. Additionally, insulin resistance  is associated with chronic low-grade inflammation, which may impair the  skin's ability to heal and regenerate. Furthermore, rapid weight gain  or fluctuations in body size, often seen in individuals with  hyperinsulinemia, can further stretch the skin and increase the  likelihood of developing striae. Managing hyperinsulinemia through  lifestyle modifications, such as weight management and  insulin-sensitizing medications, may help reduce the risk of striae  formation. Additionally, topical treatments and procedures such as laser  therapy may help improve the appearance of existing striae. It's  important for individuals with striae to consult with healthcare  professionals for proper evaluation and management. 

 Trace element deficiencies refer to inadequate levels of essential  minerals required by the body in small amounts for proper functioning.  While hyperinsulinemia isn't directly linked to trace element  deficiencies, it may indirectly impact their absorption, utilization, or  excretion in the body. Insulin resistance, a hallmark of  hyperinsulinemia and metabolic syndrome, can disrupt various metabolic  processes, including those involved in the regulation of trace elements.  For example, insulin resistance may affect the transport of trace  elements across cell membranes or interfere with their uptake by  tissues. Additionally, hyperinsulinemia may alter the balance of certain  hormones or metabolic pathways involved in trace element metabolism.  Consequently, individuals with hyperinsulinemia may be at increased risk  of developing trace element deficiencies, particularly if they have  poor dietary habits or other underlying health conditions. Managing  hyperinsulinemia through lifestyle modifications, such as improving  dietary quality and insulin sensitivity, may help prevent or alleviate  trace element deficiencies. Additionally, supplementation with specific  trace elements may be necessary in some cases to correct deficiencies  and support overall health and well-being. It's important for  individuals with hyperinsulinemia to work closely with healthcare  professionals to address any nutritional deficiencies and optimize their  nutrient intake. 

" The analysis of serum glucose concentration failed to reveal any group  difference in serum glucose in the studied sample of obese patients,  whereas serum insulin levels were found to be 40% higher.  Correspondingly, 48% higher HOMA-IR values in obese examinees are  indicative of insulin resistance without manifest hyperglycemia. "

"Obese subjects were characterized by significantly higher body fat  percentage, blood pressure, serum triglyceride concentration, and  insulin resistance. Serum Ca, Fe, Mg, Se, V, Zn levels, hair Fe, Mg, V  content, and urinary Se and V concentrations were found to be lower in  obese subjects as compared to lean controls. In turn, serum Cu and  urinary Fe levels in obese women were characterized by a significant  increase. "

(  Your body needs  small amounts of copper  (serum CU) from food to stay healthy. But a buildup of too  much copper is serious. At the extreme It can result in brain damage, liver failure, or death if it is not treated. )

Plantar keratosis refers to a dermatological condition characterized by the thickening of the skin on the soles of the feet (the plantar surface). This thickening is often due to excessive pressure or friction on specific areas of the feet, leading to the accumulation of hardened skin or calluses.

Plantar keratosis typically presents as yellowish or brownish patches of rough, thickened skin on weight-bearing areas of the feet, such as the heels or balls of the feet. It may be asymptomatic or associated with discomfort, pain, or tenderness, especially when standing or walking.

Causes of plantar keratosis may include wearing ill-fitting shoes, excessive standing or walking, abnormal foot mechanics (such as flat feet or high arches), obesity, or certain foot deformities. 

It is associated with Obesity