Comparing safety and efficacy of acoustic subcision at two different rapid acoustic pulse rates to improve the appearance of cellulite.

BACKGROUND: A recent study showed the safety and efficacy of a noninvasive acoustic subcision device to improve the appearance of cellulite via delivery of rapid acoustic pulses in a single treatment visit. OBJECTIVE: To evaluate and compare the safety and efficacy of a single rapid acoustic pulse treatment visit using an equivalent number of rapid acoustic pulses at a pulse rate of 100 or 50 Hz. METHODS: This single-center, prospective study enrolled 15 adult women with moderate to severe cellulite according to the Cellulite Dimple-At Rest Scale. Each participant would receive nominally 72,000 rapid acoustic pulses at a pulse rate of 50 Hz on the left buttock and thigh, and nominally 72,000 rapid acoustic pulses at a pulse rate of 100 Hz on the right buttock and thigh within one treatment visit. Efficacy was assessed by the ability of blinded, independent reviewers to correctly distinguish the pre- and post-treatment photos, participant satisfaction, and the change in Cellulite Dimple-At Rest scores for each treatment side. Safety was monitored throughout the conduct of the study. RESULTS: For both 100 and 50 Hz pulse rate treated areas, the majority (two out of three) of blinded reviewers correctly identified 100% of the pre/post-treatment photos. For both the 100 and 50 Hz treated areas, 80% of participants agreed/strongly agreed that their cellulite appeared improved at the 12-week follow-up visit. Significant improvements in Cellulite Dimple-At Rest scores were seen for both the 100 and 50 Hz treated areas. All participants thought both the 100 and 50 Hz pulse rate treatments were tolerable, and the pain (mean score ± SD; 2.2 ± 1.2) associated with each was identical. No unexpected or serious adverse events occurred. CONCLUSION: Acoustic subcision delivered via rapid acoustic pulses at 100 Hz, compared to 50 Hz, provides equivalent improvement in the appearance of cellulite while maintaining a similar safety and efficacy profile. For both pulse rates, treatment pain was minimal, and participant satisfaction was high.

Cellulite: Presentation and management.

BACKGROUND: Cellulite is a common dermatological condition with a female preponderance, affecting up to 90% post-pubertal females. It is characterized with dimpling and denting of the skin surface, giving it a Peau d'orange appearance. Once considered to be a benign physiological isolated skin condition of only an esthetic concern, cellulite is now considered a pathological entity with systemic associations and a negative psychological impact on patients. AIMS: The objective of this article was to discuss etiology, pathophysiology, and treatment of cellulite. MATERIALS AND METHODS: Literature was screened to retrieve articles from PubMed/Medline and Google Scholar and related websites. Cross-references from the relevant articles were also considered for review. Review articles, clinical studies, systematic reviews, meta-analysis, and relevant information from selected websites were included. RESULTS: Several treatment options from lifestyle modifications and topical cosmetic therapies to energy-based devices have been studied for its treatment. However, treatment remains a challenge despite many new modalities in the armamentarium. Laser and light therapies along with radiofrequency are useful treatment options with good safety profile. Acoustic wave therapy, subcision, and 1440-nm Nd:YAG minimally invasive laser are beneficial in cellulite reduction. DISCUSSION: Methodological differences in the trials conducted make it difficult to compare different treatment modalities. CONCLUSION: Overall, treatment needs to be individualized based on the patient characteristics and severity of the condition. A combination of treatments is often required in most patients for reducing cellulite.

Enfermedad invasiva por Streptococcus pyogenes con celulitis de manos bilateral: A propósito de un caso / Invasive Streptococcus pyogenes disease with bilateral cellulitis of the hands: A case report

El Streptococcus pyogenes o estreptococo B hemolítico Grupo A (EßHGA) suele ser una causa poco habitual de enfermedad invasiva en pediatría, la cual ha presentado un aumento en su incidencia en los últimos años. Se define como cualquier infección asociada al aislamiento de dicha bacteria de un sitio normalmente estéril y cuya presentación más frecuente es la bacteriemia. Los pacientes con EßHGA habitualmente se presentan con un sindrome febril asociado a manifestaciones clínicas relacionadas con el sitio primario de infección. Se presenta el caso de una paciente de 10 años, sin comorbilidades, que desarrolló enfermedad invasiva por EßHGA con bacteriemia e impacto secundario de piel y partes blandas resultando en una celulitis de manos bilateral

Streptococcus pyogenes or Group A Streptococcus (GAS) is an infrequent cause of invasive disease in pediatrics. Its incidence has increased in the last few years. It is defined as any infection associated with the isolation of GAS in a normally sterile site and its most frequent presentation is bacteremia. Patients with GAS bacteremia usually present with a febrile syndrome associated with clinical manifestations related to the primary site of infection. We present the case of a previously healthy, 10-year-old patient, who developed an invasive disease due to GAS with bacteremia and secondary impact of skin and soft tissues that developed in bilateral cellulitis of the hands

The Anatomical Basis of Cellulite Dimple Formation: An Ultrasound-Based Examination.

BACKGROUND: Cellulite is a common aesthetic condition that affects the majority of women. It is characterized by the inhomogeneous appearance of the skin overlying the gluteal and the posterior thigh region. Despite a wide array of treatment options, little has been done to evaluate the anatomical basis of cellulite formation. This study used ultrasound to visualize subcutaneous changes of cellulite to aid with treatment guidance and complication avoidance. METHODS: Cellulite dimples were examined on the bilateral thigh and buttock regions of 50 consecutive women and each dimple was scored with the Hexsel Cellulite Scoring System based on severity. Cellulite dimples were then analyzed by ultrasound to identify the presence, orientation, and origination of subcutaneous fibrous bands and the presence of associated vascular structures. RESULTS: Two hundred total sites were examined, with 173 dimples identified. Of these, 169 demonstrated the presence of fibrous bands (97.6 percent). The majority of bands demonstrated an oblique (versus perpendicular) orientation to the skin (84.4 percent), with the majority (90.2 percent) taking origin from the superficial fascia (versus the deep fascia). Overall, 11 percent of bands had an associated vascular structure. When stratified by body mass index, overweight and obese patients had a higher likelihood of having an associated blood vessel visualized (p = 0.01). Results were similar for dimples in the thigh compared to those located in the buttock region. CONCLUSIONS: Ultrasound appears to be a valid technique to image the subcutaneous architecture of cellulite. This technology can help guide surgeons in real time to improve outcomes and minimize complications while performing cellulite treatments.

Randomized, Double-Blind, Placebo-Controlled Study of Poly-L-Lactic acid for Treatment of Cellulite in the Lower Extremities.

BACKGROUND: Poly-l-lactic acid (PLLA) is an injectable volumizer with biostimulatory properties used for volumetric structural rejuvenation in patients with facial fat volume loss but has increasingly been utilized for off-face applications. OBJECTIVE: The objectives of this randomized, double-blind, placebo-controlled single center study was to assess the safety and effectiveness of PLLA for the treatment of lower extremity cellulite in adult women. METHODS: 31 healthy women were enrolled in the study. Eligible subjects received 3 treatments every 4 weeks with either PLLA (treatment group) or saline (control group) injections combined with subcision, into each of the glutes or thighs. Follow-up visits were at 1, 3, and 6 months after treatment. Assessments included live ratings, rating of standardized pictures by a blinded evaluator, patient questionnaires, safety, and tolerability ratings. RESULTS: At the 3 and 6-month follow-up, there was a statistically significant change in the global aesthetic improvement scale (GAIS) compared to baseline as assessed by blinded investigators. Significant improvements were shown in the cellulite severity scale (CSS) as well as in the subject satisfaction questionnaires. Treatments were found to be tolerable, and no severe treatment-related adverse events occurred. CONCLUSION: Repeated PLLA treatments combined with subcision are effective and safe in improving the appearance of cellulite. J Drugs Dermatol. 20(5): doi:10.36849/JDD.5380.

Síndrome larva migrans cutánea en pediatría / Cutaneous Larva Migrans Syndrome in Pediatrics

La dermatosis denominada larva migrans cutánea: (LMC) es una infección cutánea secundaria a infestación parasitaria por la migración de larvas de anquilostomas animales a la epidermis humana, frecuentemente por contacto directo con suelos contaminados, especialmente en zonas tropicales. Se caracteriza por la aparición de lesiones induradas, eritematosas con patrón irregular o serpiginoso acompañado de prurito. Describimos un caso de LMC en una niña, adquirido durante unas vacaciones en Colombia y tratado inicialmente como celulitis con antibióticos (AU)

Cutaneous larva migrans (CLM) is an infection secondary to parasitic infestation due to the migration of animal hookworm larvae into the human skin, frequently by direct contact with contaminated grounds, especially in the tropics. Clinically, it is characterized by the appearance of indurated, erythematous lesions with irregular or "creeping eruption" pattern and pruritus. This article describes a case of CLM infection in a pediatric patient, it was acquired during the holidays in Colombia, diagnosed as cellulitis and treated accordingly with antibiotics without success (AU)

Infecciones graves de huesos, articulaciones y tejidos blandos adquiridas en la comunidad / Severe community-acquired bone, joint, and soft tissue infections

Introducción: Las infecciones de huesos, articulaciones y partes blandas, no solo han tenido una incidencia creciente en los últimos años en el Hospital Pediátrico Universitario Paquito González Cueto de Cienfuegos, sino también una evolución más grave. Objetivo: Describir aspectos clínicos y epidemiológicos de las infecciones graves de tejidos blandos, huesos y articulaciones. Métodos: Se revisó la base de datos computadorizada del Departamento de Estadística del Hospital Pediátrico Paquito González, para identificar todos los egresos de la Unidad de Cuidados Intensivos Pediátricos, con diagnóstico de celulitis o absceso de tejidos blandos, fascitis, miositis, osteomielitis, sepsis severa y shock séptico, en el periodo de enero de 2009 a diciembre de 2019. Se estudiaron las siguientes variables: localización de la infección de piel y tejidos blandos, grupo de edad, año del egreso y sitio de origen de la sepsis. Resultados: No hubo diferencias en la incidencia entre los grupos de edad. La celulitis de los miembros fue la forma clínica más frecuente. Se encontró una incidencia creciente de las infecciones de tejidos blandos. Las infecciones de huesos y articulaciones, representaron el segundo sitio de origen más frecuente de sepsis grave y el shock séptico. Conclusiones: Ha habido un aumento de las infecciones de piel y tejidos blandos que requieren ingreso en la unidad de cuidados intensivos del citado hospital en los últimos 11 años. Estas infecciones de conjunto con las infecciones de huesos y articulaciones, constituyen un problema de salud puesto que provocan sepsis grave y shock séptico con una incidencia significativa(AU)

Introduction: Infections of bones, joints and soft parts have not only had an increasing incidence in recent years at ¨Paquito González Cueto¨ University Pediatric Hospital in Cienfuegos, but also a more serious evolution. Objective: Describe clinical and epidemiological aspects of severe soft tissues, bones and joints infections. Methods: The computerized database of the Department of Statistics of ¨Paquito González¨ Pediatric Hospital was reviewed to identify all discharges from the Pediatric Intensive Care Unit with a diagnosis of cellulite or soft tissue abscess, fasciitis, myositis, osteomyelitis, severe sepsis and septic shock, in the period from January 2009 to December 2019. The following variables were studied: location of skin and soft tissue infection, age group, year of discharge, and sepsis origin location. Results: There were no differences in the incidence between age groups. Limb cellulite was the most common clinical form. An increasing incidence of soft tissue infections was found. Bone and joint infections represented the second most frequent origin location of severe sepsis and septic shock. Conclusions: There has been an increase in skin and soft tissue infections that require admission to the intensive care unit of the aforementioned hospital in the last 11 years. These infections, together with bone and joint infections, constitute a health problem since they cause severe sepsis and septic shock with a significant incidence(AU)

Development and Validation Clinician and Patient Reported Photonumeric Scales to Assess Buttocks Cellulite Severity.

BACKGROUND: The Clinician Reported Photonumeric Cellulite Severity Scale (CR-PCSS) and Patient Reported PCSS (PR-PCSS) are newly developed tools for assessing cellulite severity. OBJECTIVE: To report on the reliability, validity, and ability to detect a change in cellulite severity on the buttocks of adult women with the CR-PCSS and PR-PCSS. MATERIALS AND METHODS: Content validity of both scales was established through concept elicitation and cognitive interviews. Test-retest reliability was evaluated, and intra-rater (both scales) and inter-rater (CR-PCSS only) reliability were estimated using intraclass correlation coefficients (ICCs) for agreement and consistency. Ability to detect a change was determined using the Subject-Global Aesthetic Improvement Scale (GAIS) or Investigator-GAIS as anchors. RESULTS: For the CR-PCSS (n = 6) at baseline and Day 2, the mean interrater ICCs were ≥0.70 and mean intrarater ICCs (95% confidence interval [CI]) were ≥0.81 (0.72-0.90) for both buttocks. For the PR-PCSS (n = 99) at baseline and Day 14, the mean test-retest reliability ICCs (95% CI) were ≥0.86 (0.79-0.91) for both buttocks. A clinically meaningful change was 1.0 point on the PR-PCSS and 1.0 on the CR-PCSS. CONCLUSION: The CR-PCSS and PR-PCSS reliably assess cellulite severity of the buttocks and can detect a clinically meaningful change after treatment for cellulite.

Subcision™ plus poly-l-lactic acid for the treatment of cellulite associated to flaccidity in the buttocks and thighs.

BACKGROUND: There is a growing demand for procedures to treat cellulite. Subcision™ is widely used for cellulite correction, and injectable poly-L-lactic acid (PLLA) has been shown to be an effective option for various body conditions. AIMS: Present the results of combining Subcision™ plus PLLA, in the same session, in patients with cellulite and flaccidity. PATIENTS/METHODS: Twenty-four women underwent Subcision™ followed by PLLA injections. An expert panel of dermatologists evaluated before and after photographs according to Global Aesthetic Improvement Scale (GAIS). Patients also answered a satisfaction questionnaire. RESULTS: The author describes the results, as well as number of sessions and dose used. The most frequent GAIS score was "great improvement." No nodules or granulomas appeared in the treated areas. CONCLUSION: The combination of Subcision™ plus PLLA, in the same treatment session, promotes safe and desirable results for cellulite associated with flaccidity.

Validated Assessment Scales for Cellulite Dimples on the Buttocks and Thighs in Female Patients.

BACKGROUND: New treatment methods for cellulite require globally accepted scales for aesthetic research and patient evaluation. OBJECTIVE: To develop a set of grading scales for objective assessment of cellulite dimples on female buttocks and thighs and assess their reliability and validity. MATERIALS AND METHODS: Two photonumeric grading scales were created and validated for dimples in the buttocks in female patients: Cellulite Dimples-At Rest, and Cellulite Dimples-Dynamic. Sixteen aesthetic experts rated photographs of 50 women in 2 validation sessions. Responses were analyzed to assess inter-rater and intra-rater reliability. RESULTS: Overall inter-rater reliability and intra-rater reliability were both "almost perfect" (≥0.81, intraclass correlation efficient and weighted kappa) for the At Rest scale. For the Dynamic scale, inter-rater reliability and intra-rater reliability were "substantial" (0.61-0.80). There was a high correlation between the cellulite scales and body mass index, age, weight, and skin laxity assessments. CONCLUSION: Consistent outcomes between raters and by individual raters at 2 time points confirm the reliability of the cellulite dimple grading scales for buttocks and thighs in female patients and suggest they will be a valuable tool for use in research and clinical practice.

A Multicenter, Retrospective Evaluation of Tissue Stabilized-Guided Subcision in the Management of Cellulite.

BACKGROUND: The first FDA-cleared, long-lasting, minimally invasive device for improving the appearance of cellulite was recently launched in Canada as a novel, tissue stabilized-guided subcision (TS-GS) system (Cellfina, Merz North America, Inc., Raleigh, NC). Clinicians from 2 of the first Canadian sites offering this procedure were interested in evaluating treatment efficacy and patient satisfaction after its first year on the market. OBJECTIVES: The authors sought to evaluate the efficacy of TS-GS and the level of patient satisfaction associated with the procedure. METHODS: Medical charts of female patients treated with the TS-GS system in 2017 were retrospectively analyzed at 2 Canadian centers. Measurements at baseline and 3 months posttreatment were assessed for patient satisfaction and physician-rated efficacy. Patient satisfaction was assessed using a 5-point Likert-type scale, and efficacy was evaluated through physician review of 2-deminsional and 3-dimensional photography, the Nürnberger-Müller Scale for cellulite, and the Global Assessment of Improvement Scale. RESULTS: We reviewed 25 patient charts. At month 3, 95.6% of patients were satisfied with treatment results and physician evaluations revealed that on average, patients displayed a 1-point improvement in their cellulite grades. Moreover, Global Assessment of Improvement Scale scores indicated that all patients had visible improvement in the global appearance of cellulite. No serious adverse events were observed within 3 months postprocedure. CONCLUSIONS: The physician ratings, patient satisfaction, and photographic evidence support the efficacy of the TS-GS system to manage grades 1 to 3 cellulite in women's thighs and buttocks. These findings indicate the safety of the TS-GS system.Level of Evidence: 4.

Updates on the understanding and treatment of cellulite.

Cellulite is a common dermatologic condition and frequent cause of cosmetic concern among women. This paper aims to update what is known about the pathogenesis of cellulite and reviews targeted treatment modalities that address its underlying components of microvascular dysfunction, endocrine-mediated inflammation, and connective tissue fibrosclerosis.

An Anatomical Approach to Evaluating and Treating Cellulite.

Cellulite is the common rippling or dimpling of skin of the thighs and buttocks of women, formed from a confluence of skin laxity, tethering fibrous septa, and fat herniation. We describe an anatomical approach to evaluating the cellulite patient and selecting the best treatment from among available non-invasive, minimally invasive, and invasive therapies. It is crucial to consider the anatomy of the patient and the morphology of cellulite while choosing a treatment. Diffuse rippling represents increased adiposity and/or increased skin laxity which may stand to benefit from lipolytic and skin tightening modalities. Dimpling represents tethering by fibrous septa which may stand to improve from subcision by minimally invasive devices such as Cell na. Patients with both morphologies may be treated with a combination of treatments or Cellulaze. Careful evaluation of the patient can help identify the best therapeutic strategy. J Drugs Dermatol. 2017;16(1):58-61..

Incidencia de celulitis facial odontógena en el territorio de Matanzas / Odontogenic Facial Cellulites incidence in the territory of Matanzas

La Celulitis Facial Odontógena es relativamente frecuente, puede convertirse en un grave riesgo vital cuando el tratamiento no es adecuado. Se realizó un estudio observacional, analítico, transversal desde enero 2006 a diciembre 2008. La muestra incluyó 49 pacientes que acudieron o fueron remitidos a los servicios de urgencias con el diagnóstico de CFO. Los niños y jóvenes resultaron los más afectados, así como el sexo masculino. Los dientes incurables y los restos radiculares constituyeron las causas más frecuentes, la región anatómica prevaleciente fue la cavidad bucal. El 51 por ciento de los casos tuvieron diagnóstico de celulitis leves, siendo necesario el ingreso hospitalario para 25 pacientes, los demás tuvieron tratamiento ambulatorio. Se recomienda diseñar una estrategia de intervención para disminuir la incidencia de CFO en el territorio de Matanzas.

The Odontogenic Facial Cellulites is relatively frequent; when the treatment is not right, it can become a serious risk for life. We carried up an observational, analytic, transversal study from January 2006 to December 2008. The sample included 49 patients assisting or remitted to the Urgent Care Services with a diagnosis of Odontogenic Facial Cellulites. The most affected were children and young people, and the female sex. The most frequent causes were teeth that can not be healed and roots remaining; the prevailing anatomic region was the oral cavity. 51 percent of the cases were diagnosed as mild cellulites, being necessary the hospital staying for 25 patients; the rest received home treatment. It is recommended to design an intervention strategy to diminish the incidence of the Odontogenic Facial Cellulite in the territory of Matanzas.

Complicaciones de rinosinusitis aguda en niños del Hospital Sótero del Río / Complications of acute rhinosinusitis in children at Sótero del Río Hospital

Introducción: La rinosonusitis aguda (RSA) es frecuente en niños, respondiendo bien a tratamiento médico en la mayoría de los casos. Sin embargo puede presentar complicaciones graves a nivel orbitario e intracerebral. Objetivo: Evaluaria frecuencia, describirias características clínicas, evaluare! tratamiento y evolución de la rinosinusitis aguda complicada, en niños del Hospital Sótero del Río. Material y método: Estudio retrospectivo-descriptivo realizado en el Hospital Sótero del Río, utilizando fichas clínicas de pacientes ingresados desde enero de 2002 hasta julio de 2007, con diagnóstico de RSA complicada. Resultados: Se incluyeron 27 pacientes con diagnóstico presuntivo de RSA complicada: 30 por ciento con celulitis preseptal aislada, 36 por ciento celulitis postseptal, 26 por ciento absceso subperióstico y 8 por ciento complicaciones intracraneales. La edad promedio fue 4.53 años (4 meses-13 años); 56 por ciento sexo masculino y 44 por ciento sexo femenino; promedio de días hospitalizados 7,24 días (2-19 días); total de días con tratamiento antibiótico 20,2 días (9-38 días); el cultivo microbiológico fue positivo en 25 por ciento de los pacientes con tratamiento quirúrgico (Staphylococcus epidermidis). No existió compromiso visual al alta en ninguno de los pacientes. Conclusión: La complicación más frecuente de RSA fue la orbitaria (92 por ciento) similar a lo descrito en la literatura. El seno etmoidal, maxilar y frontal fueron frecuentemente comprometidos. La edad de presentación de complicación de RSA fue levemente menor a lo descrito en la literatura. Se encontró predominio del género masculino, aunque en los abscesos subperiósticos predominó el sexo femenino. No se encontró relación directa entre la gravedad de RSA y los valores de proteína C reactiva (PCR) y leucocitosis. La mayoría de los abscesos subperiósticos se manejaron médicamente, teniendo la mitad de ellos más de 9 años. Sólo un paciente presentó complicación orbitaria y encefálica...

Introduction: Acute rhinosinusitis (RSA) is frequent in children. Although in most cases responds well to medical treatment, it could result in serious orbital and intracranial complications. Aim: To assess the frequency, describe the clinical characteristics and evaluate treatment and evolution of acute rhinosinusitis in children at Sótero del Rio hospital. Material and Method: Retrospective - descriptive study of clinical data from Sótero del Rio hospital between Jan 2002 and July 2007, involving patients with a diagnosis of complicated RSA. Results: Data from 27 patients were included in this study, all with presumptive RSA complications: 30 percent had isolated preseptal cellulitis, 36 percent had postseptal cellulitis, 26 percent had subperiostal abscesses, and 8 percent had intracranial complications. The average age of patients was 4,53 years (4 months-13 years old); 56 percent were males and 44 percent were females; hospitalization was in average 7,24 days (2 -19 days), the average number of days on antibiotic treatment was 20,2 (9 -38 days); microbiologic culture was positive in 25 percent of patients with surgical treatment (Staphylococcus epidermidis). None of the patients had visual complications when they were discharged from the hospital. Conclusion: The most frequent RSA complication was orbital (92 percent of complications), similar to what is reported in the literature. Ethmoidal, maxilar and frontal sinuses were more often involved. RSA complications presented at a slightly younger age than reported in the literature. More often males were affected, but subperiostal abscesses were more common in females. There was no direct relation between RSA seriousness and C-reactive protein or leukocitosis. Most subperiostal abscesses were medically treated; more than half of these patients were older than 9 years old. Only one patient presented both orbital and intracranial complications

Obesity and the skin: skin physiology and skin manifestations of obesity

Obesity is widely recognized as an epidemic in the Western world; however, the impact of obesity on the skin has received minimal attention. The purpose of this article is to highlight the association between obesity and dermatologic conditions. We review the impact of obesity on the skin, including skin physiology, skin manifestations of obesity, and dermatologic diseases aggravated by obesity. Obesity is responsible for changes in skin barrier function, sebaceous glands and sebum production, sweat glands, lymphatics, collagen structure and function, wound healing, microcirculation and macrocirculation, and subcutaneous fat. Moreover, obesity is implicated in a wide spectrum of dermatologic diseases, including acanthosis nigricans, acrochordons, keratosis pilaris, hyperandrogenism and hirsutism, striae distensae, adiposis dolorosa, and fat redistribution, lymphedema, chronic venous insufficiency, plantar hyperkeratosis, cellulitis, skin infections, hidradenitis suppurativa, psoriasis, insulin resistance syndrome, and tophaceous gout. We review the clinical features, evidence for association with obesity, and management of these various dermatoses and highlight the profound impact of obesity in clinical dermatology. LEARNING OBJECTIVE: After completing this learning activity, participants should be aware of obesity-associated changes in skin physiology, skin manifestations of obesity, and dermatologic diseases aggravated by obesity, and be able to formulate a pathophysiology-based treatment strategy for obesity-associated dermatoses.