Because the bends can present in so many ways, the problems it can cause in the skin can be overlooked. Especially as rashes after diving are common. The overarching title: ‘Decompression Illness’ (DCI) includes decompression sickness (DCS) and arterial gas embolism (AGE), reflecting the 2 theories by which bubbles cause problems. However skin bends can be associated with both processes and therefore a descriptive classification of symptoms is the most useful method of communicating information. So what could be easier to describe and treat than a skin bend? However there seems to be a few problems.
Skin bends may not be seen as part of decompression illness. Rashes are common and determining whether a skin bend is present can be difficult. A skin bend is a rash with poorly defined edges, there may be varying degrees of redness, it may be itchy, may make the skin seem more like marble and may occur in a single area or in multiple areas. Finally the rash of a skin bend is not caused by sunburn, suit squeeze, harness straps, skin infections, bites or scratching, although all these may be present and confuse the picture. Simple cases of itching, burning and increased warmth occur after many dives and probably should not be recompressed, but should still be discussed with a diving doctor. In terms of severity, next comes cutis marmorata. This is described as marbling of the skin. Blood vessels constrict and dilate in different areas over a small patch of skin, producing areas of pale skin and redder areas. This then looks like marble and should certainly be discussed with a diving doctor.
At the other end of the scale, livedo reticularis is the most severe form, as seen in the picture above, and involves patchy, reddish-purple mottled areas, especially around the shoulders and trunk. This can be intensely itchy, due to a local vascular reaction from bubbles in the tissues below the dermis, and is clearly a systemic manifestation of DCS. These divers must be treated. Another skin symptom to take seriously occurs with blockage of the lymphatics with bubbles, resulting in swelling and a peculiar pitting of the skin called peau d’orange (meaning skin of the orange) and again is evidence of a more serious form of DCS, known as lymphatic decompression sickness.
In the past skin bends on the limbs were not considered severe enough to warrant treatment. However all symptoms that start after decompression has begun, however minor, can herald severe DCI and must be assessed by a diving doctor. There have also been recent reports of an association with skin bends with patent foramen ovale (PFO) and there are now recommendations that some divers with this condition be checked for PFO.
In order to help us improve our recognition of skin bends, please help us with our Skin Bend Image and Information Bank. Scroll down the page to find the correct article at: http://www.londonhyperbaric.com/category/blog and download the 3 forms. Please print off and fill in the consent form and questionnaire and send these to the address given. Finally lease email the relevant photos to the secure NHSMail email address: email@example.com. This will in no way affect your treatment by the Divers Emergency Service or London Hyperbaric Medicine.
We do need written consent, not emailed consent. Sorry!
Picture reprinted from The Lancet, Vol. 377, Vann RD, Butler FK, Mitchell SJ, Moon RE, ‘Decompression Illness,’ Pages 153-64, 2011, with kind permission from Elsevier.
Information for Participants
Research study: Skin Bend Image and Information Bank
We would like to invite you to be part of this research project.
You should only agree to take part if you want to and it is entirely up to you. If you choose not to take part there won’t be any disadvantages for you and choosing not to take part will not affect your access to treatment or services in any way. Please read the following information carefully before you decide to take part; this will tell you why the research is being done and what you will be asked to do if you take part. Please ask if there is anything that is not clear or if you would like more information. If you decide to take part you will be asked to sign the attached form to say that you agree. You are still free to withdraw at any time and without giving a reason.
Details of study:
There are many reasons for rashes after diving, but sometimes these are due to decompression illness. (The Bends) We at London Hyperbaric Medicine (LHM) would like to collect anonymous images and information on rashes that occur up to 72 hrs after diving in order to form a bank. This will be published on the LHM web site and blog (http://www.londonhyperbaric.com/category/blog), in a Sport Diver article (http://www.sportdiver.co.uk/), for teaching purposes, in a medical journal and in The Anaesthesia UK Image Bank, (http://www.frca.co.uk/imgdefault.aspx) if accepted for publication. This will form very useful resources for doctors and divers.
Every effort will be made to ensure that you are unrecognizable from the pictures. However this cannot be absolutely guaranteed. Once the pictures are on the web site, you may request for yours to be removed at any time.
If you think you may have skin decompression illness, any other form of decompression illness or serious cause for a rash, then contact the Divers Emergency Service immediately on:
+44 (0)7 999 292 999
In order to help maintain your safety and confidentiality, the images will not be free for all to use. LHM will need to hold the copyright to the images, but will not use the images in any other fashion without express prior consent from you.