Skin Bends and Future Diving

[uncfnp]

Please keep in mind that the following info is not from a dive medicine background but rather a personal interest of mine and internet review. There is a surprising lack of medical data available for cutaneous manifestations of DCS, or skin bends. Much of the online information is personal accounts, case presentations and dated research. I'm still hopeful a more authoritative source will contribute to this thread...

In 1971 the US Naval Submarine Medical Center released "A Review of the Pathogenesis of Skin Bends." http://www.dtic.mil/dtic/tr/fulltext/u2/749317.pdf. Much of the info in it is obviously obsolete but it is interesting that a review of the literature at that time separated skin bends into six levels or presentations.

!) Pruritus only - "fleas"
2) Scarlatinaform rash - perhaps the most frequent sign, usually not accompanied by more serious forms of DCS
3) Erysipelas - may accompany or proceed the more serious forms of DCS
4) Cutis marmorata - this is "one of the danger signs in diving"

The other levels listed are not seen as isolated skin manifestation but rather result from more serious complications of DCS

5) Serious form - cyanosis and shock
6) Emphysema - intracutanous (?) and subcutaneous

The Navel paper goes on to try and explain each presentation based of the anatomy and physiology of the skin and the skin structures involved in each manifestation. Please refer to posted link for a detailed explanation.

Most of the case presentations that I could find in the medical literature were of the cutis marmorata (also referred to as livedo reticularis in other articles) form.

Alert Diver | Skin Bends
MMS: Error
Medical image. Cutaneous manifestation of decompression sickness: cutis marmorata

Some sources also list a lymphatic version of skin bends.

Another internet source also describes 6 types of skin bend presentations:

From the London Diving Chamber website:

So you�re not sure whether or not you have a �Cutaneous Manifestation� or skin bend. What are the signs and symptoms of the several types? The old tunnelers called it "fleas". Just an itchy sensation. Can be a small, localised or generalised. Affects the trunk, arms hands face and legs. It is commonly thought to follow dry dives. Comes on shortly after the dive and may last a few minutes or a few hours. There is nothing to be seen on the skin. I had this for a few minutes after an 80 metre dry dive on air but not after Heliox. Itchy sensation possibly with folliculitis (inflammation of the hair follicules), attributed to bubbles in the skin. A red rash over the trunk chest shoulders, back and upper abdomen. May last several hours. It itches. A more serious diffuse raised red rash, angry looking with little papules - blisters. Marbling of the skin - the best way to describe this is to refer you to the illustrations. This was my first case of skin bends in 1973. It had been present for 24 hours when he asked for advice before returning to work. No prizes for guessing my advice. He was otherwise symptom free. The mottling went in another 48 hours. In some cases this form of skin bend is associated with more serious symptoms and really does require urgent medical advice. Localised swelling as described in Paul Bert�s book and later by Snell. It comes on quite soon after a dive, may be on one side or both. The skin is stretched and the swelling can be indented by pressure. The natural history is for the swelling to track down the trunk, causing discomfort on the upper abdominal wall, then a need to let out the belt and then a requirement for some scrotal or equivalent support. (Skin bends like all DCI are not gender specific.) Finally, it may track down the thighs, legs and rarely into the feet. decompression sickness / DCS / decompression illness / DCI / diving and the bends, London Recompression & Hyperbaric facilities - The London Diving Chamber

 

[Duke Dive Medicine]

Natalie, sorry I'm just getting back in the thread here. The photos, along with your description of the rash, point more toward cutis marmorata, which is the more serious form of skin bends and the type associated with PFO. I think the decision to have you tested is very reasonable.

Best regards,
DDM

 

[DCBC]

After speaking with DAN immediately following the last incident, I was under the impression that having solely skin bends symptoms was not that dangerous. I was also under the impression that skin bends is not well understood and that the connection between skin bends and more serious DCS was not very well known either.

I've had this before (rashes). Skin Bends (which I've had once) usually have darker areas connected by lines (a join the numbered dots type of look to them). Sometimes the areas can be quite large and pronounced. Like has been mentioned, this could be related to cutis marmorata, but this doesn't usually show itself until hours afterward. Getting this checked-out is always advisable.

Skin Bends (or DCS for that matter) isn't understood as much as we'd like. You're right to be cautious.

If you're clear, rather than quitting diving, I'd recommend that you start by slowing down your ascent rate to 10 FPM (or slower) above 30 FSW. If you use a computer, make sure that it has a conservation setting and use it at +3 (or greater). Don't push the tables unless you're in the condition of a Navy SEAL and are happy to accept a minor DCS hit every 50 dives. You can start to adjust your diving accordingly once the rashes cease to be a problem. There is always however a chance that they are in no way related to nitrogen absorption.

 

[DocVikingo]

Skin Bends (or DCS for that matter) isn't understood as much as we'd like.

Perhaps I'm misreading this sentence, but isn't "skin bends" in fact a form of DCS/DCI? See London Recompression & Hyperbaric facilities - The London Diving Chamber and Alert Diver | DAN Medics Answer Your Questions About Dive Medicine. After all, it is formally diagnosed as cutaneous decompression sickness.

this could be related to cutis marmorata, but this doesn't usually show itself until hours afterward.

Perhaps I'm mistaken, but my reading of the literature indicates that cutaneous decompression sickness can manifest within a few minutes to a few hours after surfacing.

Cheers,

DocVikingo

 

[Superlyte27]

Perhaps I'm mistaken, but my reading of the literature indicates that cutaneous decompression sickness can manifest within a few minutes to a few hours after surfacing.

Cheers,

DocVikingo

I had a buddy doing a commercial job early in the morning. He got out of the chamber (surface deco) at about 2pm. He went to bed about midnight, when he woke up the next morning he was covered with skin bends just like the picture the OP listed.

Of course I have no idea what that tells us except that 2 minutes or 10 hours later, getting bent sucks.

 

[Duke Dive Medicine]

I had a buddy doing a commercial job early in the morning. He got out of the chamber (surface deco) at about 2pm. He went to bed about midnight, when he woke up the next morning he was covered with skin bends just like the picture the OP listed.

Of course I have no idea what that tells us except that 2 minutes or 10 hours later, getting bent sucks.

It can happen hours afterward like the case you describe, but it can also happen soon after surfacing, as DocV pointed out. When it happens quickly it's often associated with right-to-left shunt (e.g. PFO).

Best regards,
DDM

 

[DocVikingo]

Of course I have no idea what that tells us except that 2 minutes or 10 hours later, getting bent sucks.

True dat.

Cheers,

DocV

 

[DCBC]

Perhaps I'm misreading this sentence, but isn't "skin bends" in fact a form of DCS/DCI? Perhaps I'm mistaken, but my reading of the literature indicates that cutaneous decompression sickness can manifest within a few minutes to a few hours after surfacing...

I believe you're correct Doc. It can occur in less than one hour, but in the majority of cases symptoms take longer (DCIEM Diving Manual, USN database, NOAA Diving Manual). I was taught that there are three basis forms of Skin Bends (I'm not a Physician, but have a M.Sc. in Hyperbaric Physiology):

- Pruritus ("the itches"), which if there's no other symptom will resolve itself;
- "The rashes," red patches of skin, usually located on the arms, shoulders and chest (no treatment necessary); and
- "Marbling" (cutis marmorata) which includes burning, itching increased cyanosis and sometimes pitting (usually in the fatty tissue: legs, buttocks, breasts). The skin may also feel leathery and thicker.

The OP did not show marbling in the photos; so cutis marmorata seemed improbable. Cutis marmorata is referred to as "Skin Bends" in the military and commercial diving industries. The "itches" and "scratches" are considered insignificant.

When I had Skin Bends, it started with intense itching after about 5 hours after the Dive. The skin got red and patchy (joined by lines) and a purple discoloration became prominent and raised. I returned to DCIEM and went for another ride in the Chamber (the culprit). As the symptoms had developed afterwards, I was concerned that the prognosis wouldn't be as favorable. I've experienced no further problems.

My comments were made with the view that the OP's symptoms were slight in comparison with my experience with cutis marmorata and more consistent with "itches" and "rashes" that I have experienced as a Diver and witnessed as a Chamber Supervisor. The majority of more serious Type I DCS symptoms are not immediate (usually occurring within 6 hours) although more immediate symptoms are possible. Minor "itches and rashes" tend to occur relatively quickly. I suggested that the OP obtain a medical opinion (as mentioned by Eric).

 

[uncfnp]

I believe you're correct Doc. It can occur in less than one hour, but in the majority of cases symptoms take longer (DCIEM Diving Manual, USN database, NOAA Diving Manual). I was taught that there are three basis forms of Skin Bends (I'm not a Physician, but have a M.Sc. in Hyperbaric Physiology):

- Pruritus ("the itches"), which if there's no other symptom will resolve itself;
- "The rashes," red patches of skin, usually located on the arms, shoulders and chest (no treatment necessary); and
- "Marbling" (cutis marmorata) which includes burning, itching increased cyanosis and sometimes pitting (usually in the fatty tissue: legs, buttocks, breasts). The skin may also feel leathery and thicker.

The OP did not show marbling in the photos; so cutis marmorata seemed improbable. Cutis marmorata is referred to as "Skin Bends" in the military and commercial diving industries. The "itches" and "scratches" are considered insignificant.

When I had Skin Bends, it started with intense itching after about 5 hours after the Dive. The skin got red and patchy (joined by lines) and a purple discoloration became prominent and raised. I returned to DCIEM and went for another ride in the Chamber (the culprit). As the symptoms had developed afterwards, I was concerned that the prognosis wouldn't be as favorable. I've experienced no further problems.

My comments were made with the view that the OP's symptoms were slight in comparison with my experience with cutis marmorata and more consistent with "itches" and "rashes" that I have experienced as a Diver and witnessed as a Chamber Supervisor. The majority of more serious Type I DCS symptoms are not immediate (usually occurring within 6 hours) although more immediate symptoms are possible. Minor "itches and rashes" tend to occur relatively quickly. I suggested that the OP obtain a medical opinion (as mentioned by Eric).

If you don't mind my asking, did you get checked for PFO?

 

[DCBC]

If you don't mind my asking, did you get checked for PFO?

Not at that time. I had an echocardiogram/bubble study/chest X-ray/doppler as part of the Navy Diving medical.