Multiple cases of skin bends - what now?

[Duke Dive Medicine]

See attached two pictures.

View attachment 845849

This was taken in October 2023, around 3 hours after the last dive. I noticed itching probably after 2 hours or so but completely disregarded it initially. It responded well to 100% oxygen and almost disappeared the next day. Irresponsibly, I did a shallow dive (15m) after around 24 hours on Nitrox 28%. It got a bit more colour again but then it completely vanished over the next 5 days and never got that bad again during those 5 days, even though I did a few more shallow dives on Nitrox in the next few days before the trip ended.

View attachment 845850

This one was taken last Saturday at A&E. I noticed the itching an hour after the dive and immediately realised what it was, got 100% oxygen right away. I arrived at the A&E in the next 30-40 minutes when this was taken by my doctor.

These are great photos, thanks. Two possibilities come to mind. First, some people are just more susceptible to skin bends for reasons that aren't clear. Second, the rash (at least from what I can see on the photos) could also be consistent with cold-induced urticaria. If that's what it is, you can duplicate it by placing an bag of ice on your abdomen for about 5 minutes. If you try that and the rash doesn't appear, I'd recommend you seek out a UKDMC diving medical referee for an opinion if you haven't already done so.

Best regards,
DDM

 

[chillyinCanada]

Do you wear an sunguard under your wetsuit?

 

[chris-mazur]

These are great photos, thanks. Two possibilities come to mind. First, some people are just more susceptible to skin bends for reasons that aren't clear. Second, the rash (at least from what I can see on the photos) could also be consistent with cold-induced urticaria. If that's what it is, you can duplicate it by placing an bag of ice on your abdomen for about 5 minutes. If you try that and the rash doesn't appear, I'd recommend you seek out a UKDMC diving medical referee for an opinion if you haven't already done so.

Best regards,
DDM

Thanks. I’ll try the ice pack method soon. However would that respond to breathing oxygen at all?

Yes I’m in contact with a local diving physician. I was told to wait a month from the last DCS episode before I see them.

What do you think about the tight vest causing this (it was Bare Ultrawarmth Hooded Vest)? Here’s another photo showing the vest underlay pattern which you can see in the rash distribution (even in the photos above if you look closely).

Do you wear an sunguard under your wetsuit?

I am pretty sure I had it on my arms, not on my chest.

 

[chillyinCanada]

Thanks. I’ll try the ice pack method soon. Yes I’m in contact with a local diving physician. I was told to wait a month from the last DCS episode before I see them. What do you think about the tight vest causing this (it was Bare Ultrawarmth Hooded Vest)? Here’s another photo showing the vest underlay pattern which you can see in the rash distribution (even in the photos above if you look closely).

View attachment 845856


I am pretty sure I had it on my arms, not on my chest.

I'm sorry . . .you had what on your arms?
I'm talking about a sunguard shirt, made of lycra or similar.
I'm asking because while your rash looks very similar to the skin bends that I've had, mine was also accompanied with a lot of pain but you haven't mentioned pain, only the mottling (bruised look).

I have seen something similar on another diver before and it was because they had some sort of sealife (for example, thimble jellyfish larva) trapped between their skin and their suit.

When the suit and/or sunguard shirt hasn't been washed out thoroughly enough of these creatures or the creature bits, then the rash can arise again.

 

[Duke Dive Medicine]

Thanks. I’ll try the ice pack method soon. However would that respond to breathing oxygen at all?

Yes I’m in contact with a local diving physician. I was told to wait a month from the last DCS episode before I see them.

What do you think about the tight vest causing this (it was Bare Ultrawarmth Hooded Vest)? Here’s another photo showing the vest underlay pattern which you can see in the rash distribution (even in the photos above if you look closely).

View attachment 845856


I am pretty sure I had it on my arms, not on my chest.

Thanks. I’ll try the ice pack method soon. However would that respond to breathing oxygen at all?

Yes I’m in contact with a local diving physician. I was told to wait a month from the last DCS episode before I see them.

What do you think about the tight vest causing this (it was Bare Ultrawarmth Hooded Vest)? Here’s another photo showing the vest underlay pattern which you can see in the rash distribution (even in the photos above if you look closely).

View attachment 845856


I am pretty sure I had it on my arms, not on my chest.

Good question about response to O2. No, cold-induced urticaria doesn't respond to O2 but it resolves on its own fairly quickly so if it was that, it would have resolved regardless of whether you were breathing O2 or room air. We don't know what would have happened had you not breathed O2 so the fact that it resolved is a good data point but doesn't rule out the urticaria.

Re the tight vest, I doubt it (I'd echo DAN's response) but I don't think I would completely discount it. Good to know you're being followed by a diving physician. You said that shunting had been ruled out - exactly what test was done to check?

Best regards,
DDM

 

[Nick_Radov]

His BMI is 28. Maybe he’s a bit overweight, if he has no muscle. If he is decently athletic he’s normal. OP, do you lift at all? Can you bench your weight, or deadlift 2x your weight? These things all play a role.

Last time I went to the doctor, he looked at my file and told me I need to lost 35 kg. I could stand to lose 5, but 35 is absurd. I can bench 10 kilo over my weight and deadlift 190 kg. BMI doesn’t care about that tho.

The usual concern for to DCS risk has been more about total adipose tissue rather than BMI per se. Fat has lower perfusion than muscle and thus is a relatively "slow" tissue: inert gas goes in and out more slowly.
On the bright side, skin bends are like free liposuction.

 

[chris-mazur]

I'm sorry . . .you had what on your arms?
I'm talking about a sunguard shirt, made of lycra or similar.
I'm asking because while your rash looks very similar to the skin bends that I've had, mine was also accompanied with a lot of pain but you haven't mentioned pain, only the mottling (bruised look).

I have seen something similar on another diver before and it was because they had some sort of sealife (for example, thimble jellyfish larva) trapped between their skin and their suit.

When the suit and/or sunguard shirt hasn't been washed out thoroughly enough of these creatures or the creature bits, then the rash can arise again.

Oh I’m sorry I thought by sunguard you meant sunscreen implying some sort of allergic reaction. It was a brand new vest when it happened for the first time. And on top of it I wore a long sleeve wetsuit (second time use)

There was no pain. The skin was quite sensitive but not painful.

Re the tight vest, I doubt it (I'd echo DAN's response) but I don't think I would completely discount it. Good to know you're being followed by a diving physician. You said that shunting had been ruled out - exactly what test was done to check?

Best regards,
DDM

CT pulmonary angiogram. I also had CPET, and lung function and FeNO, but I think those were done to rule out asthma.

 

[Duke Dive Medicine]

Oh I’m sorry I thought by sunguard you meant sunscreen implying some sort of allergic reaction. It was a brand new vest when it happened for the first time. And on top of it I wore a long sleeve wetsuit (second time use)

There was no pain. The skin was quite sensitive but not painful.



CT pulmonary angiogram. I also had CPET, and lung function and FeNO, but I think those were done to rule out asthma.

CT angiogram is not diagnostic for PFO (I double-checked that with one of our radiologists earlier). @Dr. Doug Ebersole please feel free to jump in with your perspective if you have clarifying info. The diagnostic standard for PFO is an echocardiogram with bubble contrast.

Best regards,
DDM

 

[chris-mazur]

CT angiogram is not diagnostic for PFO (I double-checked that with one of our radiologists earlier). @Dr. Doug Ebersole please feel free to jump in with your perspective if you have clarifying info. The diagnostic standard for PFO is an echocardiogram with bubble contrast.

Best regards,
DDM

Yes apologies I had the regular echocardiogram and one with contrast (via an arm) too. The tests above, or at least the CT, were done afterwards to check for a lung shunt (which I though you meant by saying „shunt”) and asthma