dermatological manifestations of diabetes mellitus
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Dermatologic manifestations of diabetes mellitusRohan Gunathilake MDJohn Hunter Hospital, Newcastle, Australia
Dermatologic manifestations of diabetes• Incidence 30-70% of diabetics in different studies• May precede development of clinical diabetes• Prevalence similar in type 1 and 2 • Cutaneous infections are more common in
type 2, whereas autoimmune-related lesions in type 1• Good metabolic control may prevent and help
cure some
Classification
• Vascular• Metabolic• Necrobiotic• Bullous• Infections• Neuropathic• Treatment-related• Miscellaneous
Dermatologic manifestations of diabetes• Vascular• Metabolic• Necrobiotic• Bullous• Infections• Neuropathic• Treatment-related• Miscellaneous
Diabetic dermopathy
• “Shin spots”: multiple round/ oval macules over the shins (thighs, forearms) hyperpigmentation, atrophy• Twice common in (older) men• Should have ≥ 4 lesions• Marker of microvascular disease, high correlation
with diabetic retinopathy
Diabetic dermopathy
• 2ry to ?trauma, ?pyoderma• Represent post-traumatic atrophy and post-
inflammatory hyperpigmentation in poorly vascularised skin• Endothelial proliferation, PAS+ deposits in the
BM of blood vessels• Require no Rx
Rubeosis facei (diabeticorum)• Rosy redness of the face• Evident in newly diagnosed diabetics• Up to 60% hospitalised patients with diabetes • Associated with vascular tone and ↑viscosity
(functional microangiopathy)• Often a sign of poor glycaemic control• Returns to normal with improved control
Erysipelas-like erythema
• Well-demarcated red areas in feet & legs• Painless, Lack of systemic signs of infection• Seen in elderly diabetics (majority > 73 years,
duration of diabetes 5.4 years)• Underlying bone destruction+/-• Compensatory ↑ peripheral microcirculation
caused by perfusion due to large vv. disease• Spontaneous resolution over weeks but may
recur
Erysipelas-like erythema
Pigmented purpura
• RBC extravasation from superficial plexus• Cayenne pepper spots (red macules) orange
tan patches• Frequently associated with diabetic dermopathy
(50%)• ↑incidence in elderly diabetics with cardiac
failure • Marker of microvascular disease
Periungulal telangiectasia
• Seen in up to 49% diabetics• Megacapillaries and irregularly elongated loops• Often associated with nail fold erythema,
accompanied by fingertip tenderness and “ragged” cuticles• Functional microangiopathy (engorgement of
venular limbs), tortuosity indicates structural changes
Dermatologic manifestations of diabetes• Vascular• Diabetic dermopathy• Rubeosis facei• Erysipelas like erythema• Pigmented purpura• Periungual telangiectasia
• Metabolic• Necrobiotic• Bullous• Infections• Neuropathic
• Treatment-related• Miscellaneous
Acanthosis nigricans
• Symmetrical• Velvety verrucous hyperpigmented plaques• Associated with papillomatous skin tags• Axilla, nape of the neck• Occasionally hands & feet, mucous membranes• Hyperinsulinaemia stimulate IGF receptor on
KC + dermal fibroblasts• Rx: Weight Mx, keratolytics, topical retinoic acid
Acanthosis nigricans
Hyperkeratosis
Papillomatosis
Acanthosis
melanin in basal layer
Eruptive xanthomas
• Occur in less than 0.1% of diabetic patients• Crops of small (1- to 4-mm) yellow papules with
an erythematous halo• May be pruritic and tender• Buttocks and extensor surfaces• Appear in association with elevated triglycerides• Resolve with treatment of ↑glucose and lipid
Yellow skin and nails
• Prevalence 40% in T2DM, more common in elderly• Most evident in distal end of hallux• Caused by: • Hypercarotinaemia• Protein glycosylation end products
Diabetic scleredema
• Non-enzymatic glycosylation of collagen• Fingers and dorsum of the hands, with limited
joint mobility, Huntley’s papules (8-50% type 1 diabetics) • Chest, neck, shoulders - ↑Dermal thickness,
difficult to tent the skin; (common in older type 2 diabetics), Peau d’orange app.• May be subclinical• ?improves with tight glycaemic control
Dermatologic manifestations of diabetes• Vascular• Diabetic dermopathy• Rubeosis facei• Erisypelas like erythema• Pigmented purpura• Periungual telangiectasia
• Metabolic• Acanthosis nigricans• Eruptive xanthoma• Yellow skin and nails• Diabetic scleredema
• Necrobiotic
• Bullous• Infections• Neuropathic• Treatment-related• Miscellaneous
Nerobiosis lipoidica
• 0.3- 0.7% of diabetics• Case series of 171 patients, 60% diabetes, 20%
IGT• In 15% patients precede the development of
diabetes by ≈2yrs• More common in females, Caucasians, type 1• Mean age of onset ≈ 34 years
Nerobiosis lipoidica
• Well-circumscribed papules radial expansion sharply-demarcated slightly depressed yellow waxy plaques with erythematous raised border central atrophy with telangiectasia
Nerobiosis lipoidica
• Pretibial, medial malleolus• 15% outside legs• Ulcerate in 1/3 patients• Persists despite glycaemic control• Chronic course, 20% remit spontaneously in 6-
12/12• Rx: intralesional steriods, aspirin, pentoxifylline
Disseminated granuloma annulare• No clearly established association between
localized form and diabetes• Papules and annular lesions with raised skin
coloured / erythematous border and flat center• Symmetrically distributed on the arms, neck, and
upper half of the trunk and less often on the legs• Runs a protracted course
Disseminated granuloma annulare• Sporadic therapeutic success reported with
intralesional/ topical/ systemic steroids, isotretinoin, chlorambucil, cryotherapy, chloroquine, nicotinamide, dapsone, and PUVA
Dermatologic manifestations of diabetes• Vascular• Diabetic dermopathy• Rubeosis facei• Erysipelas like erythema• Pigmented purpura• Periungual telangiectasia
• Metabolic• Acanthosis nigricans• Eruptive xanthoma• Yellow skin and nails• Diabetic scleredema
• Necrobiotic• Necrobiosis lipoidica• Disseminated GA
• Bullous• Infections• Neuropathic• Treatment-related• Miscellaneous
Bullous diabeticorum
• More common in type 1, males• Usually confined to feet, occasionally hands• Spontaneous, not related to trauma or infection• Blisters contain sterile clear fluid, rest on a non-
erythematous base• Heal in 2-3 weeks without scarring
3 types1. Common type: clear sterile blisters on tips of
toes/ fingers. Heals without scarring. intraepidermal cleavage.
2. Haemorrhagic bullae: heals with scarring, Cleavage - DEJ
3. Multiple tender non-scarring blisters in sunexposed areas. IMF and porphyrins –ve. Cleavage - lamina lucida
Dermatologic manifestations of diabetes• Vascular• Diabetic dermopathy• Rubeosis facei• Erisypelas like erythema• Pigmented purpura• Periungual telangiectasia
• Metabolic• Acanthosis nigricans• Eruptive xanthoma• Yellow skin and nails• Diabetic scleredema
• Necrobiotic• Necrobiosis lipoidica• Disseminated GA
• Bullous• Bullous diabeticorum
• Infections• Neuropathic• Treatment-related• Miscellaneous
Bacterial infections
• Staphylococcal : furuncle, carbuncle, ecthyma• Strep pyogenes : cellulitis, erysipelas• Pseudomonas spp.:• Malignant otitis externa: cellulitis, osteomyelitis,
meningitis, CR nerve palsies, mortality 50% Rx: IV quinolone• Toe nail infection• Toe web infection
Bacterial infections
• Erythrasma• Chronic, asymptomatic symmetric red scaly
macerated plaques in the axillae and groin• Corynebacterium minutissimum• Rx- topical/ systemic erythromycin
• Non-clostridial gas gangrene• Develops in soft tissue near a gangrenous focus• E.coli, klebsiella, pseudomonas and bacteriodes
Fungal infections
• Candida • Oral, perliche• Vaginal/ balanoprosthitis• Intertrigenous skin incl. toe web• Paronychia• Nail infection
• Dermatophytosis• Incidence not ↑ in diabetes• Commonly caused by Trichophyton rubrum, T
mentagrophytes, and Epidermophyton floccosum
Rhinocerebral mucormycosis• Esp. associated with ketosis• Black crust/ pus in terbinate, nasal septum,
palate and orbit• Cerebral involvement in 2/3• Rx: debridement + IV amphotericin + Rx
ketosis • High mortality
Dermatologic manifestations of diabetes• Vascular• Diabetic dermopathy• Rubeosis facei• Erisypelas like erythema• Pigmented purpura• Periungual telangiectasia
• Metabolic• Acanthosis nigricans• Eruptive xanthoma• Yellow skin and nails• Diabetic scleredema
• Necrobiotic• Necrobiosis lipoidica• Disseminated GA
• Bullous• Bullous diabeticorum
• Infections• Bacterial• fungal
• Neuropathic• Treatment-related• Miscellaneous
Neuropathic • Anhidrosis • Hyperhidrosis • Neuropathic ulcers : circular, punched out ulcer
in the middle of a callosity over metatarsal heads
Dermatologic manifestations of diabetes• Vascular• Diabetic dermopathy• Rubeosis facei• Erisypelas like erythema• Pigmented purpura• Periungual telangiectasia
• Metabolic• Acanthosis nigricans• Eruptive xanthoma• Yellow skin and nails• Diabetic sclredema
• Necrobiotic• Necrobiosis lipoidica• Disseminated GA
• Bullous• Bullous diabeticorum
• Infections• Bacterial• fungal
• Neuropathic• Anhidrosis/hyperhidrosis• Neuopathic ulcers
• Treatment-related• Miscellaneous
Insulin reactions
• Immediate• Localized/ Generalised erythema, urticaria
• Delayed• Itchy nodule 4-24 h after injection
• Lipoatrophy• Circumscribed depressed areas 6-24/12 after starting Rx• lypolytic component of inulin preparation, immune complex
mediated inflammation• Less common with purified recombinant human insulins
• Lipohypertrophy • Soft nodules resembling lipoma• Local response to lipogenic action of insulin• Preventable by rotating injection sites
Dermatologic manifestations of diabetes• Vascular• Diabetic dermopathy• Rubeosis facei• Erisypelas like erythema• Pigmented purpura• Periungual telangiectasia
• Metabolic• Acanthosis nigricans• Eruptive xanthoma• Yellow skin and nails• Diabetic sclredema
• Necrobiotic• Necrobiosis lipoidica• Disseminated GA
• Bullous• Bullous diabeticorum
• Infections• Bacterial• fungal
• Neuropathic• Anhidrosis/hyperhidrosis• Neuopathic ulcers
• Treatment-related• Insulin reactions• Photosensitivity, lichenoid Rn
• Miscellaneous
Acquired Perforating Dermatoses
• Umbilicated hyperpigmented papules with a central keratotic plug• Common site = extensor surfaces of extremities• Pruritus a major symptom• Strong association with ESRD• Histology shows transepidermal elemination of
degenerative elastic/ collagen fibres• Treatments: Topical tretinoin, phototherapy
Vitiligo
• Localised/ generalised forms• 1-7% in type 1 diabetics (0.2-1% in general
population)• May be a part of polyglandular syndrome type 1• Rx: sun protection, topical/ systemic steriods,
phototherapy
Lichen planus
• Polygonal erythematous flat lesions• Wrist, dorsa of feet, lower legs• Oral/ genital lesions: white lacy pattern• DD- lichenoid drug reactions • Rx: topical steriods
Dermatologic manifestations of diabetes• Vascular• Diabetic dermopathy• Rubeosis facei• Erisypelas like erythema• Pigmented purpura• Periungual telangiectasia
• Metabolic• Acanthosis nigricans• Eruptive xanthoma• Yellow skin and nails• Diabetic scleredema
• Necrobiotic• Necrobiosis lipoidica• Disseminated GA
• Bullous• Bullous diabeticorum
• Infections• Bacterial• fungal
• Neuropathic• Anhidrosis/hyperhidrosis• Neuropathic ulcers
• Treatment-related• Insulin reactions• Photosensitivity
• Miscellaneous• APD ◦ vitiligo• pruritus ◦ lichen planus
Key points
• Diabetic dermopathy (shin spots) is considered to be the most common dermatologic manifestation of diabetes.• Skin manifestations of diabetes may also serve as
ports of entry for secondary infection.• A candidal infection can be an early sign of
undiagnosed diabetes.• NLD is not pathognomonic to diabetes, as about a
third do not have diabetes.• Diabetic scleredema may present as limited joint
mobility of hands.
References
1. Hattem SV, Bootsma AH, Thio HB. Skin manifestations of diabetes. Cleaveland clinic J of Med. 2008; 75 (11): 772-87
2. Morgan AJ . Diabetic dermopathy: A subtle sign with grave implications. J Am Acad Dermatol - 2008; 58(3): 447-51
3. Perez M, Kohn S. Cutaneous Manifestations of Diabetes Mellitus. Journal of the American Academy of Dermatology. 1994; 30 (4): 519-531