Dermatological Manifestations in Diabetics

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Dermatological Manifestations in Diabetics
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Cutaneous Manifestations

• Nearly all patients with diabetes eventually
  develop cutaneous manifestations of the disease.
• Can be first sign that a patient has diabetes.
• Cutaneous signs of diabetes can be valuable to
  physician for diagnosis, management, and
  treatment.

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Necrobiosis Lipoidica Diabeticorum

• Degenerative disease of collagen in the
  dermis and subcutaneous fat with an
  atrophic epidermis.
• Precedes onset of diabetes
  in 15-20 of patients
• Lesions progress to ulcers
  if predisposed to trauma
• Location
• 85 anterior aspect-pretibial region of lower
  extremeties, 15 hands, forearms, face, scalp

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Necrobiosis Lipoidica Diabeticorum

• Initial lesions appear as well
  circumscribed erythematous
  plaques/papules with a
  depressed-waxy center.
• Advanced, typically larger,
• lesions show translucency and
• enlargement of underlying
• blood vessels.

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Necrobiosis Lipoidica Diabeticorum

• Etiology unknown seem to occur and persist
  independent of hyperglycemic control
• Theory one immunologic role-release of cytokines
  from inflammatory cells may lead to destruction
  of the collagen matrix.
• Theory two Microvascular effects of diabetic
  retinopathy and neuropathy lead to a degradation
  of collagen.
• Women gt Men

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Necrobiosis Lipoidica Diabeticorum

• Treatment Lesions can spontaneously resolve,
  however most do not. No standard therapy.
• -used to arrest progression
• Support stockings/rest
• NSAIDs
• Intrelesional, systemic,
• topical corticosteriods
• Aspirin and dipyridamole
• Tumor necrosis factor
• Laser surgery
• Excision/grafting

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Diabetic Dermopathy

• Also known as shin spots, most common cutaneous
  finding in diabetics (approximately 50 of
  diabetics).
• Round to oval atrophic hyperpigmented lesions on
  the pretibial areas of the lower extremities.
  Early lesions usually raised, then flatten.
  Brownish hyperpigmentation due to hemosiderin
  deposits.
• Occur bilateral with asymmetrical distribution.

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Diabetic Dermopathy

• Asymptomatic, resolve spontaneously leaving a
  scar usually following improved blood glucose
  control.
• Usually occurs in older diabetic
  patients who have
  had diabetes
  gt10 years.
• Occurs more frequently in
  diabetic patients
  with
  retinopathy, neuropathy,
  and nephropathy.
• Can be indicator of poor
  control of blood glucose
  levels.

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Diabetic Dermopathy
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Diabetic Bullae

• Blisters occur spontaneously in diabetic
  patients, atraumatic/asymptomatic lesions on feet
  and legs.
• Patients tend to have adequate circulation in the
  affected extremities and peripheral neuropathy.
• Three types of Diabetic Bullae
  
• -Most common Sterile fluid
  containing that heal without
• scarring.
• -Hemorrhagic, heals with
• scarring.
• -Multiple nonscarring on
• sun exposed/tan skin.
  
  

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Diabetic Bullae

• Usually resolve without treatment within 2-5
  weeks.
• Therapy should be aimed at preventing ulceration
  and secondary infection.

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Diabetic Bullae

• When they occur in the feet can resemble friction
  blisters, however usually an absence of trauma.

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Eruptive Xanthomas

• Occur in hyperlipidemic/hyperglycemic states
  uncontrolled diabetic patients.
• Most common in young men with Type 1 diabetes
• Resistance to insulin makes it difficult for the
  body to clear the fat from the blood.

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Eruptive Xanthomas

• Usually asymptomatic firm, waxy, yellow papules
  in the skin.
• Enlargements can have erythematous halo, can
  itch.
• Occurs most often on the back of hands/feet,
  arms/legs, buttocks, face-eyes.

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Eruptive Xanthomas

• Increase risk of developing pancreatitis.
• Eruptions can resolve in a few weeks with
  hyperlipidemic/hyperglycemic control, lipid
  lowering medications.

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Acanthosis Nigricans

• Hyperpigmentation and thickening of epidermis
• Precedes diabetes, considered a marker for the
  disease, most common in overweight diabetic
  patients.
• Usually occurs in skin folds, often described as
  velvety
• Neck, back, axillae, groin region, over joints in
  the hands/feet.

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Acanthosis Nigricans

• Exact mechanism is unknown, thought to be a
  manifestation of insulin resistance, high
  concentrations of insulin may stimulate growth
  factor receptors on keratinocytes promoting
  epidermal cell proliferation.

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Acanthosis Nigricans

• Classification 5-8 types
• Type 1 hereditary-benign
• Type 2 endocrine disorders-diabetes, benign
• Type 3 complication of obesity
• Type 4 drug induced
• Type 5 malignant
• Genetically inherited, hypothyroidism,
  hyperthyroidism, acromegaly, polycystic ovarian
  disease, cushings disease
• Important to rule out underlying endocrine
  disorders and malignancies
• No cure weight loss, exercise, nutrition, creams
  may help

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Kyrles Disease

• Also known as perforating dermatosis.
• Rare condition, except in setting of diabetes
  with chronic renal failure.
• Large papules with central keratin plugs,
  widespread pattern seen in patients undergoing
  dialysis.
• Itching/scratching present

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Kyrles Disease

• Primary location extensor surfaces of the lower
  extremity, but can occur on face and trunk.
• Seen with DM, CHF, hepatic abnormalities-alcoholic
  cirrhosis, renal disease
• Elimination of collagen and elastin throughout
  epidermis.

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Kyrles Disease

• Can be difficult to treat have to manage
  underlying systemic disorder
• Antihistamines, antipruritics, topical
  corticosteriods,
• Retinoic acid, UV light therapy, laser therapy
• Rapid improvement and resolution of lesions is
  seen once underlying disease is treated.

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Conclusion

• Nearly all patients with diabetes eventually
  develop cutaneous manifestations of the disease.
• It is valuable to recognize for diagnosis,
  management, and treatment.
• Leads to prevention of ulcerations, infections,
  amputations.

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References

• 1. Chakrabarty A, Norman R, Phillips T. Cutaneous
  Manifestations of Diabetes. Wounds. 2002. 14(8).
• 2. Huntley A. The Skin and Diabetes Mellitus.
  Dermatology Online Journal. Dec. 1995 1 (2).
• 3. Bhat Y, Gupta V, Kudyar RP. Cutaneous
  Manifestations of Diabetes Mellitus.
  International Journal of Diabetes. 2006. 26 (4)
  152-155.
• 4. Hattem S, Bootsma A. Skin Manifestations of
  Diabetics. Cleveland Clinic Journal of Medicine.
  2008. 75 (11) 772-787.
• 5. Dermnet Skin Disease Image Atlas. Interactive
  Mecical Media. 2009.
• 6. Perez M, Kohn S. Cutaneous Manifestations of
  Diabetes Mellitus. Journal of the American
  Academy of Dermatology. 30 (4) 519-531.
• 7. Eaglstein W, Callen J. Dermatological
  Comorbidities of Diabetes Mellitus and Related
  Issues. Archives of Dermatology. 2009. 145 (4)
  467-469.

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