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Dermatological Manifestations of Diabetes Mellitus

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Dermatological Manifestations of Diabetes Mellitus

  1. 1. Dermatologic manifestations of diabetes mellitus Rohan Gunathilake MD John Hunter Hospital, Newcastle, Australia
  2. 2. 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
  3. 3. Classification • Vascular • Metabolic • Necrobiotic • Bullous • Infections • Neuropathic • Treatment-related • Miscellaneous
  4. 4. Dermatologic manifestations of diabetes • Vascular • Metabolic • Necrobiotic • Bullous • Infections • Neuropathic • Treatment-related • Miscellaneous
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. Erysipelas-like erythema
  10. 10. 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
  11. 11. 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
  12. 12. Dermatologic manifestations of diabetes • Vascular • Diabetic dermopathy • Rubeosis facei • Erysipelas like erythema • Pigmented purpura • Periungual telangiectasia • Metabolic • Necrobiotic • Bullous • Infections • Neuropathic • Treatment-related • Miscellaneous
  13. 13. 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
  14. 14. Acanthosis nigricans Hyperkeratosis Papillomatosis Acanthosis ↑melanin in basal layer
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. Nerobiosis lipoidica • Well-circumscribed papules radial expansion sharply-demarcated slightly depressed yellow waxy plaques with erythematous raised border  central atrophy with telangiectasia
  21. 21. 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
  22. 22. 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
  23. 23. Disseminated granuloma annulare • Sporadic therapeutic success reported with intralesional/ topical/ systemic steroids, isotretinoin, chlorambucil, cryotherapy, chloroquine, nicotinamide, dapsone, and PUVA
  24. 24. 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
  25. 25. 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
  26. 26. 3 types 1. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. Neuropathic • Anhidrosis • Hyperhidrosis • Neuropathic ulcers : circular, punched out ulcer in the middle of a callosity over metatarsal heads
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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◦
  41. 41. 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.
  42. 42. 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

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