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Cutaneous Manifestations of Diabetes Mellitus
- 1. AZEEZIA MEDICAL COLLEGE DEPARTMENT OF GENERAL MEDICINE
- 2. CUTANEOUS MANIFESTATIONS OF DIABETES MELLITUS Dr.Jayasoorya P G Junior resident Department of General medicine Azeezia medical college
- 3. Classification Vascular Metabolic Necrobiotic Bullous Infection Neuropathic Treatment related Miscellaneous
- 4. Vascular Diabetic dermopathy Rubeosis facei(diabeticorum) Erysipelas-like erythema Pigmented Purpura Periungulal telangiectasia
- 5. Diabetic Dermopathy Aka Shin spots or pigmented pretibial papules Commonest cutaneous manifestation of Diabetes (70 % of diabetes) M>F (males diabetics over 50 years of age) Multiple shin spots (4 or more) have a high specificity ,indicating microvascular complications Association exist between diabetic dermopathy and other diabetic complications (DR,D neuropathy,D nephropathy)
- 8. Shin spot-morphology Multiple bilateral annular or irregular erythematous papules or plaques that gradually evolve into atrophic hyperpigmented macules This resembles post traumatic hyperpigmentation,but no history of trauma. Common site-shin Other sites-thighs,forearm
- 9. histology Epidermal atrophy,mild dermal inflammation Microangiopathy with PAS-Positive thickening of vessel walls Pigmentation-d/t hemosiderin deposition
- 10. treatment Require no treatment
- 11. Rubeosis facei(diabeticorum) Rosy redness of face.More obvious in light skinned patients Evident in newly diagnosed diabetics Upto 60 % hospitalized patients with diabetes Associated with vascular tone and increased viscosity (functional microangiopathy) Often a sign of poor glycemic control Yellowish discolouration of the skin,more obvious on the palms,soles and face,may occur because of carotenemia,or with normal serum carotene accumulation or because of nonenzymatic collagen glycosylation Better glucose control may improve the appearance
- 13. Erysipelas-like erythema Well demarcated red areas in feet and 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 increase in peripheral microcirculation caused by decreased perfusion Spontaneous resolution over weeks, but may recur
- 15. Pigmented purpura RBC extravasation from superficial plexus Cayenne pepper spots (Red macules)orange tan patches Freequently associated with diabetic dermopathy(50 %) Increased incidence in elderly diabetic with cardiac failure Marker of microvascular disease
- 17. Periungal telangiectasia Seen in upto 49 % of diabetics Megacappillaries 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
- 18. Metabolic Acanthosis nigricans Eruptive Xanthoma Yellow skin and nails Diabetic scleredema
- 19. Acanthosis Nigricans 50 % of cases -> age >40 and 5% cases ->age <20 years Hyperpigmented velvety and on flexural skin Related to insulin binding of insulin like growth factor receptors on keratinocyte and dermal fibroblast Two syndromes where AN is associated with diabetes (Type A syndrome and Type B syndrome)
- 22. Type A syndrome (HAIR-AN syndrome) HA----- Hyperandrogenemia IR------- extreme Insulin resistance AN------ Acanthosis nigricans
- 23. Type B syndrome In middle aged women with autoimmune disease Circulating antibody to the insulin receptors Common place of AN-vulva
- 24. Eruptive xanthoma Occur in less than 0.1% of diabetic patients Crops of small (1-4 mm)yellow papules with erythematous halo May be pruritic and tender Buttock and extensor surface Appear in association with elevated Triglyceride Resolve with treatment of increase glucose and lipid
- 26. Yellow skin and nail Prevalence 40% in Type 2 DM,more common in elderly Most evident in distal end of hallux Cause-hypercarotinaemia,protein glycosylation end product
- 27. Diabetic scleredema Non enzymatic glycosyation of collagen Fingers and dorsum of hands,with limited joint mobility,Huntley papules (8-50 % type 1 diabetics) Chest,neck,shoulders-increase thickness,difficult to tent the skin (common in older type 2 diabetics ),Peau d orange appearance May be subclinical Improve with tight glycaemic control
- 28. Necrobiotic Necrobiosis lipoidica Disseminated granuloma annulare
- 29. Necrobiosis lipoidica 0.3%-0.7 % of diabetics Mean age-34 years F>M,Caucasians,type 1 is more associated In 15% patients precede the development of diabetes by about 2 years
- 30. Well circumscribed papules ->radial expansion ->sharply-demarcated slightly depressed yellow waxy plaques with erythematous raised border - >central atrophy with telangiectasia Sites-pretibial,medial malleolus,15 % cases outside legs,ulcerate in 1/3 patients Persist despite glycemic control Chronic course ,20 % remit spontaneously Rx-intralesional steroids,aspirin,pentoxifylline
- 34. Granuloma Annulare Relationship with DM is controversial Generalized GA associated with DM-mainly in oldage patients Papular morphology and more chronic relapsing course Histology-foci of necrobiosis in the upper and mid-dermis surrounded by palisaded histocytes and abundant dermal mucin Sporadic therapeutic success reported with intralesional /typical/systemic steroids,isotretinoin,chlorambucil,cryotherapy,chloroquine,nicotinamide,da psone and PUVA
- 37. Bullous diabeticorum Type 1>type 2,M>F Sites-mainly feet,occasionally hands Spontaneous,not related to trauma or infection Blisters contain sterile fluid,rest on a non-erythematous base Heal in 2-3 weeks without scarring
- 39. Types Common type-clear sterile blisters on tip of toe/fingers.Heals without scarring.intraepidermal cleavage Haemorrhagic bullae-heal with scarring,Cleavage-DEJ Multiple tender non-scarring blisters in sunexposed areas.IMF (immunoflourescence) and porphyrins negative.cleavage-lamina lucida
- 40. Infection Bacterial infections Fungal infections
- 41. Bacterial infections Staphylococcal-furuncle,carbuncle,ecthyma Strept pyogenes-cellulitis,erysipelas Pseudomonas spp- 1)malignant otitis externa-cellulitis,osteomyelitis,meningitis,cranial nerve palsy.and mortality 50%.treatment-IV Quinolones 2)Toe nail infection 3)Toe web infection
- 42. Other bacterial infections Erythrasma- 1)Chronic,asymptomatic symmetric red scaly macerated plaques in the axillae and groin 2)Corynebacterium minutissimum 3)Rx-topical/systemic erythromycin Non-clostridial gas gangrene 1)Develops in soft tissues near a gangrenous focus 2)E.coli,Klebsiella,Pseudomonas and bacteroids
- 44. Fungal infection Candida-produce oral perliche,vaginal/balanoprosthitis,intertrigenous skin in toe web,paronychia,nail infection Dermatophytosis-incidence not increase in diabetes,commonly caused by Trychophyton rubrum,T mentagrophytes,Epidermophyton floccosum
- 45. Rhinocerebral mucormycosis Associated with ketosis Black crust/pus in turbinate,nasal septum,plate and orbit Cerebral involvement may occur Treatment-debridment + IV amphotericin +treat ketosis High mortality
- 47. Neuropathic Anhidrosis/hyperhidrosis Neuropathic ulcers-circular,punched out ulcer in the middle of a callosity over metatarsal heads
- 49. Treatment related Insulin reactions OHA related
- 50. OHA related Sulphonyl urea (chlorpropamide or tolbutamide –usually on first two months of treatment )-maculopapular eruptions.these may clear on continuation of therapy Lichenoid reactions,urticarial,erythema multiforme or erythema nodosum may also occur 10%-30% of those on chlorpropamide –disulfiram like reaction occur after alcohol consumption (marked flushing,headache,tachycardia,dyspnea,lasting for about an hour )
- 51. Insulin reactions Allergic reaction-insulin itself or by preservatives (parabens),addictives (zinc),pork or beef protiens or impurities Erythematous,urticated nodules appear at the site of injection,immediately or upto four hours of administration Adjunct to manage allergic reaction-addition of dexamethasone to insulin injection and desensitization of insulin Lipodystrophy can occur(it can occur as lipoatrophy or lipohypertrophy or both).this will reduce the insulin absorbtion.treat by rotation of insulin site.
- 52. Lipoatrophy Circumscribed cutanious depressions at insulin injection sites and occasionally at distant sites,appearing 6-24 months after starting treatment Cause-mechanical trauma of injection,cryotrauma from refrigerated insulin,contamination with alcohol used for cleansing,lipolytic component in preparation or local inflammation with lysosomal enzyme release. Repeated use of same injection site increase the risk of lipoatrophy Measures-injecting insulin at edge of atrophic area,coadministration of dexamethasone with insulin,switching over to insulin pump
- 54. Lipohypertrophy Soft dermal nodules resembling lipomas At site of injection –d/t lipogenic action of insulin Most common cutaneous manifestation of insulin therapy Other complications of insulin therapy-keloid,purpura,hyperkeratotic papules,hyperpigmentation
- 56. Miscellaneous Acquired perforating dermatoses Vitiligo Lichen planus Pruritis
- 57. Acquired perforating dermatosis Umbilicated hyperpigmented papules with a central keratotic plug Common site-extensor surface of extremities Major symptom-pruritis Strong association with chronic renal failure (ESRD) Histology-transepidermal elimination of degenerative elastic /collagen fibres Treatment-topical tretinoin,phototherapy
- 59. vitiligo Localized/generalized 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 steroids,phototherapy
- 60. Lichen planus Polyerythematous flat lesions Sites-wrist,dorsal part of feet,lower leg Oral/genital lesions-white lacy pattern DD-lichenoid drug reactions Treatment-topical steroids
- 61. Thank you