Skin changes are common in patients with diabetes and can be the first sign of the disease or develop at any time. The most common manifestations are cutaneous infections, xerosis, and inflammatory skin diseases. Skin changes are classified as related to insulin resistance, infections, vascular changes, and conditions associated specifically with type 1 or type 2 diabetes. Infections like candidiasis and bacterial infections are more common in poorly controlled diabetes. Vascular changes include diabetic dermopathy, rubeosis faciei, and periungual telangectasias. Treatment-related changes can occur from insulin, oral medications, and secondary to other diabetes complications. Managing underlying conditions and blood glucose is key to treating many diabetes-related skin

1. Dermatological
Changes In
Diabetes
Dr. Wafa Alsofiani

2. Introduction
– Skin disorders will be present in 79.2% of people with diabetes
– The most common skin manifestations were cutaneous infections (47.5%),
xerosis (26.4%), and inflammatory skin diseases (20.7%)
– Cutaneous disease can appear as the first sign of diabetes or may develop at
any time in the course of the disease.

3. Classifications
– Related to insulin resistance
– Acanthosis Nigricans
– Acrochordrons (skin tags)
– Acne, Hirsutism, Androgenic alopecia
– Infections Associated With Diabetes
– Vascular
– Diabetic Dermopathy
– Rubeosis Facei
– Periungual Telangectasias
– Calciphylaxis
– Diabetic foot ulcers
– Conditions Associated With Type 1 Diabetes
– Vitiligo
– Other Diabetes-Related Conditions
– Necrobiosis Lipoidica
– Granuloma Annulare
– Bullosis Diabeticorum
– Scleredema Diabeticorum
– Xerosis
– Psoriasis
– Lichen Planus
– Acquired Perforating Dermatosis (Kyrle’s
disease)
– Onychodystrophy
– Treatment-related skin changes
– Secondary diabetes related skin changes

4. Skin changes related to
insulin resistance

5. Acanthosis Nigricans
– Characterized by darkening (hyperpigmentation)
and thickening (hyperkeratosis) of the skin,
occurring mainly in the folds of the skin in the
armpit (axilla), groin and back of the neck.
– Causes:
– Benign, Hereditary, Obesity, insulin resistance,
acromegaly, Cushing syndrome, Drug-induced
(Nicotinic acid, Corticosteroid), Malignancy
– Treatment:
– correct the underlying disease process.
– topical retinoids, dermabrasion and laser therapy.

6. Acrochordrons (skin tags)
– Asymptomatic, soft pedunculated
flesh colored papule in the axillae,
neck, eyelids, and in the
inframammary region.
– Causes: Obesity, T2D, acromegaly
– Treatment: cosmotic: (Excision,
Electrodessication and
cryotherapy)

7. Infections Associated
With Diabetes

8. – poor glycemic control can increase the risk of infection by causing abnormal
microcirculation, decreased phagocytosis, impaired leukocyte adherence and
delayed chemotaxis
– Cutaneous infections associated with diabetes.
– Yeast infections (candidiasis)
– Bacterial infection (boils and sepsis)
– Erythrasma
– Malignant otitis externa
– Necrotizing fasciitis

9. Yeast infections (candidiasis)
– Infection with Candida albicans may be a presenting feature of diabetes or
manifest as a complication of poorly controlled diabetes.
– erythematous papules with satellite pustules can affect the flexural areas in the
body ,the vulva and penis, and also the nail margins, causing Paronychia
– Oral candidiasis occurs more commonly in patients with diabetes who smoke or
wear dentures
– Treatment:
– Minimize moistureing at infection site
– antifungal drugs
– Inappropriate treatment with steroids or antibiotics can worsen Candida infection at any site.

11. Bacterial Infections
• Staphylococcal : furuncle, carbuncle
Streptococcus pyogenes : erysipelas, cellulitis

12. Management
Localised staphylococcal infections
• wound care (including incision and drainage)
• antiseptics as local application and cleanser.
• The routine use of topical antibiotics is undesirable because of increasing prevalence of MRSA
Streptococcal infections
• Mild cases may received oral antibiotics as outpatient
• More severe cases require intravenous antibiotics
• Immobilize and elevate the affected limb
• Incision and drainage of abscesses may be required
• May be complicated by thrombophlebitis, deep venous thrombosis, septicaemia, shock and endocarditis.
Consider anticoagulants.

13. Erythrasma
– caused by Corynebacterium minutissimum , is rare
– occurs with increased frequency in obese patients with diabetes.
– It presents as a red shiny or scaly patch in the intertriginous areas and with ultraviolet
light exhibits a characteristic coral – red fluorescence.
– Topical or systemic erythromycin is curative.

14. Malignant otitis externa
– Severe ( “ malignant ” ) otitis externa is an
uncommon but potentially lethal infection
caused by invasive Pseudomonas spp.
– The condition occurs in elderly patients with
diabetes and manifests as purulent discharge
with severe pain in the external ear.
– It progresses from cellulitis to osteomyelitis,
meningitis and cerebritis with a high mortality

15. Necrotizing fasciitis
– lethal skin and soft tissue infection that is more common in
those with diabetes
– Cause: Streptococcus pyogenes , anaerobic streptococci,
Bacteroides and Staphylococcus aureus
– Rapid progression ensues, with extensive tissue destruction
and severe systemic toxicity, leading to death
– should be considered in patients with diabetes and cellulitis
who have associated systemic features
– This potentially fatal infection should be treated with urgent
surgical debridement of necrotic tissue and intravenous
antibiotics, after obtaining blood and tissue culture.
– The mortality remains high (about 25%) in spite of optimal
treatment.

16. Vascular changes related
to Diabetes mellitus

17. Diabetic Dermopathy
– Occur in up to 30% of patients with diabetes.
– light brown or reddish, oval or round, slightly
indented scaly patches most often appearing on
the shins.
– Diabetic dermopathy lesions or shin spots are
harmless. They usually do not require any
treatment and tend to go away after a few
years, particularly following improved blood
glucose control.

18. Rubeosis Facei
– Facial erythema can occur in people with
diabetes
– The changes occur as a result of altered vascular
tone or diabetic microangiopathy.
– It appears more obvious in fair – skinned
individuals
– difficult to distinguish from normal facial
redness in the general population
– Hypertension is common in these patients and
may exacerbate the capillary damage.

19. Periungual Telangectasias
– Even though connective tissue diseases
can exhibit periungual tengiectases, the
lesions are morphologically different.
– In patients with diabetes, isolated
homognous engorgement of venular
limbs is seen; whereas mega - capillaries
or irregularly enlarged loops are observed
in those with connective tissue disease
(like RA and dermatomyositis)

20. Calciphylaxis
– a small - vessel vasculopathy occurring in patients
with renal failure and sometimes in those with
diabetes. It is characterized by mural calcification,
intimal proliferation, fibrosis and thrombosis
– Dx: biopsy, Bone scintigraphy using technetium Tc
99m
– The prognosis in those with calciphylaxis is poor
because of impaired wound healing and infection
leading to sepsis.
– Aggressive analgesic treatment may be required for
ischemic pain, along with optimal blood glucose
control and weight reduction

21. Diabetic
foot
ulcer

22. Conditions Associated
With Type 1 Diabetes

23. Vitiligo
– Autoimmune condition seen more commonly in patients with T1DM, but can also occur
in T2DM. Polyglandular autoimmune syndrome type 2 is characterized by adrenal failure,
autoimmune thyroid disease and T1DM, and can be associated with vitiligo
– Can cause significant emotional distress.
– Treatment is unsatisfactory but topical steroids and calcineurin inhibitors such as
tacrolimus ointment can be used.

24. Other Diabetes-Related
Conditions

25. Necrobiosis lipoidica diabeticorum
– Usually develops in young adult or early middle life, but has
occasionally been reported in childhood . Women are three
times more commonly affected than men.
– no proven association with glycemic control, but patients with
diabetes and NLD do appear to have a higher incidence of
chronic diabetic complications such as retinopathy, neuropathy
and microalbuminurea . This suggests that microangiopathy may
have an etiologic role.
– Tx: No treatment for NLD has proved effective
– For early NLD lesions corticosteroids either applied topically
(perhaps under occlusion) or by intralesional injection may be
benefi ial
– Avoid smoking and trauma

26. Granuloma Annulare
– Cause: may be a delayed hypersensitivity reaction
pattern to numerous triggers. included many
skin infections and infestations, and types of
skin trauma.
– Associations reported with systemic conditions
including autoimmune thyroiditis, diabetes
mellitus, hyperlipidaemia, and rarely
with lymphoma, HIV infection and solid tumours.
– Tx: a lot of modalities like topical , intralesional and
systemic steroid, calcineurin inhibitor , cryotherapy,
lasar ablation, antibiotics, PUVA, TNFa inhibetor

27. Bullosis Diabeticorum
– relatively rare
– Affect men more than are women, common in older
patients and those with peripheral neuropathy
– present as tense blisters, from a few millimeters up
to several centimeters in size, on a non -
inflammatory base,
– The feet and lower legs are the most common sites
– In most cases, diabetic bullae heal spontaneously
without treatment. Patients should make sure the
blister remains unbroken to avoid secondary
infection.

28. Diabetic thick skin/ Scleredema
Diabeticorum
Fibro-mucinous connective-tissue disease. Cutaneous
marker for other microvascular complications.
Diabetic hand syndrome
– early changes include thickening of the skin over the
dorsum of the hands and digits, progresses to cause a
fixed flexion deformity of the fingers and Dupuytren
Contracture, may cause carpal tunnel syndrome

29. Diabetic thick skin/ Scleredema
Diabeticorum
Scleredema of diabetes
– This is marked dermal thickening, commonly involving the
posterior aspect of the neck and upper parts of the back,
The skin can have a peau d’orange aspect.
– Men and obese patients with long-lasting type 2 diabetes
are at higher risk.
– Other causes: rheumatoid arthritis, hyperparathyroidism,
Sjogren’s syndrome, and seldom in IgG paraproteinemia or
malignancy.
– does not improve with glycemic control
– Treatment: UVA , oral corticosteroids, cyclosporine, and
cyclophosphamide, In severe cases radiotherapy

30. Treatment-related
skin changes

31. Insulin reactions
– Lipoatrophy
loss of subcutaneous fat , Circumscribed depressed areas of skin
Pathogenesis: secondary to an immunologic reaction. Other theories include mechanical
trauma
– Lipohypertrophy
subcutaneous thickening at sites of repeated injections
Pathogenesis: lipogenic action of insulin. Insulin absorption may be delayed at such sites,
potentially resulting in disruption of glycemic control
resolves spontaneously by changing the site of insulin injections

32. Insulin reactions
– Insulin allergy
The use of recombinant human and analog insulin has decreased the incidence of insulin allergy
Allergic reactions to insulin can be classified as immediate - local, general, delayed or Biphasic
– Other cutaneous complications of insulin
infection with abscess formation. Keloids, hyperkeratotic papules, purpura and localized
pigmentation can also occur.
Patients using insulin pumps for subcutaneous insulin delivery can experience local infections at
the site of needle insertion, contact allergy to the associated tape and tubing material and, rarely,
subcutaneous nodules.
Retention of fluid .

33. Oral Antidiabetic
medications skin changes
– Metformin:
– Can cause cutaneous side effects ranging from psoriasiform drug eruptions
and leukocytoclastic vasculitis to phototoxic reactions and erythema
multiforme.
– Thiazolidinediones:
– can cause lower limb edema.
– Alpha glucosidase inhibitors:
– can cause acute generalized exanthematous pustulosis and erythema
multiforme.

34. Oral Antidiabetic
medications skin changes
– Sulfonylurea:
– Has the most skin-related side effects
– Maculopapular eruptions are the most common.
– Other cutaneous side effects include erythema, urticaria, erythema multiforme,
exfoliative dermatitis, erythema nodosum, pemphigus vulgaris, psoriasiform, and
lichenoid drug eruptions.
– Second-generation sulfonylureas present with less cutaneous side effects.
– Meglitinides
– rarely cause cutaneous reactions like pruritus, rash, urticaria, or generalized
reactions such as anaphylaxis shock.

35. Oral Antidiabetic
medications skin changes
– DPP4-I
– Can cause dose-dependent necrotic skin lesions in monkeys.
– Increased rates of angioedema are noted only if they are used together with ACE inhibitors.
– Case reports show severe skin reactions such as bullous pemphigoid, Stevens-Johnson
syndrome, and toxic epidermal necrosis.
– GLP-1 Injection:
– Can cause local granulomatous reactions (e.g. eosinophilic sclerosing lipogranulomas).
– SGLT-2 I:
– Hypersensitivity reaction(angioedema)
– Risk of amputation due to diabetic foot ulcers, neuropathy, PVD
– Genital Mycotic infection
– Perineal necrotizing fasciitis (Fournier gangrene)

36. Secondary diabetes related skin
changes
– Hyperlipidemia
– Eruptive xanthoma
– Cushing syndrome
– Skin atrophy
– Striae
– Hirsutism
– Polycystic ovarian disease
– Acanthosis nigricans
– Hirsutism
– Partial and total lipodystrophy
– Absence of subcutaneous fat
– Acromegaly
– Thickened skin
– Skin tags
– Increased sweating
– Hemochromatosis
– Bronzed ” pigmentation
– Cutaneous signs of liver disease
– Glucagonoma syndrome
– Necrolytic migratory erythema

37. Necrolytic migratory erythema
– may affect any site but it most often affects
the genital and anal region, the buttocks,
groin and lower legs. The rash fluctuates in
severity. Initially there is a ring-shaped red
area that blisters, erodes and crusts over. It
can be quite itchy and painful.
– Tx: usually clears up once the glucagonoma
tumour has been surgically removed.
– somatostatin, a medication that inhibits
glucagon, may be helpful.
– Zinc supplements can result in complete
resolution of the rash in some patients.

38. Referances:
– Rodriguez-Saldana J. The Diabetes Textbook; 2019.
– Holt R. Textbook of diabetes. Chichester, West Sussex: Wiley-Blackwell;
2010.
– https://dermnetnz.org/