This document summarizes various cutaneous manifestations that can occur in patients with diabetes mellitus. It classifies them into vascular, metabolic, necrobiotic, bullous, infection, neuropathic, treatment related and miscellaneous categories. Some of the most common manifestations discussed include diabetic dermopathy, acanthosis nigricans, necrobiosis lipoidica, bullous diabeticorum, bacterial and fungal infections, lipodystrophy and various cutaneous complications related to diabetes treatment. Evaluation and management of these cutaneous signs are important for diabetes care and control.
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)
6.
7.
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
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
12.
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
14.
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
16.
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
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)
20.
21.
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
25.
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
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
31.
32.
33.
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
38.
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
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
43.
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
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
53.
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
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
58.
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