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Introduction
It is a well known fact that skin infection are more commonly associated with Diabetes Mellitus. Several other cutaneous disorder cleaily occurs commonly in diabetes Mellitus, but it is often difficult to define the exact nature of their association with the disease. Dermatological complications due to treatment of Diabetes Mellitus are also seen some times.
Classification of Cutaneous manifestation in Diabetes Mellitus:
I) Cutaneous markers of Diabetes Mellitus or skin condition associated with Diabetes
Mellitus:
(a) Diabetic dermopathy (Skin spots)
(b) Necrobiosis lipoidica diabeticorum.
(c) Garnnuloma Annulare.
(d) Acanthosis Nigricans.
(e) Diabetic Bullae
(f ) Diabetic thick skin.
(g) Generalised Pruritis.
(h) Ruheosis
(i ) Vitiligo.
(j ) Perforating disorders.
(k) Scleredema diabeticorum
(II) Complication due to Diabetes Mellitus.
(1) Infections:
(a) Candidiasis.
(b) Dermatophytosis.
(c) Phycomycosis.
(d) Malignant otitis externa.
(2) Neuropathic & Ischemic skin changes:
(a) Disordered sweating (with autonomic neuropathy)
(b) Neuropathic ulcers.
(c) Changes due to peripheral vascular disease.
(III) Metabolic Disease associated with Diabetes Mellitus:
(a) Porphyria Cutanea Tarda.
(b) Xanthomatosis
(c) Yellow skin
(d) Haemochromatosis
(e) Lip ody strop athy
(f ) Glucagonoma Syndrome. (IV) Complication of diabetic Treatment:
(1) Oral Hypoglycemic Agents.
(a) Hypersensitivity reaction.
(b) Alcohol induced flushing with chlorporpamide.
(2) Insulin induced disorders:
(a) Insulin allergy. (i) Local (ii) Systemic
(b) Insulin lipodystrophy.
(c) Insulin induced Lipohypertrophy.
Diabetic Dermopathy (Pigmented Pretibial Patches)
Initially these lesions are painless, flat topped, dull red papules which slowly evolve to atrophic hyperpigmented irregular patches of 5 to 12 mm. in diameter. Lesions are bilateral most commonly located on anterior skins but other side like forearms, anterior thighs and feet may also be involved.
It may also occur in 20% of euglycemic patients with various endocrine diseases. Men are more often affected, dermopathy occurs in about 60% of male diabetic patient and 29% of female with diabetes who are older than 50 years.2 Some reports suggest that this is the most common cutaneous finding in Diabetes Mellitus.3
Necrobiosis lipoidica diabeticorum (NLD)
This rare condition first described in 1929 by Oppenheim, has prevalence of 3 per thousand diabetic patients. Females are more commonly affected with female ratio is 3:1, with an average age of onset is 30 yr. in diabetic patients.
Typical lesion of NLD occurs on the pretibial skin as non-scaling plaques with atrophic yellow center, surface telangiectasia and a violaceous or erythematous border.4 Lesions vary in size from small papule to large irregular plaques of several cm. in diameter. Ulceration may occur in 35% of patients. Sites other than pretibial are affected in 15% of patients, other locations include hand, fingers, forearm, face and scalp.
Granuloma annulare (GA)
Grannuloma Annulare may occur in a localised or in generalised pattern. In localised form one or more annular or arciform lesion with a raised flesh coloured popular border and flat often hyperpigmented center. Localised GA characteristically located on dorsum of hands and feet. Generalised GA is characterised by symmetrical eruption of tiny papules, often on sun exposed areas.
Aii increased association of Generalised GA with Diabetes has been demonstrated repeatedly, but most studies show no relationship between Diabetes Mellitus and localised GA,5,6.
Acanthosis nigricans (AN)
A,N. characterised by brown, velvety, hyperkerototic plaques which most often affects the axilla, neck, groin and intertriginous
areas.
There is a frequent association of A.N. with a large heterogenous
group of disorders with the common features of insulin resistance. Acanthosis Nigricans is classified by FLIER into 2 types. Type A and B. In type A, there is genetic defects in insulin receptor and post receptor mechanisms while in type B there is acquired insulin resistance due to autoantibodies directed against the insulin receptor. Endocrine disorders associated Acanthosis Nigricans appears to be a true cutaneous marker of abnormal carbohydrate metabolism if not of overt diabetes.
Diabetic bullae (Bullosis diabeticorum)
Bullosis diabeticorum affects men more often than women, usually occurs in long standing diabetes complicated by neuropathy. Diabetic Bullae appears suddenly on hand, feet and distal extremities without preceding trauma and heal without scarring, notably there is no surrounding erythema.
Recent Electron microscopic studies have revealed subepithelial blister with split occurring at the level of lamina lucida.
Diabetic thick skin (Waxy Skin)
This condition more commonly associated with juvenile onset IDDM which causes waxy, tight skin with limited joint mobility. It occurs in 22 to 40% of adult patients. 51% of children with IDDM.
Generalised pruritis
Although previous studies showed increased frequency of pruritis in diabetic patients, recent study fails to show any significant
correlation.
Rubeosis
Rosy facial colouration found in many light skinned persons, mainly in sun exposed area.
Vitiligo
Increased frequency of vitiligo is associated with both IDDM and NIDDM; 3.1% of IDDM patients and 4.8% of NIDDM patients have vitiligo. Lesion typically occurs around mouth, nostrils, genitals and extensor surface of hands. A common autoimmune aetiology is proposed for IDDM & Vitiligo.
Perforating disorder
The perforating disorders are a group of disease in which dermal material perforates through the epidermis out to the surface of die skin. The four classic members of this group are reactive perforating collagenosis, Kyiie's disease, perforating follkulitis, and elastosis perforans serpigninosa. All but the last appear to be associated with diabetes, occuring most commonly in patients with coexisting nephropathy. These diseases are occasionally seen in patients with renal disease without diabetes and rarely noted in healthy individuals.
Scleredema diabeticorum
.It is diffused non pitting induration and thickening of skin. Two types have been described. Scleredema of bushke not significantly associate with diabetes. Second type Scleredema diabeticorum which is associated with long standing IDDM and NIDDM both. Male to female ratio is 4:1.
Infection: Skin infection is more prevalent in poorly controlled diabetes than in non diabetic population. Infection may be caused by bacteria, yeast or fungi.
Disordered sweating
Diabetic neuropathy is usually bilateral and more severe in lower extermities. As the autoiiomic neuropathy progresses the sweat glands become inactivated. Patient may exhibit compensatory hyperhydrosis of upper limb and trunk in response to anhydrosis of lower extermities.
Neuropathic ulcers
Most frequently occurs in areas of high pressure where repeated trauma occurs such as
heel, toes, metatarsal head,usually painless presentation.
Peripheral vascular disorder (PVD)
The skin changes of PVD (which is more prevalent in diabetics) in lower extermities include thin, smooth, cold skin and often mottled in dependent position. Hair either sparse or absent.
Porphyria cutanea tarda (PCT)
Disorder of haern synthesis caused by deficiency of uroporphyrinogen decai'boxy.lase enzyme. It is estimated that 25% of men between 45-75 yr. who have PCT also have diabetes.12
Clinical picture includes vesicles, bulla and erosion on dorsurn of hand and arms and other sun exposed areas. Primary lesion heal slowly with scarring.
Xanthomatosis
Eruptive Xanthoma are a rare feature of uncontrolled diabetes mellitus when serum triglyceride level rises about 1000mg/dl.l3 Typical lesion ate small, firm nontender, pinkish, yellow papules with erythematosis areola. Commonly occurring in crops in knees, elbow, back and trunk.
Xanthelesma are flat, lipid deposits due to hypercholestrolemia, occurs around eyes as a rare skin manifestation of uncontrolled diabetes. It may be a normal feature in those over 60 yr.
Yellow skin
As many as 10% of patients with diabetes mellitus may have yellow skin. Previously yellow skin was correlated to hypercarotenemia with diabetes, but recent studies show normal carotene level in diabetic patients. The explanation for yellow skin in diabetes is still unclear.
Haemochromatosis
It is an iron storage disorder in which 65% patients have diabetes. In 90% patients there is hyperpigmentation of skin due to cutaneous deposition of melanin and haemosiderin.
Lipodystrophy
An autosomal recessive disorder characterised by complete absence of subcutaneous fat and associated diabetes in 20% of patients. 14
Glucognoma Syndrome (migratory necrolytic erythema)
This condition occurs due to glucagon secreting islet cell carcinoma. Characteristic skin lesion is vesicular eruption with exfoliation and superficial necrosis. Other cutaneous finding are conjunctivitis, periorbital crusting and paronychia.
Cutaneous complications of diabetic treatment
Insulin allergy complication
Insulin allergy may be local or systemic, local manifestation includes localised pruritis, erythema, induration or urticaria at injection site. Systemic manifestation includes generalised urticaria and very rarely anaphylaxis.
Lipoatrophy more commonly occurs in women may appear as a circumscribed depressed area of skin at injection site. This condition respond to injection of purified insulin into atrophic area.
Insulin lipohypertrophy is more common in male patient, as soft dermal nodule at injection site. Condition responds to change in insulin site.15.
Hypoglycemic agents
Cutaneous hypersensitivity reaction may vary from mild reaction like maculopapular eruption, purpura, to serious cutaneous reaction like diffuse exfoliative dermatitis, S-J Syndrome and toxic epidermal necrolysis.16. Alcohol ingestion causes disulfiram reaction, in 10 to 30% of patients taking sulphonyleureas.
Conclusion
Skin manifestation of Diabetes Mellitus are described. Some of them are clear cut markers of diabetes while some are due to diabetic complication, and lastly drug therapy, insulin and oral hypoglycemic agents can occasionally cause cutaneous manifestations.
REFERENCES
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(13) Huntley AC. Diabetes mellitus and miscellaneous metabolic conditions affecting the
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(14) Murray t. Lipodystrophy. BMJ 1952; 2: 1236-9.
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