DERMATOLOGIC LESIONS IN DIABETES MELLITUS …

1 EPIDEMIOLOGY OF SKIN LESIONS INDIABETES MELLITUSN umerous skin LESIONS are associated with either type1 or type 2 DIABETES MELLITUS , specific chroniccomplications of the disease, use of antidiabetic drugs,and certain endocrine and metabolic disorders thatcause secondary DIABETES OF DERMATOLOGICLESIONS IN DIABETES MELLITUST here is considerable uncertainty about thepathogenesis of the many cutaneous conditionsaffecting diabetic patients in no small part because ofour inadequate understanding of the metabolic basis ofdiabetes MELLITUS is no strict classification of skin LESIONS relatedto DIABETES MELLITUS , therefore grouping them underthe following headings will give us an idea aboutvarious types of skin LESIONS occurring in DIABETES . So,one would know what are the DERMATOLOGIC conditionsoccurring in a diabetic (1). DERMATOLOGIC LESIONS associated with but notspecific for DIABETES MELLITUS (disease markers)

2 Pruritus Necrobiosis lipoidica diabeticorum Granuloma annulare Diabetic dermopathy Scleroderma-like syndrome Acanthosis nigricans Diabetic bullaeSkin alterations due to diabetic complications Diabetic foot Cutaneous infections associated with DIABETES - furunculosis- carbuncle- pyodermas- candidiasis- dermatophytosis Erythrasma Xanthomatosis Xanthelasma Pycomycetes Malignant otitis mediaDermatologic changes associated withneurovascular complications Macroangiopathy147 Diabetologia Croatica 31-3, 20021 Pathuri Skin Hospital,Near Gokawaram Bus StandRajahmundryAndhra Pradesh, India2 Vuk Vrhovac Institute, University Clinic for DIABETES ,Endocrinology and Metabolic Diseases,Dugi dol 4a, HR-10000 Zagreb, CroatiaReviewDERMATOLOGIC LESIONS IN DIABETES MELLITUSC hilukuri Sreedevi1, Nikica Car2, Ivana Pavli -Renar2 Microangiopathy Diabetic neuropathyDermatologic complications of diabetestreatment with oral hypoglycemic drugs with insulinEndocrine syndromes with skin alterations anddiabetes MELLITUS Migratory necrolytic erythema in glucagonomaDermatoses that are more common in diabetesmellitus Perforating dermatosis Vitiligo Lichen planus Eruptive xanthomas Kaposi s sarcoma Bullous pemphigoid Dermatitis herpetiformis PsoriasisVARIOUS TYPES OF DERMATOLOGICLESIONS IN DETAILD ermatologic LESIONS associated with but notspecific to DIABETES MELLITUS (disease markers)PruritusGeneralized pruritus was once considered a typicalsymptom of DIABETES but its frequency is have failed to provide a statistical basis for thisbelief (2,3).

3 A higher rate of pruritus is found in liverdiseases, uremia, parasitic infestation, endocrinedisorders (thyroid), malignant diseases, hemotologicand metabolic diseases, and as a side effect of somedrugs. Generalized pruritus is associated with diabetescomplications of chronic renal insufficiency,occasionally neuropathy (irritation of nerve endings canbe the cause). High levels of urea in the blood causethe skin to itch. Candidiasis or dermatophytosis mayunderlie pruritus in diabetic patients. Anogenitalpruritus is often caused by candidiasis in diabeticpatients (4). Some fungal infections most commonly occurring indiabetics are jock itch, athlete s foot and itch appears as a red, itchy area that will spreadfrom genitals outward over the inside of the itch is more common in men than in athlete s foot occurs the skin between the toeswill become itchy and sore.

4 It may also crack, peel orblister. Ringworm is identified by ring-shaped, red scalypatches that can itch or blister. Ringworm can appearon the feet, groin, trunk, scalp or nails. Itching in thelegs in elderly diabetics is not a feature ofhyperglycemia but rather a manifestation of lubricants and low potency corticosteroidapplication should prove helpful. Necrobiosis lipoidica diabeticorumThe disease is very rare, occurring in 7% of diabeticpatients (5). These relatively asymptomatic lesionsare three times more common in women than in is one of the cutaneous markers of DIABETES . At thetime of diagnosis 10% of the people will developdiabetes within 5 years or have abnormal glucosetolerance or history of the disease in at least one parent(6). The condition occurs at any age but it generallyfavors young adults at a mean age of 34 years.

5 In insulinusers, the onset is considered to occur much earlierthan in type 2 diabetics or nondiabetics (7). Thelesions are characteristically found on the anterior andlateral surfaces of lower legs, in the pretibial andmedial malleolar region. They may also be present onthe face, arms and trunk. There may be one or severallesions, either unilateral or bilateral. The lesion beginsas a small, dusky-red elevated nodule with a sharplycircumscribed border. It slowly enlarges to turn into aplaque of irregular outline, flattened, and eventuallydepressed as the dermis becomes more atrophic. The color turns more brownish-yellow except for theborder, which may remain red. Coalescing or enlarginglesions may in time encompass the entire anteriortibial area. The epidermis is smooth or slightly scalyand atrophic. Delicate vessels can be seen through thesurface.

6 The LESIONS may be anesthetic or havereduced sensation to pin prick and to fine touch due todestruction of cutaneous nerves (8).148C. Sreedevi, N. Car, I. Pavli -Renar / DERMATOLOGIC LESIONS IN DIABETES MELLITUSThe chronic LESIONS of necrobiosis lipoidicadiabeticorum (NLD)are indolent; shallow, oftenpainful ulcers frequently appear in long-standinglesions. In the early stages, NLD may resemblegranuloma annulare or sarcoid, but a well-developedplaque is characteristic and easily recognized. Theprimary pathologic changes are in the lower dermis,where collagen is markedly altered with focal areas ofloss of normal structure, swelling, basophilia, anddistortion of the bundles (necrobiosis). Cross-striationsand diameters of collagen fibers are irregular. Althoughthe amount of collagen is actually decreased, therelative proportions of types I and III are cultured from skin LESIONS have beenreported to produce less collagen.

7 There is also theloss and fragmentation of elastic fibers. There isincreased collagenase in the lesional skin. In theseareas, there are aggregations of inflammatory cells. Thelate appearance of foam cells accounts for thedesignation lipoidica .The vasculature is always involved, with endothelialproliferation and occlusion of the lumina of arteriolesand venules (9,10). Capillary walls are thickened withfocal deposits of PAS-positive material that may alsobe present in the lumen. The nature of the associationwith DIABETES and its pathogenesis remains NLD occurs in both IDDM and NIDDM, itspathogenesis cannot be related to genetic factors,underlying autoimmune disease, or other causes ofdiabetes. It can be reasonably assumed that thegranulomatous response is secondary to alterations indermal collagen. It is not clear whether this issecondary to an underlying vascular disease ordevelops independently.

8 The latter would ascribe thechanges in dermal collagen and vasculature to someprimary disorder of connective tissue (as yetunknown). However, the invariable presence ofarteriolar changes deep into and within the areas ofcollagen degeneration suggests an interrelationbetween the two components of NLD (11). It has beenhypothesized that increased platelet aggregation maybe a trigger factor in vascular changes (12).Immunoglobulins, complement (C3 and C4) (13), andfibrinogen are present in blood vessels in lesional and,in some cases, nonlesional skin (14). These findingsare in concordance with the presence of inflammatorychanges in adjacent clinically normal skin. Thetreatment of NLD is not very satisfactory. Progressionof LESIONS does not correlate with normalization ofhyperglycemia. Local therapy with topical applicationof glucocorticoids under occlusion or by intralesionalinjection may afford some improvement of activelesions.

9 There have been some enthusiastic reports onthe use of aspirin and dipyridamole, but these werenot confirmed in a rigorous double-blind trial (15).Favorable effects were obtained with very small dosesof aspirin: mg/kg every 48 to 72 h (16). Otherhelpful agents are clofazimine, nicotinamide, andpentoxifylline. Ultraviolet light treatment has beenfound to control this condition when it is annulareIt is a benign necrobiotic condition associated withlesions similar to NLD, the only difference being theabsence of epidermal atrophy. This is a skin diseaseusually seen in children and young adults. It isoccasionally associated with DIABETES . Skin signs arecharacterized by red spots in the initial stages thatexpand outwards in a ring-like fashion. The hands,especially the fingers, on dorsal or lateral aspect of thehands and elbows (forearms), are commonly granuloma annulare is widespread it may beassociated with underlying DIABETES MELLITUS .

10 The skinlesions may precede the symptoms and signs ofdiabetes MELLITUS . Patients with widespread granulomaannulare need to be screened for DIABETES it is asymptomatic and resolves dermopathyIt is the most common skin lesion occurring indiabetics (17). It is prominent in males who are morethan 50 years of age (18). It is seen even in euglycemic,endocrine diseases and also in healthy individuals. Thepresence of small blood vessel changes has led to theterm diabetic dermopathy (17).The LESIONS areasymptomatic, irregularly shaped patches occurringprimarily over the anterior lower legs; their surfaces aredepressed and they have a light brown color. Thepigmentation is due to deposition of hemosiderin inhistiocytes and extravasated superficial LESIONS can occur on upper arms, thighs, and anybony prominences. LESIONS appear in crops andgradually resolve over 12 to 18 months.