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Dermatologic Manifestation of Diabetes Mellitus – A Review

P. Gandhi, Senior Resident in Medicine
H. R. Choudhary, Associate Professor of Medicine
R. C. Gupta, Professor of Medicine
R. Jain, Asst. Professor of Medicine
A. Ojha, Senior Resident in Medicine
– J. L. N. Medical College & Associate Group of Hospitals, Ajmer, Rajasthan.
Source: Indian Medical Gazette, CXXXVII (3), 82-86.

Abstract

Diabetes mellitus, a metabolic disorder, is characterized by various microvascular and macrovascular complications, particularly of heart, kidney, brain, peripheral nerves and retina. Skin, in diabetes, also shows a number of lesions, some of which are directly related to it like, diabetic dermopathy, diabetic bullae, xanthomatosis, neuropathy and PVD. Some are associated with but not specific to it, like necrobiosis lipodica diabeticorum, acanthosis nigricans, granuloma annulare and lipodystrophy. Skin lesions are also described to be due to diabetic therapy.

Dermatologic Manifestation of Diabetes Mellitus

Diabetes mellitus is a metabolic disorder, characterized by hyperglycaemia, hypertriglyceridaemia and classic symptomatology.

Approximately 30% of patients with diabetes develop skin manifestations during the course of their illness. A number of skin diseases are described which are specific to diabetes but most of them also occur in non-diabetic population ^{1, 2}.

Insulin regulates the intracellular disposition of glucose in the skin and normally, the amount of glucose in the whole skin is greater than the extracellular fluid. The ratio of skin glucose/gm to blood / gm is increased in diabetic patient^{1, 2, 3.}

Skin manifestations of diabetes can be divided into –

Those that accompany sustained hyperglycaemia and other metabolic changes.
Those that correlate with chronic degenerative changes.
Those that are associated with diabetes but not specific to it.
The complications of diabetic therapy.

A. Skin manifestation that accompanies sustained hyperglycaemia and other metabolic changes

1.Cutaneous infections:^{1, 2, 3, 4, 5}Bacterial and fungal infections frequently occur in poorly controlled or undiagnosed diabetic patients. The lower extremities are affected more than other parts of body. The associated atherosclerosis and peripherosis and peripheral neuropathy leads to ulceration and gangrene as well as poor wound healing.

Cardinal infection of mucosal membranes, genitalis and nail folds are generally more prevalent in poor controlled diabetics, especially in female and even it may be the presenting feature of the disease. Oral mucosal candidiasis include thrush (white curd like material), angular cheilitis (perleche) and atrophic candidiasis. Candidal vulvovaginitis is characterized by puritus, vulvar erythema and occasionally by fissuring and pustules. Phimosis as a result of recurrent candidal balanoposthitis is common in diabetic men and requires circumcision.

Dermatophyte infections like tinea pedis and tinea cruis are more common and can create fissures and portals of entry that may lead to secondary serve bacterial infection in diabetics. In rhinocerebral mucormycosis ^{(1, 2, 3)} a serious infection of diabetics with ketoacidosis, by mucor and rhizopus, there is sudden onset of pain and swelling around orbit and nose with bloody nasal discharge and conjunctival injection. Nasal mucosa and underlying tissues become black and nacrotic. Thrombosis of intracranial sinuses and cranial nerve palsies may occur. These can also be responsible for cutaneous infarction secondary to haematogenous dissemination6. Staphylococcal pyodermas – carbuncles and furunculosis are common and require aggressive therapy. Non-clostridial gas gangrene affecting soft tissues caused by E. Coli, Klebsiella, Pseudomonas and Bacteriodes spp. has been described. Erythrasma, is superficial infection usually affecting the interitriginous areas such as axillia, groins and web spaces as reddish brown, scally patches caused by corynibacterium minutissium.

Malignant otitis externa, is caused by Pseudomonas aeruginosa and is more severe necrotizing bacterial infection in elderly, poorly controlled diabetics, characterized by severe pain in the ear, greenish discharge, fever leucocytosis, with surrounding swollen and tender soft tissue present at the junction of osseous and cartilaginous parts of ear. Facial nerve palsy may occur in about 50% of cases and is attributed to a poorer prognosis^1,2,4.

2. Xanthomatosis:

^{1, 2, 3, 4, 5} Eruptive xanathomas occur in 0.01% of diabetic patients and are associated with a more sustained hypertriglyceridaemic phase of uncontrolled diabetic patients. The decreased lypoprotein lipase activity in type-1 DM patient results in accumulation of serum triglyceride. Xanthoma results from deposition of lipid in histiocytes in the dermis or subcutaneous tissue. These are small, yellowish red papules that arise in crops in erythmatosus base over buttocks, elbows, back of the thighs and body folds. Rapid regression of these lesions occurs after control of hyperlipidaemia. Xanthelesma begins as small, yellow orange macules which thicken to form oval foamy plaque over eyelids. It does not regress with therapy for diabetes.

A yellowish dis-colouration of skin caused by deposition of carotene in the skin of palms, soles and nasolabial folds and bony prominences may occur in about 10% of diabetic patients.

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