Diabetic Dermopathy Research Articles

Clinical Pearls in Dermatology

Clinical Pearls in Dermatology

A study on the cutaneous manifestations of diabetes mellitus

Nearly one-third of diabetic patients have some type of dermatologic manifestation [1]. With time, the skin of all diabetic patients is affected in some form or another. Dermatologic manifestations of the disease can range from the more benign granuloma annulare to the more sinister diabetic ulcer [2]. Cutaneous signs of DM are extremely valuable to the clinician. For example, diabetic bullae, diabetic dermopathy, necrobiosis lipoidica diabeticorum, and the scleroderma-like syndrome of waxy skin with limited joint mobility can alert the physician to the diagnosis of diabetes. Eruptive xanthomas reflect the status of glucose and lipid metabolism. Cutaneous signs appear to be closely linked to increased glycosylated haemoglobin, an indicator of poor control of blood glucose levels [3]. The importance of cutaneous manifestations in diabetic patients is highlighted by Puri in an elegant study published in our journal. The author had looked thoroughly into the prevalence and pattern of cutaneous manifestations in diabetic patients and its correlation to disease duration and status, the author also mentioned other rare cutaneous diseases and its relation to diabetes mellitus. As emphasized in the article recognition of these findings is a key for treatment and prevention. This article will add more awareness and benefits to the physician and patient toward better health and clinical outcome. REFERENCES

A clinical study of dermatoses in diabetes to establish its markers

Background:Cutaneous manifestations of diabetes mellitus generally appear subsequent to the development of the disease, but they may be the first presenting signs and in some cases they may precede the primary disease manifestation by many years.Aims:The aim of our study was to study the spectrum of dermatoses in diabetics, to know the frequency of dermatoses specific to diabetes mellitus (DM), and to establish the mucocutaneous markers of DM.Material and Methods:The study was conducted at a diabetic clinic and our department between September 2008 and June 2010. Two hundred and twenty-four diabetic patients were included in the study group and those with gestational diabetes were excluded. Healthy age- and sex-matched individuals were taken as controls.Results:The male to female ratio was 1 : 1.21. Type 2 DM was seen in 89.7% and type 1 DM in 10.3% of the patients. Dermatoses were seen in 88.3% of the diabetics compared to 36% in non-diabetic controls (P<0.05). Cutaneous infections were the most common dermatoses followed by acanthosis nigricans and xerosis in diabetics. Type 2 DM was found to have an increased risk of complications than type 1 DM. Complications of diabetes were seen in 43.7% of the diabetic cases. Diabetic dermopathy, loss of hair over the legs, diabetic foot ulcer, and so on, were found to be the cutaneous markers of DM in our group of cases.Conclusion:Dermatoses were more common in diabetics than non-diabetics. Cutaneous infections formed the largest group of dermatoses in DM.

Defining diabetic dermopathy

Diabetic dermopathy presents as well-demarcated, hyperpigmented, atrophic depressions, macules or papules located on the anterior surface of the lower legs of diabetic patients. The histopathology remains poorly defined which may in part be due to the fact that the lesions are rarely biopsied. An advantage of studying autopsy material is the ease of obtaining large biopsy specimens. To further define the histopathological features of this entity, we studied tissue taken from characteristic lesions at autopsy. Inclusion criteria included the presence of the lesions and diabetes-related nephroarteriolosclerosis at autopsy. Surprisingly, only four out of 14 skin biopsies showed moderate to severe wall thickening of arterioles or medium-sized arteries on periodic acid Schiff (PAS) stains. Only mild basement membrane thickening was noted in 11 of 14 which was highlighted by the PAS stain. Pigmented material was identified within the dermis of 13 cases. In 10 of the cases, the material was positive for Perl's iron stain. Ten cases had material staining positive for Fontana-Masson in the dermis. Nine cases had markedly increased epidermal melanin. The findings suggest that hemosiderin deposition in conjunction with the deposition of melanin contribute to the clinical features of diabetic dermopathy.

Skin blood flow abnormalities in diabetic dermopathy

Diabetic dermopathy is the most common specific cutaneous finding in diabetes. Using laser Doppler technology, we tested the hypothesis that diabetic dermopathy arises from abnormal local skin blood flow. We measured cutaneous blood flow in patients with type 1 diabetes without dermopathy and compared values with those in a control group of patients with type 1 diabetes without diabetic dermopathy and in a nondiabetic group. We measured at 3 separate sites on the pretibial area on the legs of each participant, at dermopathy lesions, and at a number of standard sites on the upper and lower extremities. We studied 25 patients with diabetes and diabetic dermopathy, average age 51± 2 years, mean duration of diabetes 28± 3 years. In all, 58 patients with type 1 diabetes without diabetic dermopathy served as control patients, average age 41± 2 years, mean duration of diabetes 23± 2 years. There were 67nondiabetic control subjects, average age 47± 3 years. The patients with diabetic dermopathy showed a marked reduction in skin blood flow at 35°C at normal-appearing skin areas on the pretibial surface of the legs (1.1± 0.1 mL/min/100 g) compared with 1.7± 0.1 mL/min/100 g (P= .01) in the type 1 diabetic control group and 2.1± 0.3 mL/min/100 g (P< .01) in the nondiabetic group. The dermopathy lesions themselves showed markedly higher blood flow: 2.5± 0.3 mL/min/100 g. Our diabetic dermopathy patients were somewhat older than the control type 1 diabetes subjects, but were of comparable age to the nondiabetic subjects. These results suggest that patients susceptible to diabetic dermopathy have a functional abnormality in blood flow leading to this scarring process.

Skin Manifestations in Diabetic Patients Attending a Diabetic Clinic in the Qassim Region, Saudi Arabia

Objective: To investigate the prevalence of skin manifestations in diabetic patients attending a diabetic clinic in the Qassim region, Saudi Arabia. Subjects and Methods: A prospective observational study was performed on 320 patients (174 males and 146 females) attending the diabetic clinic. A detailed dermatological examination was carried out by a consultant dermatologist and the cutaneous findings were recorded. Results: The overall prevalence of skin manifestations was 91.2%. Cutaneous lesions were seen in 12 patients (34.3%) of type 1 diabetes mellitus (DM) and 280 (98.2%) of type 2 diabetics. There was a statistically significant difference (p < 0.001) in skin manifestations between type 1 and type 2 DM patients. For those patients having diabetes of less than 5 years’ duration, the incidence of skin manifestations was 80.6%; for those having had diabetes for more than 5 years, the incidence was 98%. This difference was statistically significant (p < 0.001). The skin manifestations that had a statistically significant difference (p < 0.05) in prevalence between the 2 durational groups were gangrene, diabetic dermopathy, paresthesia, diabetic feet, diabetic bullae and fungal infections. Conclusion: Diabetics had a greater prevalence of skin manifestations in type 2 than type 1, and as the duration of diabetes increased, the likelihood of developing skin manifestations also increased. Early referral to the dermatologist may help to detect complications of the skin in diabetes at an early stage and may prevent disability caused by these complications.

Cutaneous disorders in 500 diabetic patients attending diabetic clinic

Background:The metabolic complications and pathologic changes that occur in diabetes mellitus (DM) influence the occurrence of various dermatoses.Aim:To study the impact of control of diabetes on the pattern of cutaneous disorders.Materials and Methods:A cross-sectional descriptive study of patients attending diabetic clinic in a tertiary care hospital. A total of 500 consecutive patients were studied. Detailed history, clinical examination and relevant investigations were done to diagnose diabetic complications and cutaneous disorders. Dermatoses with or without known pathogenesis were correlated with age, gender, fasting plasma glucose (FPG), duration of diabetes, and complications of DM. Statistical analysis was carried out using Student “t” test and Chi-square test with 5% confidence interval (P value 0.05).Results:Majority of patients had well-controlled (FPG<130 mg/ml, 60%) type 2 DM (98.8%). No statistically significant difference (P>0.05) between the patients with or without DM specific cutaneous disorders was noticed with reference to age and gender distribution, duration of DM and FPG. Signs of insulin resistance, acrochordon (26.2%), and acanthosis nigricans (5%) were common, followed by fungal (13.8%) and bacterial (6.8%) infections. Eruptive xanthoma (0.6%), diabetic foot (0.2%), diabetic bulla (0.4%), diabetic dermopathy (0.2%), generalized granuloma annulare (0.2%), and insulin reactions (6.2%) and lipodystrophy (14%) were also seen.Conclusion:Well-controlled diabetes decreases the prevalence of DM-specific cutaneous disorders associated with chronic hyperglycemia. It is necessary to have a dermatologist in the diabetic clinic for early detection of potentially grave or predisposing conditions.

The Cutaneous Microvascular Architecture of Human Diabetic Toe Studied by Corrosion Casting and Scanning Electron Microscopy Analysis

In this morphological study, we report on the three-dimensional microvascular architecture constituting the toes of a patient affected by diabetic microangiopathy. We applied corrosion casting (CC) technique to the toes of a patient affected by Type 2 diabetes, who underwent surgery for explantation of inferior left limb due to necrotic processes of soft tissues. The toes of a foot traumatically explanted in a motorcycle accident were kept as controls. According to technical protocols, toes were injected with a low-viscosity acrylic resin (Mercox) through the major digital artery, tissues were corroded in KOH solution (8%), and resulting casts processed for SEM observations. Already at low magnification, in diabetic toes, we found an impairment of the linear track-like disposition of the vessels of plantar side, with signs of vascular disruption and obliterations, stopped resin, and leakages. Capillaries under the nail and a lot of vascular villi in eponychium and nail borders were damaged, and vascular regression phenomena acting on them were clearly visible. Resin leakages and impairment of normal vascular architecture were also observed in the root of the nail. This preliminary report represents only the first step for further investigations regarding morphological three-dimensional appearance of diabetic microangiopathy. CC and scanning electron microscopy technique well documented these morphological modifications, highlighting on both structural and ultrastructural features of diabetic toes microvessels. In conclusion, our qualitative data try to better focus on the pathophysiological mechanisms involved in diabetic dermopathy and microangiopathy, proposing CC as useful method to investigate on them.

Pattern of cutaneous manifestations in diabetes mellitus

Background:Diabetes mellitus affects individuals of all ages and socioeconomic status. Skin is affected by the acute metabolic derangements as well as by chronic degenerative complications of diabetes.Aims:To evaluate the prevalence of skin manifestations in patients with diabetes mellitus. To analyze the prevalence and pattern of skin disorders among diabetic patients from this region of Western Himalayas.Materials and Methods:One hundred consecutive patients with the diagnosis of diabetes mellitus and having skin lesions, either attending the diabetic clinic or admitted in medical wards were included in this study.Results:The common skin disorders were: Xerosis (44%), diabetic dermopathy (36%), skin tags (32%), cutaneous infections (31%), and seborrheic keratosis (30%).Conclusion:Skin is involved in diabetes quite often and the manifestations are numerous. High prevalence of xerosis in our diabetic population is perhaps due to cold and dry climatic conditions in the region for most of the time in the year.

Relação entre retinopatia diabética e dermopatia diabética em pacientes portadores de diabetes mellitus tipo 2

PURPOSE: Diabetic dermopathy is the most frequent cutaneous marker of diabetes mellitus. Although diabetic dermopathy and diabetic retinopathy are both considered as manifestations of diabetic microangiopathy, there are only few reports in the literature regarding their possible association. The purpose of this study was to investigate the association between diabetic dermopathy and diabetic retinopathy and to determine the prevalence and the associated risk factors for diabetic retinopathy in type 2 diabetes patients from the Outpatient Diabetic Clinic of the Faculty of Medicine of the University of Passo Fundo and Teaching Hospital Sao Vicente de Paulo. METHODS: Cross sectional study was performed in 90 type 2 diabetes mellitus patients who attend to the outpatient diabetic clinic, consecutively. Physical, dermatological and ophthalmologic evaluations were performed in all the patients. RESULTS: The prevalence of diabetic dermopathy was 16,6% (n = 15) and diabetic retinopathy was 34,4% (n = 31); 67,8% of those (n = 21) consisted of non-proliferative diabetic retinopathy and 32,2% (n = 10) of proliferative diabetic retinopathy. The duration of the disease greater than 10 years (p = 0,001) and age over 50 years (p = 0,014) were associated to retinopathy, but no association was found with elevated levels of HbA1c (p = 0,5) and fasting plasma glucose of 126 or higher (p = 0,8). The frequency of diabetic retinopathy in patients with diabetic dermopathy was not higher than in patients without dermopathy (7,7%, 7 cases, p = 0,586). There was no statistically significant association between diabetic retinopathy and diabetic dermopathy. CONCLUSION: No association between diabetic dermopathy and diabetic retinopathy in this group of type 2 diabetes patients was found. The presence of diabetic retinopathy was associated to the duration of the disease and the advanced age of the patients.

Caso para diagnóstico?

Mulher branca de 30 anos de idade há 15 anos apresentando lesões com depressões e herniações anulares, atróficas, bem circunscritas em pele previamente normal, predominando na região cervical e tronco; sem história familiar. Exames laboratoriais sem alterações e histopatológico com infiltrado inflamatório discreto na derme. Coloração com orceína evidenciou fibras elásticas fragmentadas e encurtadas. Após correlação anatomoclínica confirmou-se o diagnóstico de anetodermia de Schweninger-Buzzi.

Caso para diagnóstico?

Os autores relatam caso clínico de paciente do sexo masculino, diabético do tipo II insulinodependente, que apresentava lesões eritêmato-acastanhadas no abdômen e nas coxas, com ligeira atrofia assintomática. O exame histopatológico das lesões revelou a combinação de angiopatia e alterações leves do colágeno, compatíveis com o diagnóstico de dermopatia diabética.

Clinical and nerve conduction studies in female patients with diabetic dermopathy

This study aims to assess the clinical and electrophysiological characteristics of diabetic polyneuropathy (PNP) in female patients. We investigated clinical and electrophysiological features in 175 female patients with diabetes mellitus to compare those with PNP only, diabetic dermopathy (DD), or diabetic foot (DF). Among clinical features, the loss of deep tendon reflexes, the presence of negative sensory symptoms, superficial sensory loss, and the loss of vibration sense were more common in DD patients than PNP patients. As compared with DD patients, the presence of skin atrophy, superficial and positive sensory symptoms were more common in DF patients. Neuropathic symptom and disability scores were significantly higher in DD and DF patients than PNP patients. In the electrophysiological studies, the only significant difference was observed in the mean distal latencies for ulnar nerves, which were longer in DD patients as compared with PNP patients, but similar between DD and DF patients. All other parameters failed to show significant difference among patients, though values for DD patients lied in between PNP and DF patients. Carpal tunnel syndrome was present in 45% of PNP patients, 63.8% of DD patients, and 50% of DF patients (P = 0.031). Our results suggest that female patients with diabetic dermopathy might have a more severe sensorial neuropathy than patients without these skin lesions.

Non-ulcerative skin pathologies of the diabetic foot

Many of the complications of the diabetes are well studied but robust research documenting the cutaneous effects of the disease remains sparse. Various studies have suggested that the majority of patients with diabetes will suffer a skin disorder during the course of their disease and for some, the skin changes may even precede the diagnosis of diabetes. Cutaneous pathology of the diabetic foot and lower leg can arise as a result of the direct or indirect effects of diabetic complications. The most common manifestations include fungal and bacterial skin infection, nail disease and diabetic dermopathy. Other less commonly observed conditions include diabetic bullae, necrobiosis lipoidica diabeticorum (NLD), granuloma annulare and reddening of the soles. For many of the less common disorders, there is little in the way of effective treatment. However, much can be done in the clinical setting in the management of the more common manifestations such as bacterial and fungal infection. Fungal infection, in particular, although relatively inconspicuous, is a very common foot problem and if left untreated can threaten tissue viability in the diabetic foot leading to secondary bacterial infection and cellulitis. Management of fungal disease is often considered difficult due to high relapse and re-infection rates, although by introducing a combination of therapies including mechanical and pharmacological the success in treating this stubborn condition can be greatly improved.

The prevalence of cutaneous diabetic microangiopathy, and their association with diabetic microvascular complications

Introduction: Diabetes mellitus (DM) is the most common endocrine disorder. It exhibits a variety of multisystem complications involving the blood vessels, skin, eye, kidney, and the nervous system during the course of the disease process. Abnormal carbohydrate metabolism, other altered metabolic pathways, atherosclerosis, microangiopathy, neurone degeneration, and impaired host mechanisms all play roles. Objective: To determine the frequency of cutaneuos microangiopathy manifestations (CMM) that occur in diabetics, and their relation to diabetes duration, glycemic control, and the systemic complications. Study design: This is a descriptive cross sectional study. Results: This study revealed that 106 (42.1 %) have CMMs. Most were males (69.8%), and 61.6 % were at the age group 40 – 64 years old. CMMs are common among labourer ( 35.8%). Most of the patients were of type II diabetes (93.4%) for one year or more duration (87.7 %). Uncontrolled DM represents the heigher prevalence of CMs (67.9%). Diabetic dermopathy represented a higher prevalence (41.3 %). Of patients with CMMs, 57.1% was found to have systemic microvascular complications of DM. Peripheral neuropathy is considered the higher in prevalence (55.7 %) followed by retinopathy and hypertension (47.2 and 10.7%, respectively) and the least in frequency, was nephropathy (1.9%). Conclusion: Diabetic dermopathy represented a higher prevalence. Peripheral neuropathy is considered the higher in prevalence in association with diabetes dermangiopathic manifestations, where it represents 55.7 %, and the least was nephropathy (1.9% ). Keywords: Microangiopathic in Diabetes; Diabetes mellitus; Jaber Abu Eliz diabetic center. Sudanese Journal of Dermatology Vol. 4 (2) 2006: pp. 74-80

Dermopathy and Retinopathy in Diabetes: Is There an Association?

Background/Aims: Diabetic dermopathy is the most common cutaneous marker of diabetes mellitus presenting as single or multiple well-demarcated brown atrophic macules, predominantly on the shins. Although diabetic dermopathy and diabetic retinopathy are both considered by some authors as manifestations of diabetic microangiopathy, only a few studies are published about their possible association. Our purpose was to investigate the association of diabetic dermopathy and diabetic retinopathy. Methods: We conducted a cross-sectional study in an outpatient diabetes clinic during a 6-month period. One-hundred and eighty-one consecutive patients (8 cases of insulin-dependent diabetes mellitus and 173 cases of non-insulin-dependent diabetes mellitus) were examined for the presence of diabetic dermopathy and diabetic retinopathy. Results: Forty-seven (26%) showed diabetic dermopathy and 68 patients (37.6%) suffered from diabetic retinopathy. The frequency of retinopathy in patients with diabetic dermopathy (44%; 30 cases) was significantly greater than in patients without dermopathy (15%; 17 cases; p < 0.0001). Retinopathy showed a statistically significant association with dermopathy [odds ratio (OR): 3.60; 95% confidence interval (CI): 1.53–8.44; p = 0.003] and diabetes duration (OR: 3.36; 95% CI: 1.67–6.77; p = 0.001). Conclusion: Our study further supports that diabetic dermopathy might be used as a telltale sign of diabetic retinopathy, necessitating more intensive ophthalmologic care, especially in long-lasting diabetes.

Recent advances in diabetology: diabetic dermopathy, autoantibodies in the prediction of the development of type 1 diabetes, and islet cell transplantation and inhaled insulin as treatment for diabetes

Recent advances in diabetology: diabetic dermopathy, autoantibodies in the prediction of the development of type 1 diabetes, and islet cell transplantation and inhaled insulin as treatment for diabetes

Diabetes mellitus

Dermatologic problems are common in diabetes, with approximately 30% of patients experiencing some cutaneous involvement during the course of their illness. Skin manifestations generally appear during the course of the disease in patients known to have diabetes, but they may also be the first presenting sign of diabetes or even precede the diagnosis by many years. The skin involvement can be autoimmune in nature, such as acanthosis nigricans, necrobiosis lipoidica, diabetic dermopathy, scleredema, and granuloma annulare, or infectious in the form of erythrasma, necrotizing fasciitis, and mucormycosis. Pharmacologic management of diabetes, in addition, can also result in skin changes, such as lipoatrophy and lipohypertrophy, at the site of injection of insulin, and oral antidiabetic agents can cause multiple skin reactions as adverse effects. The management of these cutaneous manifestations is tailored according to the underlying pathophysiology, but a tight control of blood glucose is a prerequisite in all management strategies.

Is diabetic dermopathy a sign for severe neuropathy in patients with diabetes mellitus? Nerve conduction studies and symptom analysis

Objective To assess if diabetic dermopathy (DD) is a sign for severe polyneuropathy (PNP). Methods We investigated the clinical and electrophysiological characteristics of 166 diabetic men (59.5+11.1 years) with different degrees of peripheral nerve involvement. Results All of the clinical variables were more common in patients with diabetic foot ulcers (DF) than in patients with sole PNP ( P<0.001). Only the loss of superficial and vibration sense was more common in the DF patients than the DD patients ( P<0.02). Nerve conduction studies showed the mean compound muscle action potentials (CMAP) were smaller in the DD and DF patients than the PNP patients for peroneal, median and ulnar nerves ( P<0.01). The mean nerve conduction velocities (NCV) of all nerves were slower in the DD and DF patients in compared to sole PNP patients ( P<0.01). The mean distal latencies (DL) of the DD/DF patients were longer than the PNP group. Conclusions The DD and DF patients did not significantly differ in CMAP, NCV, and DL. Significance: Both clinical and electrophysiological features of DD and DF are similar, and significant different than PNP alone. These results suggest that DD is an important clinical sign for more severe neuropathic impairment.

Using a protease-modulating dressing to treat necrobiosis lipoidica diabeticorum

Almost one-third of patients with diabetes mellitus have some type of dermatological manifestation, such as bacterial and fungal infections, diabetic dermopathy, diabetic blisters (bullosis diabeticorum), eruptive xanthomatosis and necrobiosis lipoidica diabeticorum (NLD). These dermatological conditions are most often caused by the degenerative effect of diabetes on the microvascular and nervous systems, causing dermopathy and neuropathy.