Cutaneous ManifestationsNearly all patients with diabetes eventually

develop cutaneous manifestations of the disease.

Can be first sign that a patient has diabetes.

Cutaneous signs of diabetes can be valuable to physician for diagnosis, management, and treatment.

Necrobiosis Lipoidica DiabeticorumDegenerative disease of collagen in the

dermis and subcutaneous fat with an atrophic epidermis.

Precedes onset of diabetes in 15-20% of patients

Lesions progress to ulcers if predisposed to trauma

Location: 85% anterior aspect-pretibial region of lower

extremeties, 15% hands, forearms, face, scalp

Necrobiosis Lipoidica DiabeticorumInitial lesions appear as well

circumscribed erythematous plaques/papules with a depressed-waxy center.

Advanced, typically larger, lesions show translucency and enlargement of underlying blood vessels.

Necrobiosis Lipoidica DiabeticorumEtiology unknown: seem to occur and persist

independent of hyperglycemic controlTheory one: immunologic role-release of

cytokines from inflammatory cells may lead to destruction of the collagen matrix.

Theory two: Microvascular effects of diabetic retinopathy and neuropathy lead to a degradation of collagen.

Women > Men

Necrobiosis Lipoidica DiabeticorumTreatment: Lesions can spontaneously resolve,

however most do not. No standard therapy.-used to arrest progressionSupport stockings/restNSAIDsIntrelesional, systemic, topical corticosteriodsAspirin and dipyridamoleTumor necrosis factorLaser surgeryExcision/grafting

Diabetic DermopathyAlso known as shin spots, most common

cutaneous finding in diabetics (approximately 50% of diabetics).

Round to oval atrophic hyperpigmented lesions on the pretibial areas of the lower extremities. Early lesions usually raised, then flatten. Brownish hyperpigmentation due to hemosiderin deposits.

Occur bilateral with asymmetrical distribution.

Diabetic DermopathyAsymptomatic, resolve spontaneously leaving a

scar usually following improved blood glucose control.

Usually occurs in older diabetic patients who have had diabetes >10 years.

Occurs more frequently in diabetic patients with retinopathy, neuropathy, and nephropathy.

Can be indicator of poor control of blood glucose levels.

Diabetic Dermopathy

Diabetic Bullae Blisters occur spontaneously in diabetic patients,

atraumatic/asymptomatic lesions on feet and legs.Patients tend to have adequate circulation in the

affected extremities and peripheral neuropathy.Three types of Diabetic Bullae:

-Most common: Sterile fluid containing that heal without

scarring. -Hemorrhagic, heals with scarring.-Multiple nonscarring on sun exposed/tan skin.

Diabetic Bullae Usually resolve without treatment within 2-5

weeks.Therapy should be aimed at preventing

ulceration and secondary infection.

Diabetic Bullae When they occur in the feet can resemble

friction blisters, however usually an absence of trauma.

Eruptive XanthomasOccur in hyperlipidemic/hyperglycemic

states: uncontrolled diabetic patients.Most common in young men with Type 1

diabetesResistance to insulin makes it difficult for the

body to clear the fat from the blood.

Eruptive XanthomasUsually asymptomatic firm, waxy, yellow

papules in the skin.Enlargements can have erythematous halo,

can itch.Occurs most often on the back of hands/feet,

arms/legs, buttocks, face-eyes.

Eruptive XanthomasIncrease risk of developing pancreatitis.Eruptions can resolve in a few weeks with

hyperlipidemic/hyperglycemic control, lipid lowering medications.

Acanthosis NigricansHyperpigmentation and thickening of

epidermisPrecedes diabetes, considered a marker for

the disease, most common in overweight diabetic patients.

Usually occurs in skin folds, often described as velvetyNeck, back, axillae, groin region, over joints in

the hands/feet.

Acanthosis NigricansExact mechanism is unknown, thought to be

a manifestation of insulin resistance, high concentrations of insulin may stimulate growth factor receptors on keratinocytes promoting epidermal cell proliferation.

Acanthosis NigricansClassification: 5-8 types

Type 1: hereditary-benignType 2: endocrine disorders-diabetes, benignType 3: complication of obesityType 4: drug inducedType 5: malignant

Genetically inherited, hypothyroidism, hyperthyroidism, acromegaly, polycystic ovarian disease, cushing’s disease

Important to rule out underlying endocrine disorders and malignancies

No cure: weight loss, exercise, nutrition, creams may help

Kyrle’s DiseaseAlso known as perforating dermatosis.Rare condition, except in setting of diabetes

with chronic renal failure.Large papules with central keratin plugs,

widespread pattern seen in patients undergoing dialysis.

Itching/scratching present

Kyrle’s DiseasePrimary location: extensor surfaces of the

lower extremity, but can occur on face and trunk.

Seen with DM, CHF, hepatic abnormalities-alcoholic cirrhosis, renal disease

Elimination of collagen and elastin throughout epidermis.

Kyrle’s DiseaseCan be difficult to treat: have to manage

underlying systemic disorderAntihistamines, antipruritics, topical

corticosteriods,Retinoic acid, UV light therapy, laser therapyRapid improvement and resolution of lesions is

seen once underlying disease is treated.

ConclusionNearly all patients with diabetes eventually

develop cutaneous manifestations of the disease.

It is valuable to recognize for diagnosis, management, and treatment.

Leads to prevention of ulcerations, infections, amputations.

References 1. Chakrabarty A, Norman R, Phillips T. Cutaneous Manifestations of

Diabetes. Wounds. 2002. 14(8).

2. Huntley A. The Skin and Diabetes Mellitus. Dermatology Online Journal. Dec. 1995 1 (2).

3. Bhat Y, Gupta V, Kudyar RP. Cutaneous Manifestations of Diabetes Mellitus. International Journal of Diabetes. 2006. 26 (4): 152-155.

4. Hattem S, Bootsma A. Skin Manifestations of Diabetics. Cleveland Clinic Journal of Medicine. 2008. 75 (11): 772-787.

5. Dermnet: Skin Disease Image Atlas. Interactive Mecical Media. 2009.

6. Perez M, Kohn S. Cutaneous Manifestations of Diabetes Mellitus. Journal of the American Academy of Dermatology. 30 (4): 519-531.

7. Eaglstein W, Callen J. Dermatological Comorbidities of Diabetes Mellitus and Related Issues. Archives of Dermatology. 2009. 145 (4): 467-469.