6.2.1 Skin Changes in Diabetes Mellitus
Grading & Level of Importance: C
80% of patients with diabetes mellitus have skin changes.
The spectrum of skin changes seen as a result of hyperglycaemia and its multiple effects on the body.
Aetiology & Pathogenesis
Due to hyperglycaemia, there are pathological changes in the circulation, nerves and an increased tendency to infection, with reduced wound healing. Depending on the duration of the disease in type I vs type II diabetes.
Signs & Symptoms
- Pretibial pigmented patches (PPP): small, poorly-defined brown macules over shins.
- Rubeosis faciei: persistent facial erythema.
- Peripheral arterial occlusion: intermittent claudication, calves and feet pale or livid and cold, absent or reduced pulses in feet, sometimes ulcers or delay in wound healing.
- Neuropathic ulceration: indolent painless ulcers with hyperkeratotic border, primarily on heels, tips of toes (diabetic foot; acroosteopathia ulceromutilans). See chapter 5.1.4 Pressure sore.
- Necrobiosis lipoidica: primarily on shins, oval sharply demarcated yellow-red plaques with central glassy white-yellow area, mostly asymptomatic, may ulcerate.
- Disseminated granuloma annulare: primarily on trunk, asymptomatic papules and plaques, sometimes confluent and often with prominent border.
- Candidiasis: most often intertriginous (groins, rima ani, submammary, umbilicus), also involves mouth, genitalia (balanitis, vulvovaginitis), nails.
- Generalised pruritus: always rule out diabetes mellitus in patients with unexplained diffuse persistent pruritus.
- Nodular prurigo: pruritic papules with central excoriations, usually on shoulders and arms (females more than males).
- Bullosis diabeticorum: large acral blisters.
According to symptoms.
Laboratory & other workups
Swabs to exclude an infection (bacterial or mycotic) may be required. Doppler ultrasound. Neurological examination.
Not usually necessary and generally to be avoided, due to impaired wound healing. However, granulomatous diseases of the leg and widespread localization needs confirmation.
Depends on the underlying cause. Generalised pruritus tends to persist, even despite good glycaemic control.
Infection, particularly in the context of the diabetic foot. This may even include osteomyelitis. High dose antibiotics according to resistogram. Amputation should be considered as a last resort.
Always relies on a secure diagnosis of diabetes mellitus.
Depends on individual condition (see above symptoms).
Prevention & Therapy
Optimise glycaemic control. Regular diabetology/dermatology follow-up in high-risk patients. Treat microangiopathy. Necrobiosis diabeticorum difficult to treat (topical tacrolimus, TNF alpha blocker off label). Orthopedic shoes.
- 65-year-old acholic homeless person presents with painless ulcer on the left foot which has been present for months. He has obvious varicosities. What are the next steps?
- 70-year-old patient with diabetes mellitus presnets with asymptomatic large blisters on right foot which have become eroded. No leisons elsewhere on the body. What is your diagnosis?
- Statement 1 Bullous disease of diabetes should be treated with systemic immunosuppression.
- Which of the following diseases are common in diabetes mellitus?
- 50-year-old man presents with tibial plaques which are brown with telangiectases and central atrophy. A skin biopsy confirms your working diagnosis of necrobiosis lipoidica. What are the next steps?
- 55-year-old man with pruritus and diffuse hyperpigmentation for a few months. Internal medicine work-up revealed hyperglycemia, abnormal liver enzymes and elevated ferritin? What is your diagnosis?
- This patient with diabetes mellitus has noticed pretibial plaques for the past few months. The skin biopsy shows a granulomatous infiltrate. What is your diagnosis.
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