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6.2.1 Skin Changes in Diabetes Mellitus
ICD-11
EL3Y
Synonyms
None.
Epidemiology
30% to 70% of patients with diabetes mellitus have skin changes.
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Between 30 and 70% of patients with diabetes mellitus, both type 1 and type 2 have skin changes. Such changes are more common with advancing age, but may occur in all people with diabetes mellitus.
Definition
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
Microangiopathy:
- Pretibial pigmented patches (PPP): small, poorly-defined brown macules over shins.
- Rubeosis faciei: persistent facial erythema.
Macroangiopathy:
- 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.
Polyneuropathy:
- 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.
Granulomatous disorders:
- 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.
Infections:
- Candidiasis: most often intertriginous (groins, rima ani, submammary, umbilicus), also involves mouth, genitalia (balanitis, vulvovaginitis), nails.
- Overgrowth of staphylococci: Folliculitis and furuncles: usually on trunk.
Others:
- 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.
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Microangiopathy:
Pretibial pigmented patches (PPP): these manifest as small, poorly-defined brown macules over the shins.
Rubeosis faciei: persistent facial erythema. Macroangiopathy:
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.
Polyneuropathy:
Neurotrophic ulceration: indolent painless ulcers with hyperkeratotic border, primarily on heels and the tips of the toes.
Granulomatous disorders:
Necrobiosis lipoidica: primarily on shins, oval sharply demarcated yellow-red plaques with central glassy white-yellow area, mostly asymptomatic, may ulcerate. They may be a cosmetic problem.
Disseminated granuloma annulare: primarily on trunk, asymptomatic papules and plaques, sometimes confluent and often with prominent border (see chapter granuloma annulare).
Infections:
Candidiasis: most often intertriginous, also involves mouth, genitalia (balanitis, vulvovaginitis), nails.
Folliculitis and furuncles: usually on trunk.
Others:
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.
Scleroderma-like changes: skin tightening (fingers).
Scleredema diabeticorum: erythema and diffuse skin thickening (upper back, neck, chest, shoulders) with mucin deposition.
Localisation
See above.
Classification
According to symptoms.
Read more
This is according to pathogenesis. Skin manifestations strongly associated with diabetes includes acanthosis nigricans, diabetic dermopathy, diabetic foot syndrome, diabetic thick skin, scleredema, necrobiosis lipoidica, bullosis diabeticorum
Laboratory & other workups
Swabs to exclude an infection (bacterial or mycotic) may be required. Doppler ultrasound. Neurological examination.
Dermatopathology
Not usually necessary and generally to be avoided, due to impaired wound healing. However, granulomatous diseases of the leg and widespread localization needs confirmation.
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Histopathology different according to the different manifestations. Sometimes clinical diagnosis is enough and skin biopsy can be spared, due to impaired wound healing.
Course
Depends on the underlying cause. Generalised pruritus tends to persist, even despite good glycaemic control.
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Clinical course depends on the underlying cause. Generalised pruritus tends to persist, even despite good glycaemic control. Often there is a gradual worsening of the skin changes over time.
Complications
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.
Diagnosis
Always relies on a secure diagnosis of diabetes mellitus.
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Always relies on a secure diagnosis of diabetes mellitus (fasting plasma glucose >7mmol/L), pathologic HbA1c levels.
Differential Diagnosis
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.
Special
None.
Podcasts
Tests
- 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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