Cutaneous Manifestations of Diabetes Mellitus

Dr Noreen CowleyMD FRCP

Consultant Dermatologist

Cutaneous

No Pathonomonic Skin lesion in Diabetes

Cutaneous Manifestations of Diabetes

30% incidence cutaneous disorders ADA70% during course of illness

15% ulceration

Cutaneous Manifestations of DiabetesHyperglycaemia

Neuropathy

Impaired host response

Microvascular angiopathies with failure of the microcircutation to meet the metabolic requirements of the skin

Cutaneous Manifestations of Diabetes

• Common disorders that affect non-diabetes• Those classically associated with diabetes / reflect

microangiopathy• Lesions indicating poor control • Effect of insulin resistance• Adverse effects of therapy for diabetes• Skin changes as a result complications of diabetes• Other associated autoimmune disorders

Cutaneous Manifestations of Diabetes

• Common disorders that affect non-diabetics• Those classically associated with diabetes / reflect

microangiopathy• Lesions indicating poor control • Effect of insulin resistance• Adverse effects of therapy for diabetes• Skin changes as a result complications of diabetes• Other associated autoimmune disorders

Skin Infection

20-50% (Type 2) poor glycaemic control Poor micro and macro-circulation NeuropathyAltered immune response

Dermatoses “portal of entry”

Skin Infection

Staphylococcus folliculitisSuperficial fungal infectionCellulitis and erysipelasOral and genital candida

Non pathogenic organisms mucormycosis by phycomycetes and anaerobic cellulitis by clostridium species

Erythrasma

Cutaneous Manifestations of Diabetes

• Common disorders that affect non-diabetes• Those classically associated with diabetes / reflect

microangiopathy• Lesions indicating poor control • Effect of insulin resistance• Adverse effects of therapy for diabetes• Skin changes as a result complications of diabetes• Other associated autoimmune disorders

Necrobiosis Lipoidica

Necrobiosis Lipoidica

Necrobiosis Lipoidica

Aetiology

Microangiopathy –---collagen degradation with release cytokines from inflammatory cells – destruction collagenous matrix

Little evidence correlation retinopathy/nephropathy

Necrobiosis Lipoidica

0.3-0.7%

Differential Diagnosis

Generalized Granuloma Annulare

Diabetic Dermopathy

“Shin Spots”

Shemer et al 40%

Men – 50yrs

Diabetic Dermopathy

Severe microvascular complications

Retinopathy,neuropathy,nephropathy

Closely linked to glycosylated Hb

High risk of accelerated diabetes complications

Bullosis Diabeticorum

Bullosis DiabeticorumType 1 Diabetes

0.5%

Men

Longstanding Disease

Peripheral Neuropathy

Cutaneous Manifestations of Diabetes

• Common disorders that affect non-diabetes• Those classically associated with diabetes / reflect

microangiopathy• Lesions indicating poor control • Effect of insulin resistance• Adverse effects of therapy for diabetes• Skin changes as a result complications of diabetes• Other associated autoimmune disorders

Eruptive Xanthomas

Scleredema of Buschke

Scleredema of Buschke

Type 2ObeseTherapy resistantCardiovascularRetinopathy

Cutaneous Manifestations of Diabetes

• Common disorders that affect non-diabetes• Those classically associated with diabetes / reflect

microangiopathy• Lesions indicating poor control • Effects of insulin resistance• Adverse effects of therapy for diabetes• Skin changes as a result complications of diabetes• Other associated autoimmune disorders

Acanthosis Nigricans

8 types

Obesity – Acanthosis Nigricans

Kahn 1975 association with insulin resistance

Acanthosis Nigricans

Mechanism?

High insulin concentrations stimulate insulin–like growth factor receptors on keratinocytes promoting epidermal cell proliferation

HAIR-AN Syndrome

• HyperAndrogenism• Insulin Resistance• Acanthosis Nigricans

HAIR-AN SyndromeType A I RMutation gene that encodes the

insulin receptor

Tall black young females

Severe acanthosis nigricansbegins infancy and early childhood

Alopecia

Cutaneous Manifestations of Diabetes

• Common disorders that affect non-diabetes• Those classically associated with diabetes / reflect

microangiopathy• Lesions indicating poor control • Effect of insulin resistance• Adverse effects of therapy for diabetes• Skin changes as a result complications of diabetes• Other associated autoimmune disorders

Auto-Immune DisordersVitiligo1-7% in diabetes0.2-1% non-diabetic

Lichen Sclerosis et Atrophicus

Lichen Sclerosis et Atrophicus

Cutaneous Manifestations of Diabetes

• Common disorders that affect non-diabetes• Those classically associated with diabetes / reflect

microangiopathy• Lesions indicating poor control • Effect of insulin resistance• Adverse effects of therapy for diabetes• Skin changes as a result complications of diabetes• Other associated autoimmune disorders

Cutaneous effects of Therapy

• Insulin• Oral hypoglycaemic agents

MetforminPsoriasiform drug eruptionErythema MultiformeLeucocytoclastic Vasculitis

Lipoatrophy/hypertrophyLipoatrophyThighs/arms children and young women

LipohypertrophyMalesSubcutaneous deposition fat at injection sitesInsulin –induced stimulation of adipose tissue growth

Cutaneous Manifestations of Diabetes

• Common disorders that affect non-diabetes• Those classically associated with diabetes / reflect

microangiopathy• Lesions indicating poor control • Effect of insulin resistance• Adverse effects of therapy for diabetes• Skin changes as a result complications of diabetes• Other associated autoimmune disorders

Perforating Collagenosis

Perforating Collagenosis

Elimination of focally damaged collagen through the epidermis

Necrolytic Migratory Erythema

StomatitisWeight LossDiabetes Mellitus

Glucagon-secreting tumour of the pancreatic islet cells

Mechanism? Sustained gluconeogenesis from high glucagon levels leads to amino acid deficiency,epidermal protein deficiency and necrolysis

Thankyou

Any Questions?