Elsevier

Clinics in Dermatology

Volume 26, Issue 3, May–June 2008, Pages 235-242
Clinics in Dermatology

Skin disorders in patients with diabetes

https://doi.org/10.1016/j.clindermatol.2007.10.015Get rights and content

Abstract

Diabetes mellitus is a metabolic disorder characterized by elevated fasting and postprandial blood glucose levels. It is also accompanied with a variety of multisystem complications that include the blood vessels, nervous system, eyes, kidneys, and skin. The main cutaneous complications are discussed.

Introduction

Diabetes is a disease that leaves no tissue or organ of our body unaffected.1 The changes found in the skin are largely parallel to those occurring in internal organs. Many exogenous skin disorders show an increased incidence and severity in patients with diabetes. The biochemical factors responsible in most instances are poorly understood.

About 30% of all patients with diabetes eventually will develop cutaneous changes during the course of their disease. Perhaps, the most common problem is infection, and probably, it does not have an increased incidence in patients with diabetes, it often has a severe and protracted course.

Complications mainly result from biochemical, structural, and functional abnormalities. The concept of the skin performing as a temporary reservoir for excess blood glucose may account for the tendency to develop pruritis and both bacterial and fungal infection. Obesity provides an environment favorable for the multiplication of Candida albicans. The disturbances in the balance of bacterial flora favor the multiplication of the potentially pathogenic gram-positive cocci. A disturbed fluid balance contributes to the predisposition of patients with diabetes to infection. Allergic skin conditions are apparently not more common in patients with diabetes.

The etiological factors that produce skin lesions in patients with diabetes are summarized in five categories:

  • 1.

    Metabolic

  • 2.

    Infectious

  • 3.

    Vascular

  • 4.

    Neuropathic

  • 5.

    Associated diseases

Section snippets

Metabolic

Generalized pruritis could be a symptom of advanced diabetes mellitus. Sometimes, anogenital pruritis occurs, and it is related mainly to candidiasis. Eruptive xanthomas of the skin may develop in patients with diabetes associated with hyperlipidemia, but the lesions usually resolve with proper management of the disease. Carotenemia is also seen in patients with diabetes mellitus in addition to myxoedema who have hyperlipidemia, which occurs in patients who are unable to convert ingested β

Bacterial

Skin infections in patients with diabetes are commonly due to Staphylococcus aureus. The infection could be in the form of mild or severe recurrent boils, abscesses, furuncles, carbuncles, and styes.

Recurrent erysipelas could also occur. Otitis externa due to pseudomonas infection can progress through cellulites and osteitis to nerve damage and meningitis, with a high mortality rate.

Fungal

It occurs commonly in the form of candidiasis of the mouth, nailfolds (paronychia), and intertrigo.

Microangiopathy

It is one of the major complications of diabetes mellitus. The small blood vessels changes affecting the retinal and renal vasculature are responsible for blindness and kidney failure. Microvascular pathology has also been assumed to play a role in diabetic neuropathy and in the so-called diabetic foot. Microangiopathy is clinically detected by an examination that demonstrates the presence of microaneurysms. More severe involvement may demonstrate hemorrhages, exudates, and even some

Neurologic

Diabetic neuropathy occurs more in elderly patients in the form of polyneuropathy as distal and symmetrical affecting both sensory and motor nerves. In motor neuropathy, the foot develops subluxed digits, depressed metatarsal heads, hammertoes, and pes cavus. It is essential with such symptoms to pay attention to foot care to prevent perforating sole ulcers (Fig. 3, Fig. 4).

Diabetic foot ulcers can be divided into two groups: (1) those in neuropathic feet called neuropathic ulcers and (2) those

Necrobiosis lipoidica diabeticorum

It is an idiopathic dermatosis characterized histologically by the presence of palisading granulomas and collagen degeneration, leading to cutaneous atrophy (Fig. 8). The primary cause of collagen degeneration is proposed to be an immunologically mediated vascular disease, aimmune complex vasculitis has been described. Others suggest that it is primarily a disease of collagen with secondary inflammation (Fig. 9).13, 14, 15

The evidence of necrobiosis lipoidica diabeticorum (NLD) is 0.34 in

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