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Diabetic dermopathy: A subtle sign with grave implications

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Diabetic dermopathy (DD) is the most common cutaneous manifestation of diabetes mellitus. DD refers to atrophic, hyperpigmented macules characteristically located on the shins of patients with diabetes. They have an unfavorable association with the 3 most common microangiopathic complications of diabetes mellitus: neuropathy, nephropathy, and retinopathy. A relationship between DD and coronary artery disease has also been demonstrated. Thus, the presence of DD should prompt aggressive intervention to detect diabetes mellitus and prevent the development of ensuing complications.

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History

In the early 1960s, the Swedish physician Hans Melin1 studied and characterized a “circumscribed brownish skin lesion” on the lower extremities of patients with diabetes. Melin1 described these lesions in great detail and concluded that they were specific for diabetes mellitus. In 1965, Binkley2 coined the term “diabetic dermopathy” (DD), reflecting his concept that DD is a cutaneous manifestation of diabetic microangiopathy.

DD has been known by many names, each characterizing its clinical

Epidemiology

DD is the most common cutaneous manifestation of diabetes mellitus.2, 6, 7 The incidence of DD ranges from 9% to 55%.1, 6, 8, 9, 10, 11, 12 This distribution may result from variations among the sample sizes and ethnicities of the study groups. For example, the lowest incidence was noted among Indian patients, whose complexion may render DD more difficult to detect.12 Two studies conducted in Singapore reported that DD was present in 24% and 16% of 135 patients hospitalized with diabetes and

Origin

The origin of DD remains largely unknown. Melin1 believed that it was the result of minor trauma to the shins that went unnoticed by patients. He tested this hypothesis by striking a rubber hammer against the shins of patients with diabetes. Contrary to the anticipation of Melin,1 this crude experiment did not reproduce DD.

In 1972, Shelley13 described a mottled appearance to the skin surrounding the lesions of DD and compared it with livedo reticularis, observing that DD may represent areas of

Clinical manifestations

DD consists of small, brown, well-demarcated, shallow depressions that have an atrophic appearance (Fig 1). They are typically less than 1 cm in diameter and round. Occasionally they are elongated and may reach 2.5 cm.4 The atrophic appearance refers to a shallow depression and thin epidermis that resembles a scar. They are smooth and hyperpigmented. The intensity of brown pigmentation has been correlated with the degree of atrophy. Melin1 noted that the most prominent atrophy was associated

Associated findings

DD is associated with diabetes mellitus and its ensuing microvascular complications. Specifically, it has been linked with retinopathy, neuropathy, and nephropathy.6, 9, 10, 15, 24 In one survey, 24% of patients with diabetes had DD and 39% had concomitant retinopathy. In this study retinopathy was present in only 7% of patients without dermopathy.8 Furthermore, a 2007 study of 173 patients with diabetes in Tehran, Iran, found that 44% of patients with DD also had retinopathy, as opposed to the

Diagnosis

DD is a clinical diagnosis. With the appropriate history and physical examination, the diagnosis of DD should be evident. The presence of multiple well-demarcated, hyperpigmented, atrophic “scars” on the shins of a patient with diabetes is highly suggestive of DD. Although patients without diabetes may rarely have one or two similar lesions, it has been suggested that the presence of 4 or more with typical features of DD is characteristic of diabetes mellitus.26, 27

A biopsy is not routinely

Histopathology

Histologic findings of the epidermis includes atrophy of rete ridges, moderate hyperkeratosis, and variable pigmentation of basal cells.28 The papillary dermis exhibits telangiectasia, fibroblastic proliferation, and edema. Hyaline microangiopathy, extravasated erythrocytes, and hemosiderin deposits are universally seen.2, 8, 28, 29, 30 Periodic acid–Schiff staining is essential to accentuate the mucopolysaccharide infiltrate in the vessel wall.13

A mild perivascular infiltrate composed of

Differential diagnosis

The differential diagnosis of DD includes many entities listed in Table I. The initial lesions of DD may be mistaken for a fungal infection.20 However, the typical brown atrophic scars may sometimes require differentiation from Schamberg's disease (progressive pigmented purpuric dermatitis), purpura annularis telangiectodes, pigmented purpuric lichenoid dermatitis, stasis dermatitis, angioma serpiginosum of Hutchinson, healed lesions of papulonecrotic tuberculids, and neurotic excoriations.1, 4

Treatment

Treatment for the cutaneous element of DD is neither recommended nor effective.19, 22 The lesions themselves are asymptomatic and may persist indefinitely or resolve spontaneously without treatment.1, 23 The effect of glycemic control on their natural progression has yet to be established.

On the other hand, the conditions associated with DD require attention. First off, patients with DD must be evaluated for the presence of diabetes mellitus. If the patient does not meet the criteria for

References (30)

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    Dermopathy and retinopathy in diabetes: is there an association?

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    Cutaneous manifestation of diabetes mellitus

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    Funding sources: None.

    Conflicts of interest: None declared.

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