Presentation on theme: "Dermatological Manifestations in Diabetics"— Presentation transcript:
1Dermatological Manifestations in Diabetics -Kyrle disease:encountered in the diabetics undergoing hemodialysis for renal failure-intact blister on non-inflamed skin-necrobiosis lipoidica diabeticorum-granuloma annulare-Recently completed dermatology rotation and saw some interesting skin lesions…..
2Cutaneous Manifestations Nearly all patients with diabetes eventually develop cutaneous manifestations of the disease.Can be first sign that a patient has diabetes.Cutaneous signs of diabetes can be valuable to physician for diagnosis, management, and treatment.
3Necrobiosis Lipoidica Diabeticorum Degenerative disease of collagen in the dermis and subcutaneous fat with an atrophic epidermis.Precedes onset of diabetes in 15-20% of patientsLesions progress to ulcers if predisposed to traumaLocation:85% anterior aspect-pretibial region of lower extremeties, 15% hands, forearms, face, scalp-If occurs in regions other than the legs, less association with diabetes.-Anterior aspect of lower leg-shin typical location-Posterior aspect of legs-B/L nature of the disease.
4Necrobiosis Lipoidica Diabeticorum Initial lesions appear as well circumscribed erythematous plaques/papules with a depressed-waxy center.Advanced, typically larger,lesions show translucency andenlargement of underlyingblood vessels.-Subcutaneous vessels become more visible-slowly expand and become larger
5Necrobiosis Lipoidica Diabeticorum Etiology unknown: seem to occur and persist independent of hyperglycemic controlTheory one: immunologic role-release of cytokines from inflammatory cells may lead to destruction of the collagen matrix.Theory two: Microvascular effects of diabetic retinopathy and neuropathy lead to a degradation of collagen.Women > Men-Important-physcial exam….can advise pt. to see PCP for screening of DM-Resolution/prognosis not related to glycemic control
6Necrobiosis Lipoidica Diabeticorum Treatment: Lesions can spontaneously resolve, however most do not. No standard therapy.-used to arrest progressionSupport stockings/restNSAIDsIntrelesional, systemic,topical corticosteriodsAspirin and dipyridamoleTumor necrosis factorLaser surgeryExcision/grafting-Treatment aimed at stopping progression and preventing ulceration/infection. Unless ulcerated do not have to treat.-Many treatments because exact etiology is unclear, more than listed here.-topical/intralesional steriods lessen the inflammation of early active lesions.-Antiplatelet aggregation therapy, causes vasodilation, inhibits platelet aggregation.-Recurrence common after excision/grafting due to underlying vascular damage.
7Diabetic DermopathyAlso known as shin spots, most common cutaneous finding in diabetics (approximately 50% of diabetics).Round to oval atrophic hyperpigmented lesions on the pretibial areas of the lower extremities. Early lesions usually raised, then flatten. Brownish hyperpigmentation due to hemosiderin deposits.Occur bilateral with asymmetrical distribution.-Can occur in anyone after an injury or trauma to the area. Can occur forearm, thighs, side of foot, scalp, trunk. > 4 or more lesions indicative of diabetes. Can take up to 2 years to resolve.-Lysis of erythrocytes leaves hemosiderin deposits causing brownish hyperpigmentation.-No treatment necessary.-Etiology-diabetes causes changes to small blood vessels that supply the skin. Leakage of blood products from vessels to skin
8Diabetic DermopathyAsymptomatic, resolve spontaneously leaving a scar usually following improved blood glucose control.Usually occurs in older diabetic patients who have had diabetes >10 years.Occurs more frequently in diabetic patients with retinopathy, neuropathy, and nephropathy.Can be indicator of poor control of blood glucose levels.
9Diabetic Dermopathy-Asympromatic, no treatment necessary.
10Diabetic BullaeBlisters occur spontaneously in diabetic patients, atraumatic/asymptomatic lesions on feet and legs.Patients tend to have adequate circulation in the affected extremities and peripheral neuropathy.Three types of Diabetic Bullae:-Most common: Sterile fluid containing that heal withoutscarring.-Hemorrhagic, heals with-Multiple nonscarring onsun exposed/tan skin.-Small percentage of patients with diabetes develop spontaneous blistering on feet/legs.-Heal without treatment, however can rupture-develop an ulcer and become infected secondarily.-Picture: Intact blister
11Diabetic Bullae Usually resolve without treatment within 2-5 weeks. Therapy should be aimed at preventing ulceration and secondary infection.-Left: spontaneous blister with crusted region-Right: ulcer and cellulitis that developed as a complication of a ruptured blister.
12Diabetic BullaeWhen they occur in the feet can resemble friction blisters, however usually an absence of trauma.Again occur spontaneously etiology unkown: possible photosensitivity, increased in pressure resulting from edema of cardiac failure possible enough to result in blisters, decreased threshold to trauma.One paper said develop more frequently in patients with uncontrolled diabetes and severe peripheral neuropathy.
13Eruptive XanthomasOccur in hyperlipidemic/hyperglycemic states: uncontrolled diabetic patients.Most common in young men with Type 1 diabetesResistance to insulin makes it difficult for the body to clear the fat from the blood.-Close up of eruptive xanthoma
14Eruptive XanthomasUsually asymptomatic firm, waxy, yellow papules in the skin.Enlargements can have erythematous halo, can itch.Occurs most often on the back of hands/feet, arms/legs, buttocks, face-eyes.
15Eruptive Xanthomas Increase risk of developing pancreatitis. Eruptions can resolve in a few weeks with hyperlipidemic/hyperglycemic control, lipid lowering medications.-Spontaneously resolve when serum lipids return to normal.-Diet modifications, exercise-weight loss, medication
16Acanthosis Nigricans Hyperpigmentation and thickening of epidermis Precedes diabetes, considered a marker for the disease, most common in overweight diabetic patients.Usually occurs in skin folds, often described as velvetyNeck, back, axillae, groin region, over joints in the hands/feet.
17Acanthosis NigricansExact mechanism is unknown, thought to be a manifestation of insulin resistance, high concentrations of insulin may stimulate growth factor receptors on keratinocytes promoting epidermal cell proliferation.
18Acanthosis Nigricans Classification: 5-8 types Type 1: hereditary-benignType 2: endocrine disorders-diabetes, benignType 3: complication of obesityType 4: drug inducedType 5: malignantGenetically inherited, hypothyroidism, hyperthyroidism, acromegaly, polycystic ovarian disease, cushing’s diseaseImportant to rule out underlying endocrine disorders and malignanciesNo cure: weight loss, exercise, nutrition, creams may help-Cushing’s:hyperpituitarism characterized by an abnormally high level of ACTH produced by the anterior pituitary.-Can precede symptoms of malignancy by 5 years.
19Kyrle’s Disease Also known as perforating dermatosis. Rare condition, except in setting of diabetes with chronic renal failure.Large papules with central keratin plugs, widespread pattern seen in patients undergoing dialysis.Itching/scratching present-Work up includes sugar levels, LFT, renal function-UA, creatinine
20Kyrle’s DiseasePrimary location: extensor surfaces of the lower extremity, but can occur on face and trunk.Seen with DM, CHF, hepatic abnormalities-alcoholic cirrhosis, renal diseaseElimination of collagen and elastin throughout epidermis.-Cause unknown, host inflammatory response, alteration of dermal connective tissue, inherited-No known triggers
21Kyrle’s DiseaseCan be difficult to treat: have to manage underlying systemic disorderAntihistamines, antipruritics, topical corticosteriods,Retinoic acid, UV light therapy, laser therapyRapid improvement and resolution of lesions is seen once underlying disease is treated.
22ConclusionNearly all patients with diabetes eventually develop cutaneous manifestations of the disease.It is valuable to recognize for diagnosis, management, and treatment.Leads to prevention of ulcerations, infections, amputations.-Can reflect overall control of glucose levels, lipids…..-Can be treated and prevented if caught early…….
23References1. Chakrabarty A, Norman R, Phillips T. Cutaneous Manifestations of Diabetes. Wounds (8).2. Huntley A. The Skin and Diabetes Mellitus. Dermatology Online Journal. Dec (2).3. Bhat Y, Gupta V, Kudyar RP. Cutaneous Manifestations of Diabetes Mellitus. International Journal of Diabetes (4):4. Hattem S, Bootsma A. Skin Manifestations of Diabetics. Cleveland Clinic Journal of Medicine (11):5. Dermnet: Skin Disease Image Atlas. Interactive Mecical Media6. Perez M, Kohn S. Cutaneous Manifestations of Diabetes Mellitus. Journal of the American Academy of Dermatology. 30 (4):7. Eaglstein W, Callen J. Dermatological Comorbidities of Diabetes Mellitus and Related Issues. Archives of Dermatology (4):