Cutaneous Manifestations of Diabetes Mellitus Dr Noreen Cowley MD FRCP Consultant Dermatologist

No Pathonomonic Skin lesion in Diabetes Cutaneous No Pathonomonic Skin lesion in Diabetes

Cutaneous Manifestations of Diabetes 30% incidence cutaneous disorders ADA 70% during course of illness 15% ulceration However Over time nearly all patients will develop cutaneous complications of the disease. While mostly seen in established diabetes cutaneous signs can heighten the suspicions of a physician regarding the diagnosis of diabetes.

Cutaneous Manifestations of Diabetes Hyperglycaemia Neuropathy Impaired host response Microvascular angiopathies with failure of the microcircutation to meet the metabolic requirements of the skin Similar to other complications such as retinopathy and nephropathy skin manifestations are largely the result of a combined effect. IN GENERAL PATIENTS WITH TYPE 2 MORE OFTEN DEVELOP SKIN INFECTIONS WHERAS TYPE 1 MORE OFTEN DEMONSTRATE AUTO IMMUNE RELATED SKIN PROBLEMS.

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 Skin manifestations of diabetes are common and expressed in many and different forms. Range from what we may consider mundane to the more severe particularly in long standing disease. So recognition is crucial for treatment so by the end of this short presentation we will have visually experienced a wide range of the skin problems we encounter in diabetes.

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 manifestations of diabetes are common and expressed in many and different forms. Range from what we may consider mundane to the more severe particularly in long standing disease. So recognition is crucial for treatment so by the end of this short presentation we will have visually experienced a wide range of the skin problems we encounter in diabetes.

Skin Infection 20-50% (Type 2) poor glycaemic control Poor micro and macro-circulation Neuropathy Altered immune response Dermatoses “portal of entry” Sensory neuropathy, vascular disease and hyperglycaemia all predispose diabetics to skin and soft tissue infections.

Skin Infection Staphylococcus folliculitis Superficial fungal infection Cellulitis and erysipelas Oral and genital candida Non pathogenic organisms mucormycosis by phycomycetes and anaerobic cellulitis by clostridium species These skin infections occur with increased frequency..Cellulitis lymphangitis and staph sepsis can complicate even the most minor wound. We know that staph sepsis does occur more commonly and is more often fatal in diabetics Also normally non pathogenic organisms can have devastating effects in the diabetic.

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 Skin manifestations of diabetes are common and expressed in many and different forms. Range from what we may consider mundane to the more severe particularly in long standing disease. So recognition is crucial for treatment so by the end of this short presentation we will have visually experienced a wide range of the skin problems we encounter in diabetes.

Necrobiosis Lipoidica Necrobiosis means collagen degeneration You get degeneration of collagen in the dermis and subcutaneous fat with pallisading histiocytes. DESCRIBE Initial lesion 1. Well circumscribed plaque 2. Waxy Telangetatic centre

Necrobiosis Lipoidica The vast majority occur on the legs. Mainly shins also ankles. Do SEE ELSEWHERE BUT WHEN YOU DO it is less likely to be associated with Diabetes. .

Necrobiosis Lipoidica Aetiology Microangiopathy –---collagen degradation with release cytokines from inflammatory cells – destruction collagenous matrix Little evidence correlation retinopathy/nephropathy Aetology not well defined. The most popular theory is that

Necrobiosis Lipoidica 0.3-0.7% One third of lesions ulcerate if predisposed to any trauma Treatment No effective Protect

Differential Diagnosis Differential diagnosis GA. Because of its histo similarity to necrobiosis an association with diabetes has been suggested and someetimes there is a positive family history

Generalized Granuloma Annulare This is generalized GA..CANT SEE THE TYPICAL RINGS.BUT TOU CAN SEE THE TYPICAL DERMAL PAPULES ITS said this type has more of an association with diabetes but its still controversial

Diabetic Dermopathy “Shin Spots” Shemer et al 40% Men – 50yrs Athough 20% non-diabetics have it the presence of 4 or more lesions is always linked to patients with diabetes. HISTOLOGY SHOWS THICKENED SUPERFICIAL BLOOD VESSELLS WITH EXTRVASATION AND MILD LYMPHO INFILTRATE

Diabetic Dermopathy Severe microvascular complications Retinopathy,neuropathy,nephropathy Closely linked to glycosylated Hb High risk of accelerated diabetes complications THIS IS IMPORTANT CONDITION TO RECOGNIZE BECAUSEIt is important as it tends to reflect microvascular pathology else where and it may precede abnormal glucose metabolism. HOW IT STARTSPresent as multiple, bilateral asymmetrical annular or irregular papules/plaque on the extensor surfaces of the lower leg. The clinician usually sees the end result ..atrophic scarred hyperpigmented fineely scaled macules. May see also on the forearms, thighs and lateral malleoli. Think it may be a magnified response to injury/trauma. Tends to be in patients with long standing diabetes.. Tends to go after a few years particularly following improved blood glucose control.

Bullosis Diabeticorum Presents as asymtomatic bullae containing sterile fluid on a non-inflamed base, usually arising spontaneously on the dorsa and sides of the lower leg and feet,sometimes on the hands and forearms. The cause is unknown and it is a diagnosis of exclusion. Diff Dx

Bullosis Diabeticorum Type 1 Diabetes 0.5% Men Longstanding Disease Peripheral Neuropathy Treatment is symptomatic and conservative. Normalize blood glucose If discomfort..aspirate Resolve without scarring 2-3 weeks

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 Skin manifestations of diabetes are common and expressed in many and different forms. Range from what we may consider mundane to the more severe particularly in long standing disease. So recognition is crucial for treatment so by the end of this short presentation we will have visually experienced a wide range of the skin problems we encounter in diabetes.

Eruptive Xanthomas CAUSEUasually associated with chylomicron xcss ie TRIGLERIDE RICH LIPOPROTEINS.secondary to 1 uncontrolled daibetes, alcolol abuse or exogenous estrogens. There is reduced protein lipase activity or increased hepatic VLDL which results in the chylomicrons being less able to compete for lipoprotein lipases. APPEARANCEThe eruptive xanthomas can also be quite itchy. They are 1-mm yellow papules and youll often see a red galo around them with the koebner phenomenon from scratching DISTRIBUTION Seen her on buttocks which is typical and also see on extensor surfaces TREATMENT OTHER CAUSES CAN ALSO GET IN LIPOPROTRIN LIPASE DEF IN KIDS TYPE1 HYPERLIPIDAEMIA AND TYPE V FAMILIAL IN ADULTS

Scleredema of Buschke History The patient may have a low grade fever, malaise myalgia and arthralgia which is followed very suddenly by non pitting swelling and induration of the skin. DistributionIt affects the shoulders,back of neck,sometimes the face arms and chest and occ buttocks and legs Morphology The skin feels hard and woody that is diffuse with loss of skin markings. And it looks shiny and stretched. Treatment No specific rx..electron beam therapy

Scleredema of Buschke Type 2 Obese Therapy resistant Cardiovascular Retinopathy The cause is unknown There is replacement of the subcutaneous tissue by fibro muninous connective tissue. Athough it has other association there is a strong asociation with severe MOD. Patients are usually obese resistant to therapy and have cardiovascular disease and retinopathy.

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 Skin manifestations of diabetes are common and expressed in many and different forms. Range from what we may consider mundane to the more severe particularly in long standing disease. So recognition is crucial for treatment so by the end of this short presentation we will have visually experienced a wide range of the skin problems we encounter in diabetes.

Acanthosis Nigricans Kahn 1975 association with 8 types Obesity – Acanthosis Nigricans Kahn 1975 association with insulin resistance Describe

Acanthosis Nigricans Mechanism? High insulin concentrations stimulate insulin–like growth factor receptors on keratinocytes promoting epidermal cell proliferation Describe clinic features

HAIR-AN Syndrome HyperAndrogenism Insulin Resistance Acanthosis Nigricans

HAIR-AN Syndrome Type A I R Mutation gene that encodes the insulin receptor Tall black young females Severe acanthosis nigricans begins 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 Skin manifestations of diabetes are common and expressed in many and different forms. Range from what we may consider mundane to the more severe particularly in long standing disease. So recognition is crucial for treatment so by the end of this short presentation we will have visually experienced a wide range of the skin problems we encounter in diabetes.

Auto-Immune Disorders Vitiligo 1-7% in diabetes 0.2-1% non-diabetic

Lichen Sclerosis et Atrophicus Ivory white papules with telangectasia

Lichen Sclerosis et Atrophicus Wrinkling in add to white papules 2 obliteration normal vaginal structures

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 Skin manifestations of diabetes are common and expressed in many and different forms. Range from what we may consider mundane to the more severe particularly in long standing disease. So recognition is crucial for treatment so by the end of this short presentation we will have visually experienced a wide range of the skin problems we encounter in diabetes.

Cutaneous effects of Therapy Insulin Oral hypoglycaemic agents Metformin Psoriasiform drug eruption Erythema Multiforme Leucocytoclastic Vasculitis

Lipoatrophy/hypertrophy Thighs/arms children and young women Lipohypertrophy Males Subcutaneous deposition fat at injection sites Insulin –induced stimulation of adipose tissue growth Lipoatrophy presents as a circumscribed depressed area of skin at the site of insulin injection 6-24 months after start of therapy ?inflammatory process mediated by the immune complex Become rare since the introduction of purifed recomitant human insulin.

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 Skin manifestations of diabetes are common and expressed in many and different forms. Range from what we may consider mundane to the more severe particularly in long standing disease. So recognition is crucial for treatment so by the end of this short presentation we will have visually experienced a wide range of the skin problems we encounter in diabetes.

Perforating Collagenosis These lesions are associated with intence pruritus. Start as pinhead papules that grow into larger papules and nodules in a few weeks They are umbilicated dome shapes with a central adherent keratin plug

Perforating Collagenosis Elimination of focally damaged collagen through the epidermis He fact pts usually have intense pruritus, show the koebner phen in scratches and that it occurs on trauma prone areas suggests that trauma may be ab nb part of its aetiology

Necrolytic Migratory Erythema Stomatitis Weight Loss Diabetes 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 CLINICAL Annular or circinate lesions, starts as erythema that blisters and erodes leaving post inflammarory hyperpigmentation. The lesions are migratory.Each takes a couple of weeks to evolve and heal. DISTRUBUTION Lesions extend from lower abdomen,buttock groins and thighs. SYSTEMIC diarrhoea,anaemia venous thrombosis and psychiatric distunbances Local resection if localized or somatostatin to inhibit glucagon secretion

Thankyou Any Questions?