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

3. No Pathonomonic Skin lesion in Diabetes
Cutaneous
No Pathonomonic Skin lesion in Diabetes

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. Erythrasma

11. 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.

12. 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

13. 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. .

14. 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

15. Necrobiosis Lipoidica%
One third of lesions ulcerate if predisposed to any trauma
Treatment
No effective
Protect

16. 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

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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.

27. 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.

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

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

30. HAIR-AN Syndrome HyperAndrogenism Insulin Resistance
Acanthosis Nigricans

31. 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

32. 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.

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

34. Lichen Sclerosis et Atrophicus
Ivory white papules with telangectasia

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

36. 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.

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

38. 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.

39. 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.

40. 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

41. 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

42. 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

43. Thankyou
Any Questions?