October 1998, Volume 48, Issue 10

Original Article

Cutaneous Manifestations of Diabetes Mellitus

Zamaz Wahid  ( Department of Dermatology, Dow Medical College and Civil Hospital, Karachi. )
Anjum Kanjee  ( Department of Dermatology, Dow Medical College and Civil Hospital, Karachi. )

Abstract

Of 100 cases of diabetes mellitus examined for cutaneous findings 82% showed cutaneous lesions. Infection (49%) was the most common finding followed by involvement of foot (30%). High incidence of vitiligo (10%) and localized anogenital pruritus (19%) was an unusual feature. Some of the cutaneous markers of diabetes mellitus like necrobiosis lipoidica diabeticorum, diabetic bullae, acquired perforat­ing dermatoses and scieredema were not seen in this study (JPMA 48:304, 1998).

Introduction

Dermatological abnormalities are common in diabetes mellitus. Atleast 30% of persons with diabetes have some type of cutaneous involvement during the course of their disease1. The actual prevalence probably approaches 100%, if metabolic effects on microcirculation and changes in skin collagen are considered2. Skin manifestation can be a presenting symptom in some patients. Also trivial skin problems can lead to a major and even fatal complication in diabetics. Skin finding may be used as an indicator of patients present as well as past metabolic status. This study was done to highlight the cutaneous associations of diabetes mellitus in our patients.

Patients and Methods

One hundred cases of diabetes mellitus presenting at the diabetic clinic of Civil Hospital, Karachi were examined for cutaneous findings. There were 62 males and 38 females whose ages ranged from 12 to 74 years. Maorit (81) had type II diabetes with an average duration of 8 years, while 19 suffered from type-I diabetes with an average duration of 7.5 years. Investigation performed included urine for sugar, ketone and protein, fasting and 2 hours postprandial blood sugar, blood urea, serum creatinine, liver function tests, serum cholesterol, serum triglycerides, E.C.G., serum electrolytes and serum proteins. Special investigations like culture and sensitivity of pus, skin scrapings for fungal infections and biopsy of skin lesions was done in selected cases to support the clinical findings in skin.

Results

Of 100 cases examined, 82% had some kind of a cutaneous lesion. More than one type of skin lesions were often found in some patients. Cutaneous infections were most frequent (49%). The most common infection was staphylococcal pyodermas (3 3%) including furuncles (22%), abscesses (2%), cellulitis (3%) and carbuncle (1%). Candidiasis seen in 13%. Nine patients had vulvovaginits, 2 had intertrigo, 2 paronychia and there was one case each of angular stomatitis and thrush.
Involvement of the foot was seen in 30% patients. In majority of cases both ischemic and neuropathic lesions were present simultaneously. Paresthesia was the major complaint in 22 patients. The foot changes observed were callosities (11%), infections (8%), ulcers (7%), clawing of toes (7%), trophic changes (6%), gangrene (3%), coldness of feet (10%) and amputated toes/or foot (5%).
Psedomotor disturbances were seen in 24 patients in the form of hyperhidrosis (16%), hypohidrosis (9%) and gustatory sweating (1%). Pmritus was present in 22 patients.
Of these 19 patients had localized anogenital pruritus while 3 had generalized pruritus. Other findings included skin tags (17%), oral findings (17%), finger pebbles (14%),diabetic dermopathy (12%), vitiligo (10%), nail changes (9%), cheny angiomas (9%), naevi (9%), thickened hand skin (8%), acanthosis mgncans (5%), limited joint mobility (4%), xanthomas (4%), seborrhoeic dermatitis (4%), lichen simplex (4%), seborrhoeic keratoses (3%), therapy complications (5%).
Oral involvement was seen in 17 patients. Thirteen cases had dental caries, 8 tartar deposition, 7 gingivitis , 2 leukoplakia, 2 candidiasis and 1 had lichen planus. There was one case each of Dupuytren’s contracture, yellow skin, localized granuloma annulae, rubeosis, lichen planus and psonasis.

Discussion

A number of dermatological conditions are associated with or are a sequalae of diabetes mellitus. Many of the associations may simply be a chance finding due to high prevalence of diabetes in the general population. Itis suggested that a large number of the dermatological problems in diabetics are caused by hyperglycemia accelerated production of non-enzymatic advanced glycolsylated end products1.
Perez and Kohn stated that about 30% of diabetics have some cutaneous involvement during the course of their disease2. In our study 82% patients had some kind of skin lesions attributed to diabetes, which indicates a high incidence of cutaneous involvement.
Forty-nine percent patients had cutaneous infections. The diabetic state decreases the resistance of host to infection by impairing many functions of the neutrophils3. Specific infections in diabetics such as rhinocerebral muconnycosis and non- clostridial gas gangrene may be linked with the diabetic state3. However, the most common infections in diabetics am staphylococcal pyodermas and candidiasis4. These are probably more frequent in patients with poorly controlled disease5.
Involvement of the foot was the second commonest finding (30%) in our study. The pathogenesis of the foot lesions in diabetics is complex and principally caused by neuropathy, ischemia and infection6. Foot problems are seen in about a quarter of diabetic patients7. In majority of eases both ischemic and neuropathic lesions are present simultaneously.
Psetidomotor disturbances were also a common finding. Diabetic neuropathy commonly involves a variety of nerves, including the autonomic fibres8. Fealey et al observed sweating abnormalities in 94% patients with diabetes who had findings suggestive of neuropathy8. The frequency of generalized pruntus in diabetes is unknown. Localized anogenital pruritus appears to be a manifestation of diabetes. In one study, the incidence of localized pruritus in diabetics was 3.4%9. The relatively high incidence of localized pruritus in our study is an unusual feature.
The relatively common occurrence of finger pebbles in diabetics is reported by several authors10. In the present study Pebbly pattern of periungual and knuckle skin was seen in 14% patients, 6% of these patients also had thickened, hand skin. Diabetic cheirarthropathy is reported in 30-40% of insulin dependent diabetics and 4-70% of non-insulin dependent diabetics11. These changes are probably caused by glycosylation of collagen with consequent change in its physical properties.
Dermatopathy is the most common finding in diabetes mellitus occuring in 30% to 60% of patients2. In our study this was observed in 12% patients. The exact pathogenesis of dermopathy in diabetics is still obscure but it nmy be a cutaneous marker of microangiopathy at other sites1. The incidence of vitiligo in diabetics varies from 1-70%12. In our study the high incidence of vitiligo is an unusual feature (10%). In general population the incidence of vitiligo is 1%13. In our study, 7 patients had NIDDM and 3 had IDDM.
The occurrence of acanthosis nigricans is common in diabetics2 and insulin resistance is the key factor underlying its development. This was present in 5% cases in the present study, 4 patients were obese type 2 diabetics and one had type 1 diabetes. Allergic reactions to insulin occur in 10 to 50% of patients2, 2% patients in this study had generalized urticaria from insulin therapy. Reactions with oral hypoglycemic agents were seen in 3 patients, 2 had photosensitivity and 1 had ervthema nodosum. Some of the cutaneous markers of diabetes mellitus including necrobiosis lipoidica diabeticorum, diabetic bullae, acquired perforating dermatoses and scleredema were not seen in our study.

References

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2. Perez MI, Kohn SR. Cutaneous manifestations of diabetes mellitus. J. Am. Acad. DermatoL, 1994;30:519-31.
3. Rayfield EJ, Ault MJ, Keusch GT et al. Infection and diabetes: The case for glucose control. Am. J. Med., 1982:72:439-47.
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5. Alberti KGMM, Hockaday TDR. Diabetes mellitus In: Oxford Textbook of Medicine. Weatherall DJ, Ledingham JOG, Warrell DA (eds), Oxford, Oxford University Press, 1987, pp. 9,51, 9,91.
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7. Lipsky BA. Diabetic foot infections. Int. J. Dermatol., 1991:30:560-62.
8. Fealey RD. Low PA and Thomas JE. Thermoregulatory sweating abnormalities in diabetes mellitus. Mayo Clin. Proc. 1989:64:617- 28.
9. Huntley AC. Cutaneous manifestations in diabetes: General considerations. In: The skin in diabetes. Jelinek, JE (ed). Philadelphia, Lea and Febiger, 1986, pp. 23-28.
10. Huntley AC. Finger pebbles : A common finding in diabetes meHitus. J. Am. Acad. Dermatol., 1986;14:612-17.
11. Burton JL. Disorders of connective tissue. In: Textbook of Dermatology. Champion, Burton, Ebling (eds). Oxford, Blackwell, 1992;3:1812-18.
12. Jelinek JE. Dermatoses reported to be more frequent in diabetes. In: The skin m diabetes. Jelinek JE (eds) Philadelphia, Lea and Febiger, 1986, pp. 175-202.
13. Bleehen S Ebling FJG and Champion RH. Disorders ofskin colour. In Text book of Dermatology. Champion, Burton Ebling (eds). Oxford, Blackwell, 1992;3:1609.

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