Cutaneous manifestation of diabetes melitus
R V Koranne
A-703, Rosewood Apartments, Mayur Vihar, Phase - I, New Delhi - 110 091
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Mahajan S, Koranne R V, Sharma S K. Cutaneous manifestation of diabetes melitus. Indian J Dermatol Venereol Leprol 2003;69:105-108
AbstractOne hundred consecutive diabetes mellitus patients attending the diabetic clinic of the hospital constituted the study group. One hundred age and sex matched non-diabetics were taken as controls. The majority, 63%, belonged to the 41-60 years age group and 98% had non-insulin dependent diabetes. Among the study group, 64% had one or more cutaneous manifestations as compared to 22% in the controls. This was statistically highly significant (p<0,001). Infections comprised the largest group affecting 35 of the 64 cases. Among the bacterial infections, pyodermas were observed in 11 and erythrasma in one. Fungal infections were seen in 21, dermatophytoses in 11, and candidiasis in 10. Herpes zoster was seen in 2 cases. Pruritus was observed in 10, neurological abnormalities in the form of paresthesias was seen in 6, mal perforans in one, and meralgia paresthetica in one. Diabetic dermopathy was seen in 6 and rubeosis in 4. Six dermatoses strongly associated with DM were seen, namely one each of waxy skin syndrome, granuloma annulare, eruptive xanthoma, scleredema adultorum, and 2 cases of diabetic bulla.Ten patients exhibited other dermotoses less associated with diabetics: xanthelasmo palpebrarum in 5 patients, acrochordi in 4, and pigmented purpuric dermatoses in one.
Likewise syndromes of insulin resistance were seen in 4 patients of whom 3 had aconthosis nigricans and one had congenital lipodystrophy. Forthermore,9 patients had dermatoses known to be associated with an increased incidence of diabetes; vitiligo in 4, acquired perforating dermatoses in 3, and lichen planus in 2. Four patients hod dermatoses known to be associated with diabetes: psoriasis in 3 and diffuse alopecia in one. Three had adverse drug reactions to anti-diabetic therapy.
Diabetes mellitus (DM) is the most common endocrine disorder. It exhibits a variety of multisystem complications involving the blood vessels, skin, eye, kidney, and the nervous system during the course of the disease process. Abnormal carbohydrate metabolism, other altered metabolic pathways, atherosclerosis, microangiopathy, neurone degeneration, and impaired host mechanisms all play roles. Gilgor and lazarus observed that at least 30% of patients with diabetes mellitus have some type of cutaneous involvement during the course of their chronic disease. A number of classifications delineating dermatoses observed in DM have been proposed .2-′However Sehgal and Shanker opined that no diseases of the skin are absolutely peculiar to diabetes, except three dermatoses the incidence of which is more common in diabetics than in non-diabetics. Thus, the present study is significant in view of the increasing prevalence of diabetes mellitus and in the present scenario of a sedentary life style in the general population.
Materials and Methods
One hundred consecutive patients attending the diabetic clinic of the Smt. Suchetha Kripalani hospital constituted the subject material of the present study. One hundred age and sex matched non-diabetic patients attending the Medicine out patient department constituted the control group. Patients with the family history of diabetes, with gestational diabetes and with impaired glucose tolerance were excluded from the control group. The diagnostic criteria employed for diabetes mellitus followed the current recommendations of the Washington manual of medical therapeutics. A detailed history was elicited in each case with particular reference to cutaneous complaints and including details regarding duration, history of evolution, progression and treatment modalites, if any. A detailed dermatological examination, serum cholesterol, liver and kidney function tests and electro-cardiogram were carried out. Assessment of diabetic retinopathy was done by an opthalmologist. Assessment of diabetic neuropathy was done on the basis of the criteria detailed by Foster. Relevant microbiological and histopathological investigations were carried out to confirm the clinical diagnosis.
The age distribution of the cases showed that the most common age groups were 31-40 years (21%), 41-50(33%) and 51-60 years (30%). There were 58 females and 42 males, the male-female ratio was 1:1.38. The majority (98%) of patients were having non-insulin dependant diabetes mellitus: only 2% were suffering from the insulin dependant type. Of the 100 diabetic patients, 64 had one or more associated cutaneous manifestations [Table - 1]. On the other hand, of the 100 age and sex matched controls, only 22 had cutaneous manifestations. The cutaneous manifestations were thus positively associated with diabetes and when tested, were statistically significant (p< 0.001). Incidence of cutaneous patients had dermatoses strongly associated with DM including one each with waxy skin syndrome, granuloma annulare, eruptive xanthoma, scleredema adultorum and 2 cases of diabetic bullae. Ten patients had other skin conditions less associated with diabetes such as xanthelasma palepebrarum (5), acrochordi (4) and pigmented purpuric dermatosis (1). Insulin resistance was observed in 4 patients; 3 of these patients had acanthosis nigricans and one had congenital lipodystrophy. Nine patients had dermatoses which are known to be associated with an increased incidence of diabetes;4 had vitiligo, 3 had aquired perforating dermatosis, and 2 had oral lichen planus. Four patients had dermatoses with possible association with DM, 3 had psoriasis,one had diffuse alopecia,and 3 developed cutaneous drug reactions due to anti-diabetic therapy. Among the pyodermas which were seen in 11 cases, folliculitis was seen in 7, and one case each had bullous impetigo, carbuncle, ecthyma, and I, E.D. Dermatophytoses were seen in 11 patients, comprising tinea unguium in 5, tinea corporis et cruris in 4, and tinea pedis and tinea incognito in one case each. Candidal intertrigo in 2 and candidal paronychia in one patients. Herpes zoster was seen in 2 patients [Table - 2]. Cutaneous infections were found to be positively associated manifestations was more common during the first six years of diabetes. The various cutaneous manifestations observed in the present study as per the classifications of Huntley" are delineated in [Table - 2]. Cutaneous infections bacterial and fungal, constituted the largest group affecting 35 (54.69%). Of the 64 cases having cutaneous manifestations pruritus was second most common manifestation (15.62%) in the present study. Cutaneous manifestations due to vascular abnormalities in DM were seen in 10 patients, of which 7 had diabetic dermopathy and 3 had rubeosis facie. Eight patients had cutaneous involvement due to neurological abnormalities. Six with diabetes (Q=+0.5259) and when tested, the association was found to be statistically significant (p< 0.05).
Association with other diabetic complications
[Table - 3] delineates the systemic complications of DM in patients with and without cutaneous manifestations. Hypertension was seer in a higher percentage of cases with cutaneous manifestations (53.1 %) than in those without such manifestations (22.2%). Likewise retinopathy, nephropathy and peripheral vascular disease (PVP were in higher percentage of cases i.e 12.55% vs 11.1, 6.2%vs 5.6% and 4.7 vs 2.8%,although the difference was not statistically significant. Coronary artery disease (CVD) was slightly more common in patients without cutaneous lesions (13.8%) than in those with cutaneous manifestations (12.5%).
Correlation of dermangiopathy and other diabetic complications
The cutaneous manifestations observec in this group of cutaneous microangiopathic lesion; were diabetic dermopathy (6), rubeosis faciei, and diabetic bullae. Retinopathy was more commor in patients with cutaneous microangiopathic lesion; (58.3%). Similarly, neuropathy was also more common in this group of patients (25.0%) Hypertention showed a moderately positive association (Q=+0.5283) with cutaneou: microangiopathic lesions, but, when this was no found to be statistically significant (0>0.05, likewise,no correlation could be established between CAD, PVD, nephropathy, and dermang. iopathy.
Cutaneous manifestations in the group
Twenty-two patients out of 100 age and sex matched controls had cutaneous lesions. Infection formed the largest group (27.3%), followed by acne vulgraris (22.7%). Localised pruritus was seen in 3 patients (13.6%).Two patients (9.1 %) each had acrochordi, and senile angiomas, and one patient each had pseudoacanthosis nigricans and vitiligo.
Most documented studies have shown the incidence of cutaneous disorders associated with diabetes to be between 30% and 71.,, In this present study 64% of diabetic patients had one or more cutaneous manifestations as compared to only 22% of non-diabetic controls. The incidence of cutaneous manifestations showed a moderately positive association with diabetes (Q=+0.7261) and when tested, it was statistically highly significant (p< 0.001).
Gulati et al reported cutaneous infections in 49% of diabetics in their study group. In the present study also,infections formed the largest group affecting, 54.69% of the 64 cases having cutaneous manifestations. Pruritus was the second most common manifestation, and was seen in 15.62% patients in the present study. Rao and Pai also found that pruritus was the main presenting symptom and was noted in 60.23% patients in their series.
The cutaneous signs primarily due to microangiopathy, seen in our study group were diabetic dermopathy (9.37%) and rubeosis faciei has variously been reported in the range of 3.5% to 59%. The lesser incidence of both these conditions in an Indian study can be attributed to dark-skinned individuals in the Indian subcontinent.
Only 2 patients were noted to have diabetic bullae in the present work. One patient with insulin dependent diabetes mellitus was observed to have waxy skin and stiff joint syndrome. Scleredema diabeticorum was observed in one female (1.56%) with long standing NIDDM.
One patient in the present study with uncontrolled IDDM presented with eruptive xanthoma (1.56%) and was found to have hypotriglyceridemia. Our observations are comparable with those of Ramano et al who observed similar changes in 1.25% of their cases. Dermatoses associated with an increased incidence of DM, like vitiligo (4), lichen planus (2), acquired perforating dermatoses(3) were also detected in the present study as documented earlier. In the present work, 3 patients showed drug reactions to oral anti-diabetic drugs.
Association with other diabetic com-plications
The complications of diabetes are formidable, and no organ appears to be immune from the effects of this disease. The skin is only one of the organs affected. In the present study, a high percentage (89%) of patients with cutaneous manifestations was found to have systemic complications like hypertention, retinopathy as compared to the diabetic patients without cutaneous maninfestations (55.5%).
Correlation of dermangiopathy with other diabetic complications
Diabetic angiopathy does not obey any anatomical or physiological boundary. It affects the large arteries (macro-angiopathy) causing coronary artery disease, cerebrovascular accidents and peripheral vascular disease and the smallest capillaries (micro-angiopathy) causing retinopathy, neuropathy, nephropathy,and dermangiopathy. Such vascular complications are the leading cause of morbidity and mortality amongst the diabetics. In the present study, the correlation of skin manifestations of diabetic mico-angiopathy with other complications of diabetes was calculated. Out of the 12 cases with dermangiopathic lesions, 9(75%)had hypertension, whereas only 48.15% patients without dermangiopathic lesions had hypertention. Thus, hypertension showed a moderately positive association (Q=+0.5283) with dermangiopathy. Parving hypothesized that hypertention may accelerate the process of microangiopathy.
Likewise, neuropathy was found in 25% of patients with dermangiopathy but only 9.6% patients without diabetic dermangiopathy. This observation is in consonance with the findings of Binkely that diabetics with peripheral neuropothy are more likely to develop diabetic dermopathy. Retinopathy was also more common (58.3%) in patients with dermangiopathy than in those without it (1.9%) Binkely also reported an association between retinopathy and dermopathy.
In the final analysis, we agree with the studied opinion of Rao and Pai that the cutaneous manifestations of diabetes mellitus are due to multiple factors including abnormal carbohydrate metabolism, other altered metabolic pathways, microangiopathy, atherosclerosis, neuron degeneration and impaired host defense mechanisms. Likewise, we concur with the observations of George and Fernandez that diabetes mellitus which affects every organ of the human system, also involves the skin and indeed the cutaneous manifestations are protean in nature.
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