Cutaneous Manifestations of Internal Disease - mgsd.org · infection, tinea pedis should be treated aggressively in diabetics ... on the dorsum of the hand . Scleredema of Diabetes.

Cutaneous Manifestations

of Diabetes Mellitus

Dr.Hasan İlkova

Istanbul University

Cerrahpaşa Medical Faculty

Division of Endocrinology Metabolism and Diabetes

Diabetes Mellitus

Cutaneous lesions usually appear after the development of DM, but may be the first presenting sign

According to Perez et al (3) ,approximately 30% of patients with DM develop skin lesions at some point

Overall prevalence of cutaneous disorders does not differ between type I and type II diabetics Type I patients get more autoimmune-type lesions

Type II patients get more cutaneous infections

Skin Infections in DM

Occur in 20-50% of poorly controlled diabetics

More common in Type II

May be related to abnormal microcirculation, hypohidrosis, PVD, neuropathy, decreased phagocytosis and killing activity, impaired leukocyte adherence, and delayed chemotaxis all seen in diabetics

Candidiasis in Diabetics

White, curdlike material adherent to erythematous, fissured oral commisure; angular stomatitis


Fungal infections- most common

Candida Candidal paronychia

Inframammary candida

Genital candida

Psedudohyphae and spores on KOH prep support dx of Candida

Purulent drainage may indicate secondary bacterial infection

Because maceration and skin breaks can serve as portals of infection, tinea pedis should be treated aggressively in diabetics

Treatment includes drainage of any abscesses, keeping the digits dry, and topical antifungals (clotrimazole)


Initial pustules on erythematous base that become eroded and confluent



Bacterial Infections- can be more severe and widespread in diabetics

Malignant otitis externa

Pseudomonas aeruginosa

Fatal in over 50% patients (13)

Can progress to chondritis, osteomyelitis, and bacterial meningitis

Treat up to 3 months with oral quinolones but may need IV antibiotics

Malignant Otitis Externa in Diabetics

Erythrasma in Diabetics


Bacterial infections in DM

Erythrasma

Reddish tan scaling patches of the upper inner thighs, axillae, toe web spaces, and inframammary creases

Gram positive Corynebacterium minutissimum

Identified with Wood’s light coral fluorescence

Treat with oral erythromycin for 5 days

Erythrasma in Diabetics

Reddish tan scaling patches of the upper inner thighs, axillae, toe web spaces, and inframammary creases

Dermal Manifestations of Diabetes Mellitus

Diabetic Thick Skin

Yellow Skin

Diabetic thick skin

Knuckle Pebbles. Thickening of the skin on the dorsum of the hand

Scleredema of Diabetes. This patient with Type II diabetes gave an incidental complaint of limitation of motion of his upper extremities. To examination, this appeared to be due to the shield-like involvement of the upper back, neck, and shoulders with marked dermal thickening.

Vascular Manifestations of Diabetes Mellitus

Diabetic Dermopathy

Pigmented Purpura

Red Skin and Rubeosis Facei

Periungual Telangiectasia

Erysipelas-Like Erythema

Diabetic Dermopathy Also 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.

Diabetic Dermopathy Asymptomatic, 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.

Pigmented Purpura

Periungual Telangiectasia

Large vessel disease (atherosclerosis) may also be present in the lower extremities and result in:

skin atrophy

hair loss

coldness of the toes

nail dystrophy

pallor upon elevation

mottling on dependence

Other Skin Markers of Diabetes Mellitus

Yellow Nails

Diabetic Bullae

Necrobiosis Lipoidica

Eruptive Xanthomas

Acanthosis Nigricans

Kyrle’s Disease

Yellow Nail

Diabetic Bullae

Diabetic Bullae Approximately 0.5% of diabetics (2)

More common in men with long-standing DM and neuropathy

Pathogenesis not well-understood

Could be related to trauma with reduced threshold for blister formation Other theories include immunologic factors, disturbed catabolism of

calcium, magnesium, or carbohydrates, microangiopathy, and vascular insufficiency

Appearance

Painless bullae on non-inflamed base that appear suddenly Most common on the dorsa and sides of lower legs and feet,

sometimes with similar lesions on the hands and forearms Bullae contain clear, sterile fluid

Diabetic Bullae

Bullae tend to heal spontaneously in 2-5 weeks

Bullosis diabeticorum remains a diagnosis of exclusion with negative immunofluorescence studies, porphyrin levels, and cultures

DDx: bullous pemphigoid, epidermolysis bullosa acquisita, porphyria cutanea tarda, bullous impetigo, erythema multiforme, and coma blisters

If large and symptomatic, can aspirate the fluid leaving an intact blister roof as a wound covering

Diabetic Bullae Therapy should be aimed at preventing ulceration and

secondary infection.

Necrobiosis Lipoidica (NL)


NL appears in 0.3-1.6% of diabetics

Anywhere from 11-65% of patients with NL have DM at the time of skin dx

If they do not have DM at time of dx, about 90% will develop diabetes, have abnormal glucose tolerance, or report parents with DM

Diabetic control has no effect on the course ofNL.

According to Jelinek, NL appears earlier (mean age 22) in Type I diabetics than Type II (mean age 49.)


Classically, NL occurs bilaterally on the pretibial or medial malleolar areas.

Not painful.

Spontaneous resolution occurs in 13-19% with residual scarring.

Treatment: potent topical steroids, intralesional steroids at the active border, or rarely systemic steroids


Eruptive Xanthomas Occur in hyperlipidemic/hyperglycemic states:

uncontrolled diabetic patients.

Most common in young men with Type 1 diabetes

Resistance to insulin makes it difficult for the body to clear the fat from the blood.



Seen in situations of insulin resistance Besides in DM, also seen in the following:

Carcinomas, especially of the stomach Secondary to meds (nicotinic acid, estrogen, or

corticosteroids) Pineal tumors Other endocrine syndromes (PCOS, acromegaly,

Cushing’s disease, hypothyroidism) Obesity

Pathogenesis According to Cruz , it may be related to insulin binding

insulin-like growth factor receptors on keratinocytes and dermal fibroblasts, thus stimulating growth.


Appearance

Hyperpigmented, velvety plaques in body folds, mostly axillae and neck

Can also present on groin, umbilicus, areolae, submammary areas, and on the hands (tripe hands)

Treatment- usually asymptomatic

Weight loss

Retinoic acid and salicylic acid


Kyrle’s Disease Primary location: extensor surfaces of the lower

extremity, but can occur on face and trunk.

Seen with DM, CHF, hepatic abnormalities-alcoholic cirrhosis, renal disease

Elimination of collagen and elastin throughout epidermis.

Granuloma Annulare (GA)


Controversy surrounds the association between GA and DM.

A case-control study by Nebesio et al. failed to reveal a statistically significant correlation between the two.

A retrospective study by Studer et al. suggested that up to 12% of patients presenting with GA had DM.

Despite conflicting studies, it is reasonable to screen patients presenting with GA for DM.

Granuloma Annulare (GA) Appearance

Ring of small, firm, flesh-colored or red papules

If localized, most frequently found on lateral and dorsal surfaces of hands and feet

Can spontaneously regress without scarring

Pathogenesis unknown

Treatment : If localized, best left untreated.Can treat with intralesional steroids, if needed. If generalized, can also use dapsone, isotretinoin, freezing, cyclosporin, or PUVA.


Diabetic Neuropathy and the Skin

Autonomic Neuropathy

Motor Neuropathy

Sensory Neuropathy

Autonomic Neuropathy

Disturbance of sweating (anhydrosis of the feet)

Oversweating (elsewhere)

Abnormally cold feet

Brittle feet and fissures serving as a portal for infection

Sensory Neuropathy The erosion with callus on the tip of the toe is typical of the type of injury which results with sensory neuropathy of diabetes

Cutaneous Reactions to Diabetic

Treatment

Insulin Allergy may be local or systemic and usually occurs within the

first month of therapy Erythematous or urticarial pruritic nodules at the site of injection

Lipoatrophy can also occur Circumscribed depressed areas of skin at the insulin injection site

6-24 months after starting insulin

More common in women and children

Pathogenesis unknown but may be related to lipolytic components of the insulin preparation, an immune complex-mediated inflammatory process with lysosomal enzyme release, cryotrauma from refrigerated insulin, or mechanical trauma from injection

Lipohypertrophy can also occur Soft dermal nodules that resemble lipomas at sites of frequent

injection

May be a response to the lipogenic action of insulin

Treat and prevent by rotating sites of injection

Conclusion Nearly 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.

Osteoarthritis Carpal Tunnel Syndrome Bone Health and Osteoporosis Diffuse Idiopathic Skeletal Hyperostosis

(DISH) Crystal-induced Arthritis Charcot Arthropathy Tendinopathy

Although not a true neuroarthropathy, the CTS is a frequent cause of hand pain in patients with diabetes.

Compression of median

nerve in carpal tunnel.

Numbness, tingling, or burning sensations in the thumb and fingers, pain in the hands or wrists , lost gripping strength.

Weakness and atrophy of the thenar muscles

Diagnosis: history taking, physical examination, Electromyogram and nerve conduction velocity.

14 – 30% of patients with diabetes will develop carpal tunnel syndrome.*

10-15% of patients with carpal tunnel syndrome will have diabetes

*Diabetes Care March 2002 vol. 25 no. 3 565-569

More common in women than men (3:1)

Increased incidence in patients with limited joint mobility.

Treatment: Wrist splinting, NSAIDs, Localized corticosteroid injections and Surgery.

Tendinopathies occur frequently in patients with diabetes.

The shoulder and hand are particularly commonly involved.

Painful tendinopathies affect 30-60% of diabetic patients, and cause considerable disability among affected patients

Frozen shoulder, shoulder periarthritis, obliterative bursitis.

Progressive painful loss of motion in all directions, especially external rotation and abduction.

Joint capsule adheres to humeral head

Associated with age(T1 & T2DM) and duration of diabetes(T1DM)*

In diabetics, occurs at younger age, less painful, responds less to treatment

Associated with high morbidity

Treatment: steroid injections in early stages, adequate analgesia, exercise

Resolves over time *Br J Rheumatol 1986:25:147–151.

Shoulder arthrogram showing a contracted and adherent joint capsule in adhesive capsulitis.

Smith L L et al. Br J Sports Med 2003;37:30-35

Cheiropathy, stiff-hand syndrome, diabetic stiff hand, diabetic contractures, or syndrome of limited joint mobility.

Prevalence is 8 – 53% More common in patients with T1DM Risk increases with poor glycemic control

(↑HbA1c ) and duration of diabetes

Mechanism: Deposition of periarticular collagen as seen in

biopsy

Glycosylation of collagen, abnormal cross linking of collagen and increased collagen hydration all contribute

Microangiopathy and neuropathy may lead to contractures via fibrosis and disuse

Diagnosis

“prayer sign”

“table top test”

Treatment: optimizing glycemic control and physiotherapy

Present in 21- 63% of patients with diabetes

Prevalence increases with age

Generally milder in patients with diabetes compared to patients with other conditions

Treatment: Optimize glycemic control, aggressive physiotherapy, NSAIDs, analgesic, Intralesional glucocorticoid injections

Rarely surgery is required

Trigger finger Caused by fibrous tissue proliferation in the

tendon sheath. Limitation of the normal movement of the

tendon. Prevalence 11% in DM patient, < 1% in non-DM Pt.

MSK complications related to diabetes is common and can lead to severe morbidity

Having a long duration of diabetes, especially with poor glycemic control, increases the risk of developing many of these conditions

Health care teams need to be aware of the potential MSK complications in patients with diabetes

Further research is necessary to clearly define the relationship between diabetes and its associated MSK conditions

Cutaneous Manifestations of Internal Disease - mgsd.org · infection, tinea pedis should be treated aggressively in diabetics ... on the dorsum of the hand . Scleredema of Diabetes.

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