REVIEW ARTICLE
Dermatologic manifestation of diabetes
Lauren LEVY, Joshua A. ZEICHNER,
Joshua A. ZEICHNER
Mt Sinai Medical Center, New York, New York, USA
Search for more papers by this authorLauren LEVY, Joshua A. ZEICHNER,
Joshua A. ZEICHNER
Mt Sinai Medical Center, New York, New York, USA
Search for more papers by this authorJoshua A. Zeichner, Department of Dermatology, Mount Sinai Medical Center, 5 East 98th Street, 5th Floor, New York, NY 10029, USA. Tel: +1 212 241 9728 Fax: +1 212 987 1197 Email: [email protected]
Abstract
With the rising incidence of diabetes mellitus (DM) in the US, it is of paramount importance that practitioners understand the complications of DM and how best to manage them. Diabetes affects every organ system and the skin is no exception. There are numerous cutaneous manifestations of DM that have similar etiologies and result from the same pathologic mechanisms as the internal complications of this disease state. In addition, skin manifestations may precede the diagnosis of diabetes. The present article reviews both the common and less common cutaneous manifestations of DM, including presenting lesions, pathogenesis, and management.
References
- 1 Centers for Disease Control and Prevention. National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States, 2011. US Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta, Georgia, 2011.
- 2 American Diabetes Association. Skin Complications. 2011. Available from: http://www.diabetes.org/living-with-diabetes/complications/skin-complications.html (accessed 21 March 2011).
- 3 Garcia Hidalgo L. Dermatological complications of obesity. Am J Clin Dermatol. 2002; 3: 497–506.
- 4 Hud JA Jr, Cohen JB, Wagner JM, Cruz PD Jr. Prevalence and significance of acanthosis nigricans in an adult obese population. Arch Dermatol. 1992; 128: 941–944.
- 5 Brockow K, Steinkraus V, Rinninger F, Abeck D, Ring J. Acanthosis nigricans: A marker for hyperinsulinemia. Pediatr Dermatol. 1995; 12: 323–326.
- 6 Stuart CA, Gilkison CR, Smith MM, Bosma AM, Keenan BS, Nagamani M. Acanthosis nigricans as a risk factor for non-insulin dependent diabetes mellitus. Clin Pediatr. 1998; 37: 73–79.
- 7 Verrando P, Ortonne JP. Insulin binding properties of normal and transformed human epidermal cultured keratinocytes. J Invest Dermatol. 1985; 85: 328–332.
- 8 Cruz PD Jr, Hud JA Jr. Excess insulin binding to insulin-like growth factor receptors: proposed mechanism for acanthosis nigricans. J Invest Dermatol. 1992; 98(Suppl.): S82–S85.
- 9 Lunetta M, Di Mauro M, Le Moli R, Burrafato S. Long-term octreotide treatment reduced hyperinsulinemia, excess body weight and skin lesions in severe obesity with acanthosis nigricans. J Endocrinol Invest. 1996; 19: 699–703.
- 10 Schwartz RA. Acanthosis nigricans. J Am Acad Dermatol. 1994; 31: 1–19.
- 11 Gregoriou S, Anyfandakis V, Kontoleon P, Christofidou E, Rigopoulos D, Kontochristopoulos G. Acanthosis nigricans associated with primary hypogonadism: Successful treatment with topical calcipotriol. J Dermatol Treat. 2008; 19: 373–375.
- 12 Akovbyan VA, Talanin NY, Arifov SS et al. Successful treatment of acanthosis nigricans with etretinate. J Am Acad Dermatol. 1994; 31: 118–120.
- 13 Darmstadt GL, Yokel BK, Horn TD. Treatment of acanthosis nigricans with tretinoin. Arch Dermatol. 1991; 127: 1139–1140.
- 14 Bhargava P, Mathur SK, Mathur DK et al. Acrochordon, diabetes and associations. Indian J Dermatol Venereol Leprol. 1996; 62: 226–228.
- 15 Kahana M, Grossman E, Feinstein A, Ronnen M, Cohen M, Millet MS. Skin tags: A cutaneous marker for diabetes mellitus. Acta Derm Venereol. 1987; 67: 175–177.
- 16 Rasi A, Soltani-Arabshahi R, Shahbazi N. Skin tag as a cutaneous marker for impaired carbohydrate metabolism: A case-control study. Int J Dermatol. 2007; 46: 1155–1159.
- 17 Hoerer E, Dreyfuss F, Herzberg M. Carotenemic, skin colour and diabetes mellitus. Acta Diabetol Lat. 1975; 12: 202–207.
- 18 Chakrabarty A, Norman R, Phillips T Cutaneous manifestations of diabetes. In: R Norman (ed.) Diagnosis of Aging Skin Diseases. Springer, London, 2008; 253–263.
- 19 Danowski TS, Sabeh G, Sarver ME, Shelkrot J, Fisher ER. Shin spots and diabetes mellitus. Am J Med Sci. 1966; 251: 570–575.
- 20 Shemer A, Bergman R, Linn S, Kantor Y, Friedman-Birnbaum R. Diabetic dermopathy and internal complications in diabetes mellitus. Int J Dermatol. 1998; 37: 113–115.
- 21 Vijayasingam SM, Thai AC, Chan HL. Non-infective skin associations of diabetes mellitus. Ann Acad Med Singapore. 1988; 17: 526–535.
- 22 Abdollahi A, Daneshpazhooh M, Amirchaghmaghi E, Sheikhi S, Eshrati B, Bastanhagh MH. Dermopathy and retinopathy in diabetes: Is there an association? Dermatology. 2007; 214: 133–136.
- 23 Morgan AJ, Schwartz RA. Diabetic dermopathy: A subtle sign with grave implications. J Am Acad Dermatol. 2008; 58: 447–451.
- 24 Stawiski MA, Voorhees JJ. Cutaneous signs of diabetes mellitus. Cutis. 1976; 18: 415–421.
- 25 Gitelson S, Wertheimer-kaplinski N. Color of the face in diabetes mellitus: Observations on a group of patients in Jerusalem. Diabetes. 1965; 14: 201–208.
- 26 Ditzel J. Functional microangiopathy in diabetes mellitus. Diabetes. 1968; 17: 388–397.
- 27 Namazi MR, Jorizzo JL, Fallahzadeh MK. Rubeosis faciei diabeticorum: A common, but often unnoticed, clinical manifestation of diabetes mellitus. Sci World J. 2010; 10: 70–71.
- 28 Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes. Diabetes Care. 1998; 21: 2161–2177.
- 29 Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005; 293: 217–228.
- 30 Boulton AJ. What you can’t feel can hurt you. J Am Podiatr Med Assoc. 2010; 100: 349–352.
- 31 Kurwa A, Roberts P, Whitehead R. Concurrence of bullous and atrophic skin lesions in diabetes mellitus. Arch Dermatol. 1971; 103: 670–675.
- 32 Cantwell AR Jr, Martz W. Idiopathic bullae in diabetics Bullosis diabeticorum. Arch Dermatol. 1967; 96: 42–44.
- 33 Bernstein JE, Levine LE, Medenica MM, Yung CW, Soltani K. Reduced threshold to suction-induced blister formation in insulin-dependent diabetics. J Am Acad Dermatol. 1983; 8: 790–791.
- 34 Lipsky BA, Baker PD, Ahroni JH. Diabetic bullae: 12 cases of a purportedly rare cutaneous disorder. Int J Dermatol. 2000; 39: 196–200.
- 35 James WD, Odom RB, Goette DK. Bullous eruption of diabetes mellitus. A case with positive immunofluorescence microscopy findings. Arch Dermatol. 1980; 116: 1191–1192.
- 36 Derighetti M, Hohl D, Krayenbuhl BH, Panizzon RG. Bullosis diabeticorum in a newly discovered type 2 diabetes mellitus. Dermatology. 2000; 200: 366–367.
- 37 Huntley AC, Walter RM Jr. Quantitative determination of skin thickness in diabetes mellitus: Relationship to disease parameters. J Med. 1990; 21: 257–264.
- 38 Brik R, Berant M, Vardi P. The scleroderma-like syndrome of insulin-dependent diabetes mellitus. Diabetes Metab Rev. 1991; 7: 120–128.
- 39 Wilson BE, Newmark JJ. Severe scleredema diabeticorum and insulin resistance. J Am Board Fam Pract. 1995; 8: 55–57.
- 40 Hollister DS, Brodell RT. Finger “pebbles”. A dermatologic sign of diabetes mellitus. Postgrad Med. 2000; 107: 209–210.
- 41 Libecco JF, Brodell RT. Finger pebbles and diabetes: A case with broad involvement of the dorsal fingers and hands. Arch Dermatol. 2001; 137: 510–511.
- 42 Yosipovitch G, Hodak E, Vardi P et al. The prevalence of cutaneous manifestations in IDDM patients and their association with diabetes risk factors and microvascular complications. Diabetes Care. 1998; 21: 506–509.
- 43 Forst T, Kann P, Pfutzner A, Lobmann R, Schafer H, Beyer J. Association between “diabetic thick skin syndrome” and neurological disorders in diabetes mellitus. Acta Diabetol. 1994; 31: 73–77.
- 44 Sattar MA, Diab S, Sugathan TN, Sivanandasingham P, Fenech FF. Scleroedema diabeticorum: A minor but often unrecognized complication of diabetes mellitus. Diabet Med. 1988; 5: 465–468.
- 45 Cole GW, Headley J, Skowsky R. Scleredema diabeticorum: A common and distinct cutaneous manifestation of diabetes mellitus. Diabetes Care. 1983; 6: 189–192.
- 46 Haustein UF. Scleroderma-like lesions in insulin-dependent diabetes mellitus. J Eur Acad Dermatol Venereol. 1999; 13: 50–53.
- 47 Ferringer T, Miller F III. Cutaneous manifestations of diabetes mellitus. Dermatol Clin. 2002; 20: 483–492.
- 48 Gruson LM, Franks A Jr. Scleredema and diabetic sclerodactyly. Dermatol Online J. 2005; 11: 3.
- 49 Jelinek JE. Cutaneous manifestations of diabetes mellitus. Int J Dermatol. 1994; 33: 605–617.
- 50 Seyger MM, van den Hoogen FH, de Mare S, van Haelst U, de Jong EM. A patient with a severe scleroedema diabeticorum, partially responding to low-dose methotrexate. Dermatology. 1999; 198: 177–179.
- 51 Renner R, Teuwen I, Harth W, Treudler R, Simon JC. Eruptive xanthomas with hypertriglyceridemia. Hautarzt. 2008; 59: 995–9 (In German).
- 52 Haim S, Friedman-Birnbaum R, Shafrir A. Generalized granuloma annulare: Relationship to diabetes mellitus as revealed in 8 cases. Br J Dermatol. 1970; 83: 302–305.
- 53 Nebesio CL, Lewis C, Chuang TY. Lack of an association between granuloma annulare and type 2 diabetes mellitus. Br J Dermatol. 2002; 146: 122–124.
- 54 Studer EM, Calza AM, Saurat JH. Precipitating factors and associated diseases in 84 patients with granuloma annulare: A retrospective study. Dermatology. 1996; 193: 364–368.
- 55 Ahmed I, Goldstein B. Diabetes mellitus. Clin Dermatol. 2006; 24: 237–246.
- 56 Lowitt MH, Dover JS. Necrobiosis lipoidica. J Am Acad Dermatol. 1991; 25: 735–748.
- 57 Clement M, Guy R, Pembroke AC. Squamous cell carcinoma arising in long-standing necrobiosis lipoidica. Arch Dermatol. 1985; 121: 24–25.
- 58 Lim C, Tschuchnigg M, Lim J. Squamous cell carcinoma arising in an area of long-standing necrobiosis lipoidica. J Cutan Pathol. 2006; 33: 581–583.
- 59 Mann RJ, Harman RR. Cutaneous anaesthesia in necrobiosis lipoidica. Br J Dermatol. 1984; 110: 323–325.
- 60 Boulton AJ, Cutfield RG, Abouganem D et al. Necrobiosis lipoidica diabeticorum: A clinicopathologic study. J Am Acad Dermatol. 1988; 18: 530–537.
- 61 Alonso ML, Rios JC, Gonzalez-Beato MJ, Herranz P. Necrobiosis lipoidica of the glans penis. Acta Derm Venereol. 2011; 91: 105–106.
- 62 Jones EW. Necrobiosis lipoidica presenting on the face and scalp. An account of 29 patients and a detailed consideration of recent histochemical findings. Trans St Johns Hosp Dermatol Soc. 1971; 57: 202–220.
- 63 Sawada Y, Mori T, Nakashima D, Nakamura M, Tokura Y. Necrobiosis lipoidica of the scrotum. Eur J Dermatol. 2011; 21: 98–99.
- 64 Muller SA, Winkelmann RK. Necrobiosis lipoidica diabeticorum. A clinical and pathological investigation of 171 cases. Arch Dermatol. 1966; 93: 272–281.
- 65 Jelinek JE. The skin in diabetes. Diabet Med. 1993; 10: 201–213.
- 66 Ngo BT, Hayes KD, DiMiao DJ, Srinivasan SK, Huerter CJ, Rendell MS. Manifestations of cutaneous diabetic microangiopathy. Am J Clin Dermatol. 2005; 6: 225–237.
- 67 Tan E, Patel V, Berth-Jones J. Systemic corticosteroids for the outpatient treatment of necrobiosis lipoidica in a diabetic patient. J Dermatolog Treat. 2007; 18: 246–248.
- 68 Hu SW, Bevona C, Winterfield L, Qureshi AA, Li VW. Treatment of refractory ulcerative necrobiosis lipoidica diabeticorum with infliximab: Report of a case. Arch Dermatol. 2009; 145: 437–439.
- 69 Suarez-Amor O, Perez-Bustillo A, Ruiz-Gonzalez I, Rodriguez-Prieto MA. Necrobiosis lipoidica therapy with biologicals: An ulcerated case responding to etanercept and a review of the literature. Dermatology. 2010; 221: 117–121.
- 70 Zeichner JA, Stern DW, Lebwohl M. Treatment of necrobiosis lipoidica with the tumor necrosis factor antagonist etanercept. J Am Acad Dermatol. 2006; 54(Suppl.): S120–1.
- 71 Zhang KS, Quan LT, Hsu S. Treatment of necrobiosis lipoidica with etanercept and adalimumab. Dermatol Online J. 2009; 15: 12.
- 72 Lynde CB, Pratt MD. Clinical images: Acquired perforating dermatosis: association with diabetes and renal failure. CMAJ. 2009; 181: 615.
- 73 Faver IR, Daoud MS, Su WP. Acquired reactive perforating collagenosis. Report of six cases and review of the literature. J Am Acad Dermatol. 1994; 30: 575–580.
- 74 Morton CA, Henderson IS, Jones MC, Lowe JG. Acquired perforating dermatosis in a British dialysis population. Br J Dermatol. 1996; 135: 671–677.
- 75 Poliak SC, Lebwohl MG, Parris A, Prioleau PG. Reactive perforating collagenosis associated with diabetes mellitus. N Engl J Med. 1982; 306: 81–84.
- 76 Rapini RP, Herbert AA, Drucker CR. Acquired perforating dermatosis. Evidence for combined transepidermal elimination of both collagen and elastic fibers. Arch Dermatol. 1989; 125: 1074–1078.
- 77 Saray Y, Seckin D, Bilezikci B. Acquired perforating dermatosis: Clinicopathological features in twenty-two cases. J Eur Acad Dermatol Venereol. 2006; 20: 679–688.
- 78 Iyoda M, Hayashi F, Kuroki A et al. Acquired reactive perforating collagenosis in a nondiabetic hemodialysis patient: Successful treatment with allopurinol. Am J Kidney Dis. 2003; 42(Suppl.): E11–13.
- 79 Karpouzis A, Giatromanolaki A, Sivridis E, Kouskoukis C. Acquired reactive perforating collagenosis: current status. J Dermatol. 2010; 37: 585–592.
- 80 Kovich O. Acquired perforating disorder. Dermatol Online J. 2004; 10: 16.
- 81 Ohe S, Danno K, Sasaki H, Isei T, Okamoto H, Horio T. Treatment of acquired perforating dermatosis with narrowband ultraviolet B. J Am Acad Dermatol. 2004; 50: 892–894.
- 82 Querings K, Balda BR, Bachter D. Treatment of acquired reactive perforating collagenosis with allopurinol. Br J Dermatol. 2001; 145: 174–176.
- 83 Pozzilli P, Leslie RD. Infections and diabetes: Mechanisms and prospects for prevention. Diabet Med. 1994; 11: 935–941.
- 84 Graham PL III, Lin SX, Larson EL. A U.S. population-based survey of Staphylococcus aureus colonization. Ann Intern Med. 2006; 144: 318–325.
- 85 Montes LF, Dobson H, Dodge BG, Knowles WR. Erythrasma and diabetes mellitus. Arch Dermatol. 1969; 99: 674–680.
- 86 Bartholomew GA, Rodu B, Bell DS. Oral candidiasis in patients with diabetes mellitus: A thorough analysis. Diabetes Care. 1987; 10: 607–612.
- 87 Guggenheimer J, Moore PA, Rossie K et al. Insulin-dependent diabetes mellitus and oral soft tissue pathologies: II. Prevalence and characteristics of Candida and candidal lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000; 89: 570–576.
- 88 Vazquez JA, Sobel JD. Fungal infections in diabetes. Infect Dis Clin North Am. 1995; 9: 97–116.
- 89 Wolf R, Oumeish OY, Parish LC. Intertriginous eruption. Clin Dermatol. 2011; 29: 173–179.
- 90 Gupta AK, Humke S. The prevalence and management of onychomycosis in diabetic patients. Eur J Dermatol. 2000; 10: 379–384.
- 91 Boyko EJ, Ahroni JH, Cohen V, Nelson KM, Heagerty PJ. Prediction of diabetic foot ulcer occurrence using commonly available clinical information: The Seattle Diabetic Foot Study. Diabetes Care. 2006; 29: 1202–1207.
- 92 Rich P, Hare A. Onychomycosis in a special patient population: Focus on the diabetic. Int J Dermatol. 1999; 38(Suppl. 2): 17–19.
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