Diabetes and Skin. Benjamin Barankin, MD, FRCPC. Dermatologist & Director, Toronto Dermatology Centre
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1 Diabetes and Skin Benjamin Barankin, MD, FRCPC Dermatologist & Director, Toronto Dermatology Centre
2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.
3 Famous Diabetics
4 Diabetes and Skin 30% of diabetics develop diabetes-related skin problems With improper care, a minor skin condition can turn into a serious problem, with potentially severe consequences Most skin conditions can be prevented and successfully treated if diagnosed early
5 Cutaneous manifestations of diabetes mellitus 1. Acute metabolic derangement 2. Chronic degenerative complications 3. Other manifestations common to diabetes 4. Cutaneous reactions to diabetes treatment
6 Skin changes due to acute metabolic derangement I. Infections II. Eruptive xanthomas
7 I. Infections Infections most often seen in patients with poorly controlled diabetes 20-50%, mostly diabetes type II Predisposing factors Decreased ability to deal with infection Impaired microcirculation Decreased cell mediated immunity Abnormal leukocyte fxn: chemotaxis & phagocytosis
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9 Bacterial Infections Folliculitis, furuncles, carbuncles Pyodermic infections are more severe: Staph, Strep, Pseudomonas Malignant otitis media: Pseudomonas aeruginosa Erythrasma: Corynebacterium minutissimum Treatment: topical +/- systemic antibiotics
10 Fungal infections
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14 Fungal Infections Candida albicans is a yeast organism responsible for many fungal infections in diabetics Candida: candidal intertrigo, angular stomatitis, paronychia, candidal balanitis & vulvo-vaginitis Dermatophytes: tinea pedis (athlete s feet), tinea cruris (jock itch), onychomycosis - serves as portal of entry for other infections
15 Treatment of fungal infections Tinea corporis, cruris, etc Loprox or Lamisil or Ketoderm or Canesten Oral antifungals Onychomycosis Jublia & Penlac nail lacquers Oral antifungals Laser/NdYag
16 Using Jublia/Penlac Nail Lacquers Apply daily for 48 weeks Penlac: Remove once a week & Do not apply over nail polish. Not the case with Jublia. No need for blood work Use in patients instead of oral Tx or in conjunction - synergy
17 Eruptive xanthomas
18 II. Eruptive xanthomas triglycerides & cholesterol common with hyperglycemia; 2º chylomicronemia Chylomicrons migrate through dermal capillaries and are phagocytosed Multiple small reddish-yellow nodules appearing in crops on extensor surfaces and buttocks Regression with glucose control
19 Skin changes due to diabetic chronic degenerative complications I. Diabetic dermopathy II. Bullous lesions III. Diabetic thick skin IV. Scleredema diabeticorum V. Cutaneous neuropathy VI. Diabetic foot ulcers
20 Skin changes due to chronic degenerative complications Microangiopathy in dermal vasculature cutaneous blood flow Thickened basement membrane Changes in dermal connective tissue and cutaneous innervation
21 I. Diabetic dermopathy
22 I. Diabetic dermopathy Most common skin finding in diabetes Asymptomatic depressed brown patches over shins Appear in crops and resolve months Caused by decreased blood supply to skin 2º to vessel thickening, hemosiderin deposits and extravasation of RBCs Often accompanied by microangiopathy elsewhere
23 II. Bullous lesions
24 II. Bullous lesions Bullosis diabeticorum or diabetic blisters Usually in severe diabetes, diabetic neuropathy Spontaneous blisters on extremities (esp. feet) Heal in few weeks with minimal scarring Sub-epidermal basement membrane weakening 75% also have retinopathy
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26 III. Diabetic thick skin 1/3 of diabetes patients Tight, thick, and waxy skin over dorsa of hands, +/- minute knuckle papules (Huntley s papules) Strong correlation with microangiopathy risk Treatment: glucose control, topical steroids
27 Huntley s papules
28 Scleredema diabeticorum
29 IV. Scleredema diabeticorum Induration of the back of the neck & shoulders Most often associated with diabetes type 2, with vascular complications 2º thickened collagen bundles & deposits of glycosaminoglycans in dermis Treatment: glucose control, topical steroids
30 V. Cutaneous neuropathy Sensory: loss pain & temp., paraesthesias Autonomic: anhydrosis facial rubeosis Motor: imbalance flexor/extensor muscles displacement of fat pads & toes subluxation (hammer toes), end-stage Charcot foot Use 10g monofilament on dorsal and plantar surface to diagnose
31 VI. Diabetic foot ulcers
32 VI. Diabetic foot ulcers 15% of diabetics will develop ulcers Diabetic foot ulcers may be due to one or a combination of underlying pathologies: Angiopathy: large, medium, small vessels Peripheral neuropathy: sensory, motor, autonomic Infections Combined and others: venous, vasculitis
33 VI. Diabetic foot ulcers Peripheral vascular disease Peripheral Neuropathy Infection
34 Angiopathy in diabetic patients Diabetic peripheral vascular disease common: often distal, smaller below the knee vessels are involved such as tibial or peroneal arteries and often more distal branches of these vessels Medial calcinosis = vessel calcification
35 Neuropathy in diabetic patients Sensory Neuropathy reduced or absent pain sensation can result in unnoticed trauma Mechanical (tight shoes, sharp object) Thermal (hot bath, water bottle too close to heater) Chemical (Callus or Corn removers) Motor Neuropathy foot deformity due to atrophy of the small muscles of the foot clawing of toes and prominent metatarsal heads change in gait and prolonged pressure leads to callus and ulceration under first metatarsal, enlarged bunions and bony toes prominences Autonomic Neuropathy absence of sweating & dry skin fungal and bacterial infections Neuropathic ulcers develop initially deep within the tissues Infection is common often down to tendons and bone
36
37 Principles of therapy Relieve weight bearing pressure: offload, wheel-chair for long distances Prevention: foot care, footwear, stop smoking Proper debridement Restore arterial perfusion if required Rule out osteomyelitis, control infection Glycemic control
38 Other diabetes-associated skin disorders I. Necrobiosis Lipoidica Diabeticorum II. Acanthosis Nigricans III. Vitiligo
39 I. Necrobiosis Lipoidica
40 I. Necrobiosis Lipoidica 0.3% of DM NL; 90% NL DM, glc intol 15% precede (2yrs), 25% concomitantly Erythematous enlarging plaques, +/- ulcerate Microangiopathy Treatment: difficult - does not respond/unrelated to glucose control topical or intralesional steroids reports on ASA, nicotinamide, pentoxifyllin
41 II. Acanthosis Nigricans
42 II. Acanthosis Nigricans Hyperpigmented velvety plaques, in flexures Reflection of insulin resistance Usually precedes diabetes Treatment: weight reduction, diabetes control or see derm for various concoctions
43 II. Acanthosis Nigricans types Endocrinopathies: diabetes, PCO, acromegaly, Cushing s, hypothyroid, hyperandrogenism Obesity Malignancies: stomach adenocarcinoma, lung and breast carcinomas Familial Drug related: nicotinic acid, estrogens
44 III. Vitiligo
45 III. Vitiligo Seen in type 1 (mostly) & type 2 diabetes Melanocytes are damaged or destroyed patches of discoloured skin Treatment: repigmentation using topical steroids or calcineurin inhibitors (ProtopicR, ElidelR), phototherapy ; new therapies on horizon (JAK inhibitors)
46
47 Skin reactions to diabetes therapy Sulfonylureas 1-5% allergic reaction, maculopapular eruption during first few months of therapy Photosensitivity reactions Insulin reactions at s/c site Hyperkeratotic verrucous plaques, nodules Lipoatrophy (6-24 months) Treatment: rotate injection sites
48 Conclusions Skin manifestations of diabetes: Can alert the physician to screen for diabetes Can be an indicator of severity of diabetes Important to recognize, educate patient and initiate appropriate therapy
49 Thank You!
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