This story is the second in an ongoing series on managing special patient populations in dermatology care.
Data from the Centers for Disease Control and Prevention report that 30.3 million people of all ages are living with diabetes in the United States.1 Although any person can develop dermatologic conditions, individuals with diabetes are more susceptible to cutaneous-related complications. The American Diabetes Association estimates that one-third of individuals living with diabetes will develop some type of skin disorder that is caused or affected by diabetes.2 In some instances, the development of skin-related issues may be a first indicator that an individual has diabetes.3 Dermatologists can play an important role not only in the early detection, but also in the follow-up of patients with diabetes.
“We have seen some increase in diabetes mellitus-related skin disease in our dermatology clinic, as diabetes increases in prevalence in the local community,” said Whitney A. High, MD, JD, MEng, professor of dermatology and pathology, clinical vice chairman, director of dermatology clinic, and director of dermatopathology at the University of Colorado School of Medicine in Aurora.
Whitney A. High, MD, JD, MEng, professor of dermatology and pathology, clinical vice chairman, director of dermatology clinic, and director of dermatopathology at the University of Colorado School of Medicine in Aurora.
Skin disorders frequently precede a diabetes diagnosis. Therefore, dermatologists need to be able to recognize the wide spectrum of cutaneous manifestations of the endocrine disease. “There are certainly a large range of presentations for diabetes-related skin disease, ranging from lesser wound healing and increased risk of infection to actual diabetes-associated skin diseases,” said Dr High.
In a review article, Makrantonaki et al4 classified cutaneous manifestations of the disease into four categories: infections, skin diseases with a direct association, skin disorders due to diabetic complications, and skin reactions due to antidiabetic treatment (Table 1).
Patients with diabetes may experience infectious skin diseases, such as bacterial and fungal infections. Examples of bacterial skin infections include styes, boils, folliculitis, carbuncles, and infections around the nails. The most commonly occurring pathogen causing bacterial skin infections is Staphylococcus bacteria.3 Athlete’s foot and ringworm caused by dermatophytes are two types of fungal infections seen in patients with diabetes.3
Adam Friedman, MD, professor and interim chair of dermatology and residency program director for the department of dermatology at George Washington University School of Medicine and Health Sciences in Washington, DC.
Individuals with diabetes can experience chronic pruritus, a common skin manifestation caused by high glucose levels, skin infection, or poor blood circulation. Lima et al5 reported that anywhere from 3% to 49% of people with diabetes have pruritus, which impacts quality of life.
“As in many cutaneous manifestations of systemic disease, the skin findings could be the diagnostic clue for underlying disease,” said Adam Friedman, MD, professor and interim chair of dermatology and residency program director for the department of dermatology at George Washington University School of Medicine and Health Sciences in Washington, DC. “I have diagnosed multiple patients, [including], sadly, a good number of teenagers, with type 2 diabetes based on their clinical picture.” One such diagnosis, he said, is acanthosis nigricans, a brown to black, poorly-defined, hyperpigmentation of the skin commonly seen in the flexural areas.4 While not specific to diabetes per se, when observed in combination with obesity, features of hyperandrogenism, and increased acrochordons, this condition has been what Dr Friedman calls “a pretty good slam dunk when it comes to identifying a pre-diabetic or actual diabetic.”
Insulin and oral antidiabetic treatment may also cause skin-related adverse effects (Table 2).4 Dr High noted that diabetes-related medications may present with variable cutaneous side effects. “Some diabetics, particularly type 2 diabetics, may have increased triglycerides and bad cholesterol levels, and may need to be placed on statin drugs to improve their lipid profiles in the blood. These statin drugs, while helpful and necessary, may lead to increased skin dryness and itching, meaning that bathing and moisturization patterns may need to be modified,” explained Dr High. “Other drugs used in diabetic patients may cause drug-induced allergic rashes.”