The Skin In Diabetes

A variety of disorders of the skin occur in patients with DM. Some of these conditions are associated with endocrine or metabolic disorders that may themselves cause diabetes.

Acanthosis nigricans

This skin manifestation is often missed on examination, but is, nevertheless, fairly frequently encountered in patients with DM especially in those with genetic syndromes of insulin resistance and the metabolic syndrome. It is characterized by a velvety, papillomatous, usually pigmented, overgrowth of the epidermis and occurs particularly in the axillae, neck, groin and infra-mammary areas (Figure 143). It may be caused by hyperinsulinemia induced stimulation of insulin-like growth factor (IGF)-1 receptors on keratinocytes.

Necrobiosis lipoidica diabeticorum

Necrobiosis is rare in patients with DM. Although traditionally thought of as a classical diabetic skin manifestation, it can also occur in patients without diabetes. Necrobiosis usually develops in young adults or in early middle life and is much more common in women than in men. The skin is the most commonly affected site and the appearance ranges from early dull red papules or plaques, through indurated plaques with skin atrophy often with telangiectactic vessels on a waxy yellowish background to actual skin ulceration (Figures 137 and 138). Treatment is controversial, largely unproven and usually ineffective. Intralesional or topical corticosteroids or excision and skin grafting may have a limited role.

Diabetic dermopathy

These well circumscribed, atrophic, brownish scars commonly seen on the shin ('shin spots') occur in up to 50% of diabetic patients (Figure 140) and are also seen much less frequently in non-diabetic subjects. Although there is no effective treatment, they tend to regress over time.

Diabetic bullae

Tense blisters, more common in men than women, occurring most frequently on the lower legs and feet occur rarely in diabetic patients (Figure 142). They appear rapidly and heal after a few weeks.

Other

Other skin conditions encountered in diabetic patients are diabetic erythema, periungual telangiectasia, diabetic thick skin (linked with the formation of advanced glycation end-products), vitiligo (autoimmune destruction of melanocytes, Figure 136), eruptive xanthomata (caused by hypertriglyceridemia in diabetic dyslipidemia, Figures 148 and 149), migratory necrolytic erythema (associated with glucagonoma syndrome, Figure 141) and urticarial reactions to insulin allergy.

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