A Closer Look at Dermatological Manifestations of Diabetes
Studies estimate that 30 to 70% of patients with diabetes will experience related skin manifestations of the disease.1-4 In some instances, these findings may even precede the actual diabetes diagnosis. A 2023 retrospective study aimed to analyze the presentation of such manifestations in a given cohort and compare their data with that of the current literature.5 Given that these dermatological conditions can have a wide range of impacts on patients, podiatrists may be a prime source of clinical expertise in identifying and addressing these issues when they arise in the lower extremity, thus this piece will highlight key clinical findings from the study.
The study authors divided these skin disorders into 5 designations:5
• Manifestations Strongly Associated with Diabetes Mellitus
• Non-Specific Signs and Symptoms Associated with Diabetes Mellitus
• Dermatological Disorders Associated With Diabetes Mellitus
• Frequent Skin Infections Occurring in Diabetes Mellitus
• Skin Changes Associated With Diabetes Mellitus Therapy
They reviewed records associated with 427 patients with diabetes that presented to a dermatology clinic over a 5-year period. In total, 103 patients in this group had at least one dermatological issue associated with diabetes at the time of their initial presentation. These patients (including 60 females and 43 males) were included in the study data. The mean age was 63.3 years (32 to 88 years range), and a Chi-Square Test-Likelihood Ratio found no significant differences by distribution of age and sex. In total 101 patients had type 2 diabetes, and 2 had type 1 diabetes.5
What Did the Data Show?
Manifestations Strongly Associated With Diabetes. In this study cohort, the authors found that diabetic foot complications specifically occurred in 18.4% of patients, followed by necrobiosis lipoidica (6.8%), bullous diabeticorum (5.8%), and acanthosis nigricans (4.9%).5
Signs and Symptoms Commonly Associated With Diabetes. Skin xerosis was evident in 42.7% of the patients studied and 15.5% reported pruritus. Just under 15% of patients had acrochordons (skin tags or papillomas), and 5.8% presented with rubeosis faciei (facial redness).5
Skin and Mucosal Infections. In this category, they found bacterial infections as the most common infectious condition, presenting in 33.9% of those studied. These included cases of erythrasma, folliculitis, and cellulitis. Tinea pedis impacted 31.1% and they noted other cutaneous mycoses 27.1%. Oral and genital candidiasis were also noted among these patients.5
Other Dermatological Disorders Associated With Diabetes Mellitus. Bullous autoimmune dermatoses (ie, bullous pemphigoid, morphea, dermatitis herpetiformis) existed in 18.4% of patients, and 10.6% reported psoriasis. Lichen planus and granuloma annulare were also reported within the group.5
The authors also shared key highlights of the features of some of these conditions, and their pathophysiology.5 Additionally, although none of the study group presented with them, the authors discussed some of the skin conditions related to antidiabetic therapy, including lipohypertrophy at insulin injection sites, subcutaneous nodules, lipoatrophy, and allergic reactions.5 They noted that skin manifestations of reactions to oral diabetes medications (usually sulfonylureas) are not common, but can include drug eruptions, vasculitis, photosensitivity, and polymorphic erythema. Additionally, the authors cited the possibility of metformin-related leukocytoclastic vasculitis or psoriatic eruptions.
Important Pearls to Remember
The authors of this study noted that in the literature and in their cohort, many of these conditions arose after diabetes diagnosis. However, it is possible for some conditions to manifest prior to the diabetes itself.5 Thus, it could be important to maintain an appropriate index of suspicion, along with evaluating diabetes risk, when treating patients with some of these manifestations. The authors commented that those with type 2 diabetes experienced infectious skin issues more frequently than those with type 1, and conversely those with type 1 had more prevalence of autoimmune skin issues in comparison.1,4,5 The exact presentation of skin conditions in patients can vary, and may or may not correlate with elevated blood glucose.1,4,5 However, the authors did discuss the mechanism by which hyperglycemia can result in skin changes.5
The authors stressed that the skin is a significant area of involvement with respect to diabetes complications.5 Early identification and attention to these manifestations and findings as part of a comprehensive care plan for diabetes, and an index of suspicion for those without a current diagnosis of diabetes could potentially improve care and quality of life for patients.
Dr. Spector is the Assistant Editorial Director for Podiatry Today, a Fellow of the American College of Foot and Ankle Surgeons, and a Past President of the American Association for Women Podiatrists.
References
1. Murphy-Chutorian B, Han G, Cohen SR. Dermatologic manifestations of diabetes mellitus. Endocrinol Metab Clin. 2013;42:869–898. doi: 10.1016/j.ecl.2013.07.004.
2. Duff M, Demidova O, Blackburn S, Shubrook J. Cutaneous manifestations of diabetes mellitus. Clin Diabetes. 2015;33:40–48. doi: 10.2337/diaclin.33.1.40.
3. Garg P, Chandra MGP. Cutaneous manifestation of diabetes mellitus. J Adv Med Dent Scie Res. 2021;9:100–105.
4. Lima AL, Illing T, Schliemann S, Elsner P. Cutaneous manifestations of diabetes mellitus: a review. Am J Clin Dermatol. 2017;18:541–553. doi: 10.1007/s40257-017-0275-z.
5. Vâță D, Stanciu DE, Temelie-Olinici D, et al. Cutaneous manifestations associated with diabetes mellitus—a retrospective study. Diseases. 2023;11(3):106. doi: 10.3390/diseases11030106. PMID: 37606477; PMCID: PMC10443279.
