Diabetes and skin disorders: cutaneous manifestations to watch for

The skin offers a window to what is happening inside the body, so changes to the skin may signal a more serious health problem, often serving as a marker for underlying internal disease. For those living with diabetes, hyperglycemia affects skin homeostasis. Skin disorders may appear during the course of the disease or often may be the first sign of the condition.

How common are skin disorders in people with diabetes?

Skin disorders occur more commonly in those with type 2 diabetes; however, overall prevalence has ranged from approximately 51% to 97% of patients. The most frequent disorder is infection, which occurs in approximately 20% of diagnosed patients.

What types of cutaneous manifestations occur?

The cutaneous presentations can be divided into four categories, including:

• Skin lesions (presenting features described in the following section)
• Infections (bacterial – usually Staphylococcus resulting in styes, boils, folliculitis, carbuncles, nail infections; fungal – usually Candida albicans causing jock itch, athlete’s foot, ringworm and vaginal infections)
• Cutaneous manifestations of other diabetes complications (microangiopathy, macroangiopathy, neuropathy)
• Skin reactions to diabetes medications (sulphonylureas or insulin)

What are the presenting features of diabetes-related skin disorders?

People with diabetes may present initially with xerosis, or calluses and fissures.

Among other diabetes-related lesions:

• Necrobiosis lipoidica diabeticorum (begins as small raised solid bumps that evolve into patches of swollen, hard skin which are yellowish, reddish or brown in colour; usually on the lower parts of the legs; may be itchy and painful)
• Acanthosis nigricans (appears as a dark patch of velvety skin on the back of the neck, armpit, groin; often the first sign that someone has diabetes or a sign of prediabetes)
• Digital sclerosis (develops as tight, waxy skin on the fingers, toes, arms, back, shoulders, neck, knees, ankles, or elbows, and may result in mobility issues)
• Bullosis diabetricorum/diabetic bullae (blisters which resemble burn blisters but are not painful)

  Diabetic ulcers (note: these require immediate attention; those with a diameter of cellulitis greater than or equal to 2 cm at the largest area with signs of serious ischemia, systemic toxicity and bone and/or joint involvement are considered ‘limb-threatening’)

• Diabetic dermopathy (brown spots or lines usually appearing on the shins, also known as ‘shin spots’)

  Xanthelasma (yellowish scaly patches on and around the eyelids)

• Eruptive xanthomatosus (tender, itchy bumps that become yellowish; appear mainly on buttocks, thighs, elbow creases and backs of the knees; occurs with hyperglycemia and/or hypertriglyceridemia)
• Disseminated granuloma annulare (sharply defined ring- or arc-shaped raised areas usually on parts of the body far from the trunk)

How can you help your patients?

One of the most important ways to prevent serious skin-related complications is to help your patients living with diabetes manage their blood glucose levels since chronic hyperglycemia can lead to several skin disorders. Proper foot care (washing daily and drying thoroughly, applying moisturizer other than between the toes, inspecting daily for cuts and scrapes) is essential in minimizing the risk of foot ulcers.

Skin disorders are often underdiagnosed in people with diabetes, and pharmacists may be the first touchpoint for questions about skin complications. Lack of diagnosis and treatment with early-stage skin disorders can lead to clinical worsening, and progression to foot neuropathy, ulcers and even amputation, which can eventually result in fatalities. Recognition of early symptoms is vital to advise patients accordingly so they can avert serious life-threatening complications.

Shelley Diamond, BsCPhm, is the president of Pedipharm Consultants and Diabetes Care Community Inc.