Cutaneous Manifestations of Diabetes
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Introduction
Diabetes mellitus (DM) is a heterogenous group of metabolic disorders characterized by elevated serum glucose levels resulting from defects in insulin production, insulin action, or a combination. Complications include retinopathy, nephropathy, and neuropathy. The two main types of diabetes of are Type 1 insulin-dependent DM, which is characterized by the destruction of insulin-producing beta cells of the pancreas creating the absolute need for exogenous insulin, and Type 2 noninsulin-dependent mellitus, which is associated with older age, obesity, physical inactivity, and family history. Type 2 diabetes is increasingly being diagnosed in children and adolescents. Diabetes has been implicated as the single largest cause of end-stage renal disease, the main reason for nontraumatic amputation, and an independent risk factor for cardiovascular disease.1 Nearly one-third of diabetic patients have some type of dermatologic manifestation. With time, the skin of all diabetic patients is affected in some form or another. Cutaneous signs of DM are extremely valuable to the clinician. For example, diabetic bullae, diabetic dermopathy, necrobiosis lipoidica diabeticorum, and the scleroderma-like syndrome of waxy skin with limited joint mobility can alert the physician to the diagnosis of diabetes.2,3 Eruptive xanthomas reflect the status of glucose and lipid metabolism. This review will focus on the clinical features, the pathogenesis, and treatment strategies of the cutaneous manifestations of diabetes.
Necrobiosis Lipoidica Diabeticorum
Necrobiosis lipoidica diabeticorum (NLD) (Figure 1) is a degenerative disease of collagen in the dermis and subcutaneous fat with an atrophic epidermis and granulomatous dermis. The initial lesions of NLD are well-circumscribed erythematous plaques with a depressed, waxy telangiectatic center.4,5 In early lesions, a neutrophilic vasculitis is evident. With the passage of time, granulomatous lesions evolve into a sclerotic stage of the reticular dermis and subcutaneous fat.6–8 One-third of lesions may progress to ulcers if predisposed to any trauma. The vast majority of lesions occur on the pretibial region of the lower extremities. When NLD occurs in regions other than the legs, there is less of an association with diabetes. NLD affects women more than men, and only 0.3 to 0.7 percent of people with diabetes ever develop the lesions.4,9
The etiology of NLD has not been clearly defined. Most popular theories suggest that a microangiopathic basis with neuropathy leads to the degradation of collagen.4,10 Few studies have found a correlation between NLD and the microvascular effects of diabetic retinopathy and nephropathy.4,10,11 An immunologic role, such as the release of cytokines from inflammatory cells, may lead to destruction of the collagenous matrix.
At present, there is no standard therapy for necrobiosis lipoidica. The majority of the literature on the management of necrobiosis lipoidica refers to anecdotal reports. The main modalities of treatment options include nonsteroidal anti-inflammatory agents, intralesional, systemic, or topical corticosteroids, and even laser surgery.3,4,7 A randomized, double-blind, Swedish trial of aspirin and dipyridamole combination versus a placebo did not reveal any significant benefit.12
Acanthosis Nigricans
Acanthosis nigricans (Figures 2a and b) is a disorder characterized by a velvety, light brown to black hyperpigmented, cutaneous thickening usually on the back, the sides of the neck, the axillae, and flexural surfaces.
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A very long and well described article!
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